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The making of a midwife : the cultural constructions of British midwifery and American nurse-midwifery

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Title:
The making of a midwife : the cultural constructions of British midwifery and American nurse-midwifery
Physical Description:
xiii, 398 leaves : ill. ; 29 cm.
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English
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Jevitt, Cecilia Marie
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University of South Florida
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Tampa, Florida
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Subjects / Keywords:
Obstetrics -- United States   ( lcsh )
Obstetrics -- Great Britain   ( lcsh )
Dissertations, Academic -- Applied Anthropology -- Doctoral -- USF   ( fts )

Notes

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Thesis (Ph.D.)--University of South Florida, 1994. Includes bibliographical references (leaves 366-389).

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University of South Florida
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University of South Florida
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aleph - 030259999
oclc - 32293487
usfldc doi - F51-00188
usfldc handle - f51.188
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SFS0040031:00001


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THE MAKING OF A MIDWIFE: THE CULTURAL CONSTRUCTIONS OF BRITISH MIDWIFERY NURSE-MIDWIFERY by Marie Jevitt A dissertation submitted in partial fulfillme of the requirements for the degree of Doctor of Philosophy Department of Anthropology University of South Florida August 1994 Major Professor: Linda Whiteford, Ph.D.

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Graduate School University of South Florida Tampa, Florida CERTIFICATE OF APPROVAL Doctoral Dissertation This is to certify that the Doctoral Dissertation of CECILIA MARIE JEVITT with a major in Anthropology has been approved by the Examining Committee on June 2, 1994, as satisfactory for the dissertation requirement for the Doctor of Philosophy degree. Examining Committee: Major Professor: Linda Whiteford, Ph.D. Member: Michael Anqrosino, Ph.D. Member: Carol Bryant, Ph.D. Member: Lorena Madrigal, Ph.D. Member: Cindy Selleck, Ph.D.

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Cecilia Marie Jevitt 1994 (c) --------------------------------------------------------All Rights Reserved

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DEDICATION This work is dedicated to all those who have worked and will work to preserve the skills of midwifery. I especially remember Ann Hazelhurst, the first British midwife who taught me. This work also is dedicated to the nurse-midwives of the Tampa General Hospital Nurse-Midwifery Service, who covered my clinical hours while I did the work of this study: Deborah Benenson, Ethel Sage Brook, Mary Sue Brown, Mary Kay Collins, Joyce Elinghueysen, Pamela Givens, Hazel Johnson, Lynn Johnson, D. Kobliska, Mary O'Meara, Diane Pelletier, B.J. Penansky, and Marsha Watkins. Finally, this work is dedicated to my daughters: Maura, who endured data collection in Great Britain as a four year old, and Lorna, who experienced Great Britain in a longitudinal lie.

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ACKNOWLEDGEMENTS I express my gratitude to the members of my committee: Linda Whiteford, Michael Angrosino, Carol Bryant, Lorena Madrigal, and Cindy Selleck, for expanding my skills as an anthropologist and for supporting and refining my work. A special thanks is extended to Sr. Jeanne Meurer, CNM, an original committee member and my midwifery mentor. The faculty and staff of the Frontier School of Midwifery and Family Nursing of Hyden, Kentucky, especially Judith Treistman, CNM, PhD, and Debra Browning, ARNP, were instrumental in providing records and archival material, and financial and emotional support. Special thanks go to Betty Bear, CNM, PhD, and Eugene Declercq, PhD, for their seasoned advice on data collection in the United Kingdom. My appreciation is extended to all the British midwives who generously shared their time and knowledge with me, particularly Margaret Brain, Valerie Tickner, Emily Armour, Doreen Stevenson, and Elizabeth Munro. My deepest debt of gratitude is owed to my husband, David McCallister, my proof-reader and my British travel specialist. Without his constant support, this study would still be an idea.

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TABLE OF CONTENTS INTRODUCTION CHAPTER I: REVIEW OF THE PROFESSIONAL LITERATURE ... The Definition of Midwife . . . . . . Midwifery and Anthropology . . . . . Anthropology and American Birth . . . Summary: Chapter 1 . . . . . CHAPTER 2: CONCEPTUAL BASIS . . .... Definition of Critical Medical Anthropology . Limitations of Conventional Medical Anthropology Limitations of Critical Medical Anthropology . The Theoretical Foundations of Critical Medical Anthropology . . . . . . . . The Development of Critical Medical Anthropology Summary: Chapter 2 . . . . . . . CHAPTER 3 : METHODOLOGY Collection of American Data . . . . . Collection of British Data . . Key Informant Interview and Participant Observation in the United Kingdom . . . . . . Key Informant and Site Selection .... The Site Schedule . . . . . . British Key Informant Interviews ..... Validity . . . . . . . . Limitations . . . . . . Data Analysis . . . . Summary: Chapter 3 . . . . . . . . CHAPTER 4: ETHNOGRAPHIC CONTEXT OF MIDWIFERY ..... The History of Midwifery in The United Kingdom and the United States .......... Cultural Variables Affecting Midwifery Practice and Education . . . . . . . Age of Culture . . . . Religion . . . . . . . . Class and Status . . . . . Technology . . . . . . Pace of Life . . . . . . Popular Support of Midwifery . . . i 1 7 7 11 13 19 20 20 21 26 27 36 42 43 43 46 47 48 53 54 62 63 64 65 66 66 71 71 72 73 74 78 80

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Personal Safety . . . . . Date Notation . . . . . Language . . . . . . Social Moveme nts S upporting Midwifery National Childbirth Trust Iolanthe Trust . . Green Movements . . . . . Complimentary Therapies . . . Co nsumerism . . . . . . Social Security Systems Supporting Midwifery Descriptions of Study Sites Located in England London . . . . . . . . . The United Kingdom Central Council ... The English National Board. . The Department of Health . The Royal College of Midwives . St. Mary' s Paddington ..... Winchester-Basingstoke . . . . . Portsmouth . . . . . . . . Descriptions of Study Sites Located in Scotland The Lothian College of Nursin g and Midwifery The Simpson Memorial Pavilion . . The Simpson Community Midwifery Office The Scottis h National Board . . . Descriptions of Study Sites Located in the United States . . . . . . . . . The Tampa General Hospital . . . The Frontier School of Midwifery and Family Nursing . . . . . . WomenCare . . . . . . . . East Pasco Medical Center . . . S ummary: C hapter 4 . . . CHAPTE R 5: FINDINGS . .. Models of Midwifery Practice Midwifery Philosophy of Practice . Midwifery Practice . . Hospital Midwifery ... . Midwifery Care During Labor and Birth Midwifery Care in Neonatal Intensive Care Units . . . . . Community Midwifery Interconceptional . . . . ii 81 82 83 89 89 90 91 92 93 94 98 98 99 99 100 102 104 106 107 110 111 112 114 114 116 116 119 121 121 121 123 123 123 125 129 129 133 134 137

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Summary: Types of Midwifery Specializations in the United Kingdom and the United States . . . . . . . . 137 Variations In Midwifery Practice . . 140 Prenatal Care . . . . 140 Medical Records . . . . 142 Labor Admission . . . . . 143 Food and Fluids During Labor . 144 Assessing Progress of Labor . . 147 Electronic Fetal Monitoring . 149 Cesarean Birth . . . . . 150 Episiotomy . . . . . 150 Labor Complications and Emergencies 151 Newborn Care . . . . . 153 Infant Feeding . . . . . . 154 Length of Postpartum Stay . . 154 Political Variables Influencing Midwifery Practice . . . . . . . 155 Certification . . . . . 155 Independent Practice . . . 164 Registration and State Control of Midwifery . . . . . . 166 The District Supervisor of Midwives 167 Midwifery Access to Hospitals . . 172 The Department of Health . . . 173 The British Commonwealth and Midwifery 176 European Economic Community Support of Midwifery . . . . . . 180 Economic Variables Influencing Midwifery Practice . . . . . . . 181 The Health Care System . . . . 182 Professional Midwifery Organization 190 The Royal College of Midwives . 190 Association of Radical Midwives 194 Independent Midwives Association 196 The American College of Nurse-Midwives . . . . 197 Midwives' Alliance of North America . . . . 201 Unionization . . . . . 203 Competition With Physicians . 206 Employment Opportunities . . 208 Salary Levels and Hours . 212 Midwifery Malpractice Liability . 214 Midwifery Practice Model Summary . 214 iii

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Models of Midwifery E ducation . . . Educational Finance . . . . . . Structure of Educational System . Co ntent of Educational Program s . . Clinical Education . . . . Pre-Registration E d ucation . . Midwifery Educators . . . . Continuing Education in Midwifery . . Midwifery Educational Models Summary . Summary: Chapter 5 . . . .... CHAP TER 6 : ANALYSI S AND DISCUSS IO N ....... Models of Midwifery Practice Midw ifery Philosophy . Midwifery Identity . . . . . Hospital Midwifery . . . . Labor Admission . . . Assessing Progress of Labor . Electronic Fetal Monitoring . . Cesarean Birth . . . . Episiotomy . . . . . . Infant Feeding . . . . . Gynecological Care . . . . . . Medical Records . . . . . . Political Variables Influencing the Practice of Midwifery . . . . Certification . . . Independent Practice. ..... Midwifery Access to Hospitals T h e Department of Health . . . T h e British Commonwealth and Midwifery European Economic Community Support of Midwifery . . . . . The Health Care System . . . .. Equity in Health Care Access . . Economic Variables Influencing Midwifery . Privatization of British Health Care Professional Midwifery Organization . 1'he Royal College of Midwives and the American College of NurseMidwives . . . . . Association of Radical Midwives Independent Midwives Association Midwives' Alliance of North America . . . . . iv 217 217 218 222 225 228 231 232 233 233 235 235 235 246 247 251 252 256 259 261 265 266 272 274 274 276 279 281 282 285 287 290 299 299 301 301 303 303 304

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Unionization . . . . . . The Relationship of Nursing to Midwifery . . . . . . Competition With Physicians Scope of Practice . Employment Opportunities . . Salary Levels and Hours Models of Midwifery Education . Midwifery Education . . . . Cultural Value of Education ..... Structure of Educational System . . Content of Educational Programs . . Status of Midwifery Students . . . Pre-registration Education . . Midwifery Educators . . . Continuing Education in Midwifery . . Summary: Chapter 6 . . . . . . . CHAPTER 7: CONCLUSIONS AND RECOMMENDATIONS Conclusions . . . . . . Historical Matrices of Midwifery Sociocultural Matrices of Midwifery Midwifery Practice . . . . . . Midwifery Education . . . . . Politico-Economic Matrices of Midwifery Recommendations . . . . . REFERENCE LIST APPENDICES . APPENDIX I. APPENDIX 2. APPENDIX 3. APPENDIX 4. APPENDIX 5 APPENDIX 6. APPENDIX 7. CONTACT SUMMARY SHEET . PREFIELD CODE LIST . . POSTFIELD CODE LIST . . POSTFIELD CODES SORTED BY STUDY VARIABLES . . . . . EUROPEAN ECONOMIC COMMUNITY M IDWIVES DIR ECTIVES 80/155/EEC ARTICL E 4 THE PHILOSOPHY OF THE AMERICAN COLLEGE OF NURSE-MIDWIVES . . . A PHILOSOPHY FOR MIDWIFERY . . v 305 307 312 319 321 322 324 324 324 326 328 331 334 339 339 340 342 345 345 349 352 355 357 362 366 390 391 392 393 394 395 396 397

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Table 1. Table 2 LIST OF TABLES The 1992 Demographics of the United Kingdom and the United States. Common British Midwifery Terms and American Analogues. Table 3 Spelling Variations in British and American 75 88 Midwifery Terms. 89 Table 4. British Commonwealth Nations. 178 Table 5 Funding Sources for Midwifery in the United Kingdom and the United States. 189 Table 6. The Goals of Midwifery Professional Organizations. 198 Table 7 A curricula Comparison Between the Lothian College, Edinburgh, Scotland, and the University of Miami, Florida. 223 Table 8 A Curricula Comparison Between King Alfred's College, Winchester, England, and the University of Florida, Gainesville 224 Table 9. Scope of Practice Differences Between British Midwifery and American Nurse-Midwifery. 269 Table 10. Midwifery Birth Management in the United Kingdom and the United States. 271 Table 11. Summary of the Political Control of Midwifery in the United Kingdom and the Unj .ted States. 286 Table 12. Health C are System Variables in the United Kingdom and the United States. 289 vi

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Table 13. Table 14. Table 15. Table 16. Table 17. Economic Control of Midwifery: The Cost of Practicing Midwifery. Historical Matrices of British Midwifery and American Nurse-Midwifery. The Sociocultural Matrices of British Midwifery and American Nurse-Midwifery. The P olitical Control of British Midwifery and American Nurse-Midwifery. The Economic Control of Midwifery in the United Kingdom and the United States: The Cost of Being a Midwife. vii 322 346 350 358 360

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LIST OF FIGURES Figure 1. The Construction of a Health Care Profession. 3 Figure 2 Bibeau's Tridimensional Model of Analysis. 39 Figure 3. The United Kingdom and British Study Sites. 97 Figure 4. Types of Midwifery Specialization in the United Kingdom and the United States. 139 Figure 5. Midwifery Employers in the United Kingdom and the United States. 185 Figure 6. Midwives' Organizationa l Affiliations in the United Kingdom and the United States. 186 Figure 7. Structure of the Royal College of Midwives Council. 193 Figure 8. Organizational Structure of the America n College o f Nurse-Midwives. 200 Figure 9. Models of Midwifery Practice in the United Kingdo m and the United States. 216 Figure 10. Sulliva n and Weitz's Model of Midwifery Care. 244 Figure 11. The Foci of Midwifery and Biomedical Assessment. Figure 12. Cognitive Domains of Midwifery, Nursing, and Medicine in the United Kingdom and 245 the United States. 310 viii

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Figure 13. The Place of Midwifery Within the Health Care Delivery System in the United Kingdom and the United States. 315 Figure 14. Historical Changes in the Scope of Practice in British and American Midwifery 1930, 1970, and 1990. 319 Figure 15. Routes of Entry into Midwifery in the United Kingdom and the United States. 338 Figure 16. The Formation of Core Cognitive Domains in Midwifery. 353 Figure 17. Core Cognitive Domains in British Midwifery and American Nurse-Midwifery. 354 X

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THE MAKING OF A MIDWIFE: THE CULTURAL CONSTRUCTIONS OF BRITISH MIDWIFERY NURSE-MIDWIFERY by Cecilia Marie Jevitt An Abstract Of a dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Anthropology University of South Florida August 1994 Major Professor: Linda Whiteford, Ph.D. xi

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This descriptive anthropological theory to study used explore the critical medical historical, socio-cultural, political, and economic variables that shape a national construction of midwifery. The study consisted of key informant interviews of British-educated midwives working in the United States and participant observation experiences in the United States during 1989 through 1993. Observation and key informant interviews were continued in the United Kingdom at 17 sites during July 1992. Transcripts from journals, notes, and recordings were coded and sorted b y variables for analysis. Control of British midwifery includes national certification, registration, and unionization. American nursemidwifery is controlled at the state and individual hospital levels. The British government bears the cost of midwifery education and certification. American education, certification, registration, and liability insurance costs are born by individual nurse-midwives. British midwifery practice occurs within a single payor, single employer system. Health care providers are salaried and midwifery is legally independent. American nurse-midwives are employed by numerous employers and are reimbursed by numerous funding sources. American nurse-midwifery is legally controlled by biomedicine. British midwives of all educational backgrounds are integrated into a single midwifery system. American midwives of differing xii

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divides American birth into normal and abnormal domains, limiting nurse-midwifery care to the normal domain. The study concluded that the core cognitive domain of British midwifery is location of practice: community, hospital, or independent. American nurse-midwives organize midwifery according to funding sources: public or private. The study recommends that principles from both constructions of midwifery be studied for application cross-culturally to increase the effectiveness and efficiency of midwifery practice. Abstract Approved: -------------------------------------------Major Professor: Linda Whiteford, Ph.D. Assistant Professor, Department of Anthropology Date Approved: __ (Q---=-{_z__,(..__Cf_4.....___ ___ x i i i

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1 INTRODUCTION Health care professions, such as nursing, have traditionally been evaluated by comparing the content of their educational programs and the structure of their practices. Relying on these two areas to define health care professions, schools and governments move health care professionals in and out of positions disregarding the cultural context of the professions. Kleinman (1980:35) wrote that "health care systems are socially and culturally constructed." If health care systems are uniquely constructed, then the health care professions that staff the health care systems are also culturally constructed. Being culturally constructed, the specifics of being an American nurse or a French nurse would contain more differences than curricula variations and differences in practice structure. From 1989 to 1992, my doctoral internship involved the preparation of foreign educated nurse-midwives for American practice. The American College of Nurse-Midwives, the certifying body for American nurse-midwives, and the Frontier School of Midwifery and Family Nursing, the school providing the certification preparation, followed traditional assumptions about health care professionals. Their method of

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2 preparing foreign educated nurse-midwives for American practice was reduced to 4 easy steps: 1. Evaluate basic midwifery education and practice experience for deficiencies. 2. Teach educational deficits. 3. Provide midwifery practice time in America. 4. Have the foreign educated nurse-midwife take the American certification exam. The method was easy only for the evaluators. After 6 months of preparation time, certification exam failure rates for foreign educated nurse-midwives sites were as high as 33% in some sites. The model used by the American College of NurseMidwives and the Frontier School of Midwifery (Figure 1} focused on the midwife's knowledge base. In that model, the different education systems in different countries gave students a different knowledge base. The different knowledge yielded different clinical practice. "Inferior" was implied in the use of "different." If only foreign educated midwives were taught as much as American nurse-midwives, their practice would be the same. Certification exam failure rates indicated that there was more to entering a profession than mastering the knowledge base. The preparation of foreign educated midwives for American practice ignored the

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Figure 1. The construction of a Health Care Profession EDUCATIONAL ----> SYSTEM KNOWLEDGE BASE ----> PRACTICE 3 historical, political, economic, and cultural variables that shaped their health care system of origination. Investigation of the historical, political, economic, and socio-cultural similarities and differences between the cultural constructions of British and American midwifery using critical medical anthropology as a conceptual base became the focus of my doctoral research. The United Kingdom was chosen as the foreign midwifery construction t o investigate because almost 80% of foreign educated midwives entering American nurse-midwifery practice are educated in the United Kingdom (Yates 1983:15). The British construction of midwifery was brought to the United States in 1925 by an American nurse educated in midwifery in England. If the practice of midwifery depended solely on a knowledge and practice base, the constructions of midwifery in the United Kingdom and the United States should have few differences and midwives should be able to move easily between the constructions. The study included key informant interviews of British and American midwives, midwifery educators, and midwifery policy makers and participant observation in British and

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4 American midwifery practice and education. The study methods were planned to answer these research questions: 1. What historical variables influence the cultural constructions of British midwifery and American nursemidwifery? 2. What socio-cultural variables influence the cultural constructions of British midwifery and American nursemidwifery? 3. What philosophical similarities and differences are found between British midwifery and American nurse-midwifery? 4. What similarities and differences are found between British midwifery practice and American nurse-midwifery practice? 5. What similarities and differences are found between British midwifery education and American nurse-midwifery education? 6. What politico-economic variables affect the practice of midwifery in the United Kingdom and the United States? 7. What similarities and differences are found between British and American midwifery core domains? Study data revealed many similarities in midwifery philosophy in the two constructions of midwifery, including use of pregnancy and birth as normal processes, passive management, and wholistic care. Universal access to care in

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5 the United Kingdom created a niche for midwives and decreased physician incentives to control midwifery practice. Because the United Kingdom has an uninterrupted history of midwifery, midwifery is a profession known and trusted by the general public. American midwifery as a profession almost disappeared due to economic competition from physicians practicing obstetrics. Americans continue to view midwifery care as oldfashioned and inferior to biomedical care. In the United States, nurse-midwifery has grown beyond prenatal and birth care into gynecology and family planning. Growth is, however, largely in areas where physicians will not serve. The fee for service health systems in the United States encourage physicians to be the gatekeepers of health care. In all but two states, physicians control the practice of nursemidwifery. The largest difference between the two constructions of midwifery is in the amount of legal independence in midwifery practice. British midwives have legal independence. American nurse-midwives are educated and regulated within nursing and biomedical systems into dependent practices. The conflict between separate philosophies of care and dependent practice pushes American nurse-midwifery to be a culture of resistance within American biomedicine. American nurse-midwifery could be improved by attaining the legal independence and integrated regulation of midwifery found in the British system. British midwifery could be improved by expanding the scope of

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6 midwifery practice into pregnancy diagnosis and family planning. Since data collection in 1992, both the British and the American health care systems have undergone numerous changes. While most data remained unchanged at the time of publication in 1994, some data is limited to 1992.

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7 CHAPTER I REVIEW OF THE PROFESSIONAL LITERATURE Chapter 1 reviews the definition of a midwife and midwifery, the anthropological research related to midwifery, and demonstrates how anthropological writings formed a data base for American nurse-midwifery. Deficiencies in anthropological knowledge about modern midwifery are identified. The Definition of Midwife Human birth follows a process that is unique among mammals (Rosenberg 1992:89). Changes in the shape of the human pel vis resulting from bipedal locomotion coupled with the increased encephalization of the human fetus require birth mechanisms that place the emerging fetus in an occiput anterior position (Rosenberg 1992: 89). The human fetus emerges face down, making the mother unable to guide the fetus, clear the fetal airway, or remove a nuchal cord. Trevathan (1994:197) proposed that, "from the earliest stages of human evolution, females have had to rely on assistance at delivery." Trevathan further writes that this required

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8 assistance makes birth a social phenomena for humans not simply a biological process. ... based on a presumed five million year history of social and emotional dependence on others at birth, those needs are as critical to contemporary health and well-being of both mother and child as are their physical needs (Trevathan 1994:198) ." The person specializing in human birth assistance has traditionally been the midwife. Barash (1979:167) wrote that altruistic behavior during childbirth may have allowed for the increasing encephalization of humans. Cooperative behavior increased the chances for a successful birth in the face of selective pressures against pel vic structure changes and increased brain size. Barash ( 1979:167) wrote further, "I rather like the idea that midwifery and obstetrics may literally be our oldest professions, or at least the ones that 'gave birth' to our humanity." In America, the word midwife brings to mind wizened grannies helping women give birth on the frontier. In most other countries of the globe, whether developing or industrialized, the midwife is the primary birth attendant. The process of making a midwife ranges from week long, government sponsored programs for apprenticed midwives in rural Guatemala to college preparation in industrialized Europe. Regardless of background, a midwife is define d by The World Health Organization and the International Confederation of Midwives as:

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9 ... a person who, having been regularly admitted to a a midwifery educational program fully recognized in a country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered andjor legally licensed to practice midwifery ... She must be able to give the necessary supervision, care and advice to women during pregnancy, labor and postpartum period, to conduct deliveries on her own responsibility, and to care for the newborn and the infant. This care includes preventive measures, the detection of abnormal condition in mother and child, the procurement of medical assistance, and the execution of emergency measures in the absence of medical help. She has an important task in counseling and educationnot only for patients, but also within the family and community. The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynecology, family planning, and child care. She may practice in hospitals, clinics, health units, domiciliary conditions or any other service (Varney 1987: 4) The World Health Organization definition tells what a midwife does, but does not define midwifery. In the United States and Canada, midwifery as a profession was almost driven to extinction by the emerging profession of medical obstetrics. Webster's Dictionary (1989:633) defines midwifery as, "obstetrics." It then defines obstetrics as, "the branch of medical practice which is concerned with the care of mothers before, during and immediately after childbirth ( 1989:693) Since the practice of midwifery preceded the practice of obstetrics (Ehrenreich and English 1973, Litoff 1978, Oakley 1982, Rooks, 1986, Sullivan and Weitz 1988, Varney 1981, Donnison 1977) obstetrics cannot be used to define midwifery.

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10 In the United states, the profession of nurse-midwifery has aligned midwifery with nursing. The American Nurses' Association defines nursing as, "the diagnosis and treatment of human responses to actual or potential health problems" (Hawkins and Thibodeau 1989:24). Nursing uses diagnosis and treatment, long considered the territory of medicine, to manage human responses to health problems. Leininger, attempting to distill the essence of nursing, identifies caring behavior as the central construct of nursing, and offers this definition of nursing: (Nursing is) a learned humanistic art and science that focuses upon personalized (individual and group) care behaviors, functions, and processes directed toward promoting and maintaining health behaviors or recovery from illnesses which have physical, psychocultural, and social significance or meaning for those being assisted generally by a professional nurse or one with similar role competencies (1984:4-5). This study used an operational definition of midwifery that incorporated Leininger's definition of nursing as its base. When referring to midwifery, this study assumes that: Midwifery is a learned art and science that focuses on human care behaviors intended to promote, maintain, or recover health during the periods of normal, physiologic change in a woman's life: menarche, reproduction, childbirth, lactation, and menopause. The mother-newborn dyad performs behaviors essential to the recovery and growth of both dyad members. Therefore, midwifery care extends to the newborn.

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11 Use of this definition aligned American midwifery w ith an American definition of nursing, but avoided the use of diagnosis and treatment used in the biomedical illness model. If midwifery care occurs during times of physiologic changes in women, then obstetrics and gynecology would be defined as the branches of biomedicine involved with treating or curing deviations from the normal, physiologic changes in a woman's life. This would include problems such as obstructed labor or reproductive organ cancer. Midwifery and Anthropology American midwifery has a long tradition of using anthropological writings as supplementary texts. Anthropological accounts of pregnancy, birth, and breastfeeding in nonindustrialized cultures document views of these events as physiologic processes embedded in sociocultural traditions. American medical writings describe pregnancy, birth, and breastfeeding as periods of disease. If only medical texts were used during midwifery education, American nurse-midwifery would have no unique philosophical base of practice. During the 1970s and 1980s, anthropological writings about pregnancy, birth, and breastfeeding by Meade, Jordan, Kitzinger, and Kay circulated among midwifery students as an underground reading list. While schools of nursemidwifery taught the m edical literature using f o r e x ample

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12 William's Obstetrics as a text, students read Jordan's description ( 1980) of a home birth attended by a Yucatan midwife (partera) Anthropologists working outside the biomedical system were free to examine and challenge the medical management of pregnancy and birth. Jordan (1980) compared the cultural contexts of birth in the Yucatan, Holland, Sweden, and the United States. Her writing contrasted the use of low technology midwifery assistance in the Yucatan with the routine use of technology by physicians in American biomedically managed birth. Jordan encouraged biomedical and traditional birth systems to learn from each other. Ethnography of Fertility and Birth (1982) contains accounts of birth assisted by traditional birth attendants in Sierra Leone by Maccormack and a review of change s in Guatemalan midwifery practice by Cominsky. Laderman (1983 ) described Malay conception and pregnancy beliefs and detailed the work of traditional Malay midwiv e s These three anthropology texts gave evidence that birth did not have to b e attended by a physician, a position not the n found in biomedical literature. Sibley (1994:181) studied 3 0 traditional midwives in Belize and concluded that the concepts and practices of the midwives were empirically derived, internally consistent, widespread among the traditional midwives, and differe d from biomedical understandings of birth.

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13 Anthropology and American Birth Anthropological study of birth attended by midwives gave way to the study of technological birth, specifically, how women and midwives lost control of pregnancy and birth. Whiteford and Poland (1989:1-3) describe how women ceased to view pregnancy and birth as a women-centered experiences, believing that "medical control was superior to control through natural or supernatural means ( 1989:2) Confidence in the medical model of pregnancy and birth as treatable diseases ignores the potential for error in diagnosis and iatrogenesis, physician or treatment caused disease. Martin (1987:196-201) writes that the medical model of illness has been imposed on pregnancy, birth, and female aging. Medical textbooks and the popular press contain images that convince women their bodies are faulty, incapable of reproduction and aging without medical assistance. Numerous authors document how physicians conspired to replace midwives as the preferred American birth attendant: Wertz and Wertz (1979), Sullivan and Weitz (1988), Michaelson (1988), Whiteford and Poland (1989. Starr (1982) describes how American physicians from varying philosophies and educational backgrounds consolidated during the late 1800s to monopolize American medical care. Propaganda campaigns were used against alternative providers such as herbalists and midwives, so that

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14 all diagnosis, treatment, and prescription came under the legal control of physicians (Starr 1982:128-131). Davis-Floyd ( 1992:283) writes that instead of seeing pregnancy and birth as natural processes under artificial control, many American women enthusiastically embrace medical technological management. She explains this belief by showing how the use of machines to speed activities is part of everyday life in industrialized nations. The manner of giving birth must be consistent with the cultural pattern of life (Petersen 1983:3). If women cook dinner in 30 minutes using microwave ovens, they are conceptually unprepared for the 24-36 hours of contractions a first labor might have. They will embrace any management that promises speed and ease. Similar to Davis-Floyd's assertion that American women seek technological birth care, is Robertson's statement that the family has not been displaced by industrial institutions in reproduction. Robertson contends that the family has successfully dumped a great many of the costs and burdens of reproduction on the institutions of industrial society ... a wide variety of organizations-banks and schools, factories and clinics, mortgages and retirement communities, even governments and political parties-are all involved in various ways in the vital tasks of reproduction, producing new individuals ... (Robertson 1991:4). Families accustomed to outside support of its activities will not view technological intervention in pregnancy and birth as meddling control, but as relief from its work. Tew (1990:4) challenges the belief that physicians and medical care are responsible for improved pregnancy outcomes.

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15 She writes that British maternal and infant mortality were falling during the late 1800s not due to the use of physicians to manage birth or their obstetrical treatments, but because general mortality rates were falling with improved nutrition and a decline in infectious diseases. Tew (1990:87) describes a 1934 campaign to increase physician-provided antenatal care in Wales. Maternal mortality actually increased until 1935, when free food (dried milk, Ovaltine, and Marmite) was distributed in place of physician care. Then, the maternal mortality fell by half. Tew (1990:209-210) continues to reexamine British childbirth statistics, revealing that in 1930-1932, the mothers with the lowest mortality rates were the poorest. Medical theory places the poorest women at highest risk for childbirth mortality due to poor baseline health and unsanitary living conditions. Tew explains this statistical anomaly by saying the poorest women had fewer contacts with physicians. Their care was relegated to British midwives, therefore, they suffered less mortality-causing iatrogenesis. Turshen (1989) sees control over reproduction as the most important factor influencing women's health. Where state control provides an equitable distribution of medical services, including maternal health services, women's health can be improved (Turshen 1989:188). Industrialization, however, has tended to take economic control away from women. Lack of economic control becomes a double-edged knife: women may lack basic health services or they may lack the control to

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16 refuse unnecessary, potentially harmful treatments. to bridge the two birth philosophies, midwifery and medical technology, is the American certified nurse-midwife. As American nurse-midwifery expanded during the 1980s, it carne under the scrutiny of birth anthropologists and sociologists. Arms (1975:199) accused nurse-midwives of "looking much like the physician authority whom she is licensed to assist." Nursing and midwifery are not easily combined, Arms wrote, because nursing prepares a midwife to expect disease ... and she has a lusty respect for modern forms of interference which will protect (a) woman from her own working body. It is a rare nurse who leaves her training unscarred by that emphasis and expectation of disease or disorder. Thus examined closely in light of her history as a nurse and the harsh reality of her hospital surroundings, the nurse takes h e r place on the growing obstetric team, but the midwife has changed and lost her essence in the process (Arms 1975:199). Rothman ( 19 8 2 : 6 3-7 7) describes how nurse-rnidw i ves are pulled into the use of technology by their work within hospitals and their legal dependence on physician s to practice. Rothman (1982:69) calls American nurse-midwifery a "manufactured occupation," facilitated by American obstetricians when their technological territory: normal obstetrics, perinatology, and gynecology, became too large to manage What Arms and Rothman miss is the perspective of the nurse-midwife. They do not c redit nurse-midwifery for creating a culture of its own. While nascent, nurse-midwifery has

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17 philosophies separate from the medical model. Lazarus (1988:48-49), after observing both obstetrical residents and nurse-midwives for two months in an inner city hospital, concluded that, "The midwives 1 attitudes and goals for the clinical encounter, which emphasized making women feel good about themselves and their pregnancies, were very different from those of the residents ... midwives pointedly tried to be sensitive to patients 1 needs," even though she viewed the midwives' care as medicalized. Further describing her understanding of midwifery philosophy, Lazarus ( 1990:283) writes: Midwives are not opposed to the use of technology, but their training and their experience is oriented toward reduced use ... midwives vie w e d pregnancy as a natural process within a woman's life. Midwife training includes understanding nutrition, breastfeeding, pharmacology, family planning, and applied psychology, all of which reflect a health rather than pathology orientation. Lichtman {1988:130-141) describes, as an anthropologist and a nurse-midwife, how she differentially applies midwifery or medical philosophies during practice depending on the amount of physician control at the time of care. What is not determined in her description is whether the construction of nurse-midwifery is situational or whether the nurse-midwife sometimes practices midwifery and sometimes practices biomedicine. Taplin (1989:3) writes that "many anthropological/ feminist ... a nalyses that emphasis the subordination of one group of social actors to another group of social actors

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18 explore the victimization of the subordinated group rather than it's resistance." It is the resistance of nurse-midwifery to medical control that has been ignored by anthropological research. Resistance has been used to describe class struggle within capitalistic societies (Humphries 1977). Caulfied (1974) and MacLean (1982) argued that family relations are "cultures of resistance" to capitalist exploitation. A culture of resistance is a group that works against outside economic domination. American nurse-midwifery works within the American medical establishment to resist the imposition of a medical illness model on the processes of pregnancy, birth, and female aging. Nurse-midwifery care has been more than a costeffective, physician substitute for the poor. Nurse-midwifery care has resisted the effects of inadequate access to health care on women's health. Rothman, using Myle's Textbook for Midwives as a source, perceives a difference between American and British midwifery. While she calls American nurse-midwifery "manufactured," she sees British midwifery as "created by a succession of legislative controls over traditional midwives, usurping their professional authority (Rothman 1982: 69) In the United Kingdom, the midwife is the most senior practitioner at 80% of births. British midwives have statutory independent practice.

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19 Summary: Chapter l The anthropological literature provides a wealth of information on midwifery practice 1n native cultures. Anthropological studies are beginning to investigate midwifery practice in industrialized nations where biomedical theory and technology dominate health care. This study expands the anthropological literature by describing the historical, socio-cultural, and politico-economic factors that shape the constructions of midwifery in the United Kingdom and the United States. Chapter 2 Conceptual Basis, describes the critical medical anthropology perspective and how that perspective i s used to organize this study.

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CHAPTER 2 CONCEPTUAL BASIS Anthropology's unique contribution to the social science of medicine is its ability to draw attention to the nature of categories of thought usually left implicit and unexamined. This perspective allows us to treat medicine as a cultural system rather than accepting medicine as value-free, legitimized by its association with science. (Lazarus 1986:136) 20 Chapter 2 describes the theoretical foundation of the study: critical medical anthropology (CMA). Critical medical anthropology views medical systems as cultural systems shaped not only by historical and socio-cultural factors, but by politico-economic factors. Chapter 2 contrasts critical medical anthropology with other anthropological perspectives and describes how Bibeau's critical model was applied to study data. Definition of Critical Medical Anthropology Health, as defined by the World Health Organization, is, "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (Turshen

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21 1989:17,18). Use of the WHO definition that includes social well-being 1.n health implies a connection between health, politics, and economics. Followers of the critical medical model of anthropology attempt to make that connection explicit. "Critical medical anthropology ( CMA) understands health issues in light of the larger political and economic forces that pattern human relationships, shape social behavior, and condition collective experience, including forces of institutional, national, and global scale ... Central to the new approach is a concern with the relationship between macro-and micro-levels of explanation" (Singer 1986:189). Baer, Singer and Johnson (1986:95) define health as "access to and control over the basic material and non-material resources that sustain and promote life at a high level of satisfaction." Singer ( 1989: 1196) defines critical medical anthropology as a methodology that studies the relationship between the State, health policy, and resource allocation. Limitations of Conventional Medical Anthropology Anthropologists aligned with the CMA perspective found that conventional approaches to medical anthropology limited their analyses in several ways. First, traditional medical anthropology primarily researched traditional healers or folk medicine systems as if these systems operated in isolation from other systems (Singer 1989:1198). Baer (1989:181) advises

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22 that is imperative for anthropologists to understand the history and meanings of capitalism, communism, and socialism if they are to be able to complete holistic studies of complex societies, particularly postcolonial or postrevolutionary societies. Second, medical anthropologists focused primarily on the ritual and symbolic aspects of behaviors. Onoge (1975:221) labeled this focus "socioculturalism", accusing it of ignoring the effects of the larger social structure on health. To Onoge, socioculturalism amounted to nothing more than cultural determinism. Third, traditional medical anthropology used a definition of social relations, "personal bonds connecting individuals through reciprocal exchange systems, reticular networks, and social support structures," that is more suited to the study of tribal peoples than complex, urban groups (Singer 1990:179). This narrow definition of social relations is used in Kleinman' s work on the doctor-patient relationship. ... doctors and patients meet as equals, with the former rendering advice and the latter bearing ultimate responsibility for deciding whether or not to follow that advice "(Katon and Kleinman 1981:112). This view of the doctor-patient relationship is an example of medical anthropology's focus on the microlevel ( Baer, Singer, and Johnsen 1986:97, Singer 1989:1193). It ignores the constraints on the relationship imposed by hospital policies, state and federal laws regarding medical treatment, restrictions from

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23 third party reimbursers, and work/health stipulations from the patient's employer. These constraints work to make the doctor and patient unequal. Baer ( 1989:1103) writes that medical pluralism in America continues to reflect class, racial/ethnic, and gender relations within American society. He sees the history of the rise of biomedicine in America during the 19th and 20th centuries as a history of domination by biomedicine following educational reforms that changed medicine into a white upper class profession. Some alternative providers, such as osteopaths and chiropractors, have survived the biomedical consolidation process at the expense of adopting the biomedical disease model into their philosophies (Baer 1987). Good and Good (1980:165-181), using a hermeneutic model, called for a meaning-centered approach to health, one tha t acknowledged that, "culture affects the experience and expression of symptoms." Their approach was intended to counteract the tendency of the biomedical model to focus on biological measures of illness rather than the patient's experience of symptoms. If health care providers could understand the explanatory models and networks of meanings in the patient's perception of illness, the providers could translate meaning across medical subcultures to enhance patient education, improve problems with patient compliance, and for m "therapeutic alliances" with patients. The fourth charge of the CMA perspective is that hermeneutic models,

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24 while searching for culturally constructed meanings, have ignored their historical, economic, and political contexts (Singer 1990:180). Fifth, CMA examines the shortcomings of the ecological/ adaption model (Singer 1989, 1990:180). Singer (1989:225) writes that medical ecology is best sui ted for studies of groups and populations. McElroy and Townsend (1992:11), using an ecological model, define health as "a measure of how well a population has adapted to its environment." Ecology models use intake and output of energy as core variables. McElroy and Townsend (1992:10) claim that by adding ethnographic details such as seasonality of work load, and differential distribution of resources to a study, a complete model is formed. They illustrate this model by describing the energy expenditure of women in rural Uttar Pradesh and the insufficiency in their nutrient intake. McElroy and Townsend acknowledge that the heavier work loads of women, their lack of mechanical h elp, and the preferential distribution of food to males deprives women of the energy needed for safe reproduction, but fail to investigate the political and economic factors that reinforce the differential distribution of resources, thereby perpetuating poor reproductive outcomes. While ecologists investigate human links with the environment, they may fail to recognize that humans are now adapting to man-made environmental changes. Using works that date back to

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25 Engels, CMA postulates that what is adaptive for some groups produces disease for others (Singer 1990:180). McElroy and Townsend ( 1979: 13) attempt to expand the medical ecology model by saying that human populations adapt to physical and social environments. Singer (1989:227) refutes adaptation to social environments, saying this tends to "disguise social relations as natural relations." "Social relations, he reminds us, "can be imposed suddenly from without onto a seemingly stable community" (1989:227). Additionally, medical ecology views homeostasis as the endpoint of adaptation (Singer 1989:228). This is the opposite of CMA, which holds that groups try to maintain differential power. Sixth, CMA accuses conventional medical anthropology of becoming medicalized (Lazarus, 1986:136, Singer 1989:1194) .. Medical anthropology depends on biomedicine for research funding and employment. Such dependency causes medical anthropology to ignore the nontherapeutic behaviors of biomedicine, such as the advertisement of new diseases in print and television to stimulate more diagnostic visits and the purchase of more medicines. Scheper-Hughes (1990:189,190) calls this the "double agent role" of clinically applied anthropologists. She claims that cultural brokers serve the needs of health care practitioners and may do more manipulation than negotiation.

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26 Limitations of Critical Medical Anthropology The concept of hegemony is ever present in CMA writings. csordas (1988) takes issue with its use. First, he asks if CMA really represents the implicit critiques of those anthropologists it seeks to represent (1988:420). Second, csordas finds the use of biomedical hegemony problematic. It is used as if "biomedicine itself constituted a ruling class" (1988:417). Estroff (1988:423) points out that separation of class cultures and biomedicine into opposing groups ignores the "integration and causal overlap" b e tween these groups. According to Pel to, CMA shares a problem with other contemporary anthropological methods. ... (T) heory seems to be brought in ex post facto to explain and to label empirical results, rather than to generate new questions that become the focus of new research" (Pelto 1988:437). Finally, Singer (1990:298) cautions anthropologists united under CMA to beware of the tendency of anthropologists to "speak for rather than with ethnographic others." Speaking for others creates an intellectual hegemony of its own (Estroff 1988:422). Lastly, Singer (1990:298) advises that a critical medical biomedicine so anthropology that medical must disengage anthropology itself from can "avoid reproducing biomedical authority patterns in the ways we develop, express, and use the body of knowledge unique to our discipline."

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27 The Theoretical Foundations of critical Medical Anthropology Critical medical anthropology derives its focus on political and economic determinants of behavior from the political economy of health developed by sociologists in the 1970s. Morsy (1979) is credited with being the first anthropologist to value political economy, calling it a "missing link" in medical anthropology. Baer wrote the first anthropological definition of the political economy of health in 1982, saying it was: a critical endeavor which attempts to understand health-related issues within the context of class and imperialist relations inherent in the capitalist work-system. (Baer 1982:1) Morgan defined the political economy of health as: a macroanalytical, critical, and historical perspective for analyzing disease distribution and health services under a variety of economic systems, with particular emphasis on the effects of stratified social, political, and economic relations within the world economic system. (Morgan 1987:132) The political economy of health synthesizes several theoretical bases: classic Marxism, the world economy theory, and the cultural critique of medicine (Morgan 1987:131). The resurgence of Marxism in the 1960s and 1970s can be seen as a reaction against the modernization theory of development (Rostow 1962) which held that underdeveloped countries are underdeveloped because they hold fast to cultural traditions and remain economically backward.

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28 According to modernization theory, infusions of capital would spur development in Third World Nations. Gunder Frank (1972:5-8} refuted modernization theory, writing that the now developed countries were never underdeveloped, although they were once undeveloped. Gunder Frank hypothesized that capitalist growth in metropolitan areas extracted resources from peripheral areas thereby causing the underdevelopment of the periphery. Capital infusions would not cure underdevelopment (1972:8,9}. The extraction of resources impoverishes an area, weakening health. Gish ( 1979: 2 04) wrote that "the health sector in most countries, including those of the Third World, follows closely the socio-political characteristics of the nation." He reviews the development of mission and colonial health systems in the Third World and their persistence in the postcolonial period, saying that primary care alone will not improve health. An understanding of underdevelopment will be critical to improvements in health care systems ( 1979: 2 03) Frankenberg (1989:197) defined development as "the process whereby capitalism as a mode of production comes to dominate over precapitalist forms." He held that in studying development, attention had to be given to the commoditization of medical technology and pharmaceuticals, and class interests in those technologies. Gunder Frank 1 s theory was supported by Wallerstein 1 s (1974) description of the growth of a European-based world-

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29 economy starting in the late fifteenth century. European nations formed trade networks that extracted resources from Africa, Asia, and the Americas. .. (T)he basic linkage between the parts of the system is economic, although this was reinforced to some extent by cultural links and eventually ... by political arrangements and even con federal structures" (Wallerstein 1974: 15). Wolf brought world economy theory into anthropology using Marxism as a theoretical base. His Europe and the People Without History (1982) examined how noneuropeans were drawn into the world economy. Wolf wrote that structuralism gives a model that is a, "hollow representation of societal complexity ... it makes no statement about any processes generating the structure, or about the specific features that integrate it ... "(1982:15). Ecologists, he claimed, analyzed a "single case, now hypothesized as an integral, self-regulating ecological whole ( 1982: 16) To Wolf, both structuralists and ecologists missed the historical processes that formed links between cultures. Gish (1979) places medical migration within the context of a world economy. Developed nations, particularly the United Kingdom and the United States, have been accused of being a "brain-drain" on Third World health systems. Gish contends that medical migration is a rational, economic response to international inequalities in the distribution of income and that some nations educate their elite for export. He further proposes that the health systems of the US and the UK could

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30 not function without tens of thousands of doctors and nurses from less developed nations filling low status emp loyment positions (Gish 1979:5,6). Navarro (1989:195) uses Marx's definition of capitalism as the dictatorship of the bourgeoisie, explaining that capitalism is not a form of government, but a type of domination. Navarro postulates that: the major cause of death and disease in the poor parts of the world today in which the majority of the human race lives is not a scarcity of resources, nor the process of industrialization, nor even the the much heralded population explosion but, rather, a pattern of control over the resources of those countries in which the majority of the population has no control over their resources. (Navarro 1974:7) Navarro asserts that an elite corporate class controls access to health care through support of health care providers. This creates a conflict between the providers interest in helping the working class and maintaining their support from the corporate class (1973:103). Navarro (1973:106) and Elling (1981:89) postulate that state intervention in health care has two roles: to and defend the private enterprise system, and to strengthen that system. As an example of these roles, Donaldson Brown (1978), and Gish (1979) describe how Third World nations were pressured to accept a biomedical model o f health care provision that may not have been most suited to their needs -Beginning in the 1920s, the Rockefeller Foundation provided consultation and funding to establish Western style schools in developing nations. Thailand, for example w desired

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31 a system of health officers, who would treat simple diseases and spread the use of public health measures in rural areas. Acceptance of the Rockefeller model was tied to other forms of us financial aid, and the Thai royal family was pressured into accepting the Rockefeller professional physician model. Longer educational time was required for professional physicians, who then had little incentive to practice in rural areas where support services were not available for their technological cures. Acceptance of the Rockefeller model increased foreign dependency on US aid and US professors for medical schools, provided inexpensive medical labor for developed nations through the brain-drain, and created new markets for drugs, medical technology, and technical assistance (Morgan 1987:137). Furthermore, Gish (1979:207) adds, "Many centres of 'excellent teaching' also became centres of 'excellent research' for American and other universities." Whiteford ( 1990) describes how the Dominican Republic adopted the primary health care (PHC) model, even though the resources were not in place to support the model. Medical residents were obligated to spend one year serving a rural area. However, they were taught curative, high-technology medicine when they need preventative health care skills. The rural areas lacked medical supplies and nursing support for any effective care. Whiteford's analysis suggests that although PHC did not meet health care needs, it met political needs "By adopting the proffered PHC model, the Dominican

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32 Republic reaffirmed its historical relationship with the US, opened channels for desperately needed scarce resources, and provided employment in a time of joblessness (Whiteford 1990: 221) II The application of Marxism to health analysis yielded a theory called "the social production of health and illness" (Turshen 1989: 24) Marxist analysis moves away from biomedical explanations of how disease develops and investigates why disease develops. Marxists see biomedicine as reductionist, Marxism as holistic (Turshen 1989:270). Marxists recognize that health and illness are products of the global organization of society and of the way subsistence and surplus are produced and distributed internationally among society' s members. He alth and illness are products of complicated power relationships between n ational producers and, often, multinational owners, and between producers and distributors. They are also products of the way reproduction is organized, not only childbearing, but also child rearing. Health and illness are social products of the specific historical circumstances and relations (Turshen 1989:270). One method for capitalist economies to take attention away from budget cuts in public health i s to situate control of health with the individual (Elling 1981:213). This method ignores the stresses produced by industrialization as contributors to disease and blames the victi m for stress-coping behaviors such as cigarette smoking and alcohol use. Assigning health control to the individual a lso ignores food distribution patterns and differential purchasing power. Waitzkin (1991) analyzed the doctor-patient relationship f rom a Marxist perspective, saying both the patient and the

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33 doctor bring a broader social context with them into their relationship. Unless the physician attempts to understand the social context of the patient's disease and illness, healing potential is limited. The "micropolitics" of an individual patient encounter limit the ability of physicians to produce health (1991:9). These interpersonal, "rnicrolevel" processes are shaped by "macro level" structures. Macrolevel changes have the most potential for improving health (1990:11,12). Cultural Critique Theory is best exemplified by the writings of Illich and the Ehrenreichs Illich (1976:3) views modern medicine as more of a threat to health than a help. He labels three types of iatrogenesis (conditions resulting from medical intervention) : ( 1) clinical iatrogenesis, ( 2) social iatrogenesis, and ( 3) cultural iatrogenesis. Clinical iatrogenesis is the most commonly recognized form of iatrogenesis. Examples of clinical iatrogenesis include bone marrow suppression resulting from antibiotic use, hemorrhage resulting from the overuse of the hormone pitocin to stimulate labor (Doyal 1979:235) and exposure t o the bacteria that cause endometritis (uterine infection) following hospitalization for uncomplicated childbirth. Illich d efines social iatrogenesis as "all impairments to health that are due precisely to those socio-economic transformations which have been made attractive, possible, or necessary by the institutional shape health care has taken" (1976:40). Modern medicine "medicalizes" life, taking control

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34 of health, sickness, birth, and death away from people and institutionalizing that control (1976:41). "It turns mutual care and self-medication into felonies" (1976:42). The movements in many states to make home birth illegal are examples of the medicalization of life. Medicalization also takes the ritualization of life stages and converts them into periods of health risk (Illich 1976:78). Instead of women going through phases of puberty, childbearing potential, and menopause, those stages are redefined and reduced to a stage of irregular menstruation, a stage of unrestrained fertility, and a stage of degeneration, all requiring control by exogenous hormonal feeding fostered therapy. The the movement purchased formulas (1976:89,90). medicalization of infant against breastfeeding to In Illich's view, each culture forms unique beliefs about health and illness and unique strategies for coping with illness. Cultural iatrogenesis is the ability of modern medicine to "undermine old cultural programs and prevents the emergence of new ones that would provide a pattern for selfcare and suffering" (Illich 1976: 131). If only organized medicine can stop pain and heal, people lose the ability to cope with other crises such as childhood illnesses. Ehrenreich (1978:27,28) refutes the use of Marxism in the analysis of health seeing medical care as fundamentally a social not a technical or commercial relationship. His critique finds that humans must be dependent during times of

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35 birth, pain, and death. What is lacking is a "dignified, nurturing" method of managing that dependency. Ehrenreich (1978:25) says political economy is based on a worldview that believes in scarcity, while cultural critique grows out of plenty. "The political economic critique challenges the poor distribution of an otherwise admirable service; the cultural critique disputes the value of the services themselves" ( 1978:4) Physicians and nurses claim that professionalism maintains high standards i n education and the provision of care. Under cultural critique, professionalism consolidates power, allowing health care providers to be agents of social control (197843-52). For example, physicians have the power to label the discomforts of pregnancy as physiologic and encourage women to continue their employment or school respon sibilities regardless of the women's perceived level of illness. Unlike Marxists, followers of the cultural critique perspective acknowledge that biomedicine does have successes in preventing death and pain. Cultural critique shares with Marxism its use of Gramsci's concept of hegemony: the power and domination ever present in human cultural action (Kapferer 1988:427). The publicized successes of biomedicine are used to extend the cultural and political hegemony of the bourgeois. Like cultural critique, Doyal's The Political Economy of Health (1979) agrees that biomedicine does work to alleviate illness and pain. Waxman (1990:195) documents how Navajo women

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36 increasingly accepted birth attendance in hospitals not only for pain reduction, but because being in the hospital exempted them from observing ritual taboos that many found tedious. Doyal recognizes that "the distribution of ill health in capitalist societies broadly follows the distribution of income. Those with lower incomes tend to have higher rates of morbidity and mortality ... (1979:26). Doyal (1979:12,13) examined the belief that organized medicine is the mediator between people and disease. As a limited good, medicine was unavailable to all people. Health for all depended on democratic distribution of resources and the potential for capitalism to provide for all through continued econom1c growth. Political economists question the unlimited growth potential of capitalism. Political economists claim that biomedicine uses a mechanistic model of the human body, reducing it to a collection of unrelated organs, while ignoring the social context of illness and disease (Doyal 1979:33,36). The Development of critical Medical Anthropology The political economy of health, beginning as a sociology model, posed several limitations for anthropologists. First, it ignored the concept of medical pluralism, the co-existence of traditional healing methods with biomedicine, an area much

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37 studied by traditional medical anthropology (Morgan 1987:144). Morgan ( 1987: 145) follows Frankenberg ( 1980: 197) in saying that medical pluralism is not so much a function of cultural preference or eclecticism, as it is a reflection o f social control and power structures in h ealth systems. Thos e with s o cial pow e r can afford the m edical care o f their choosing. Second, political economy could not a ccommodate the u s e of critica l theory being d e v eloped in philosophy, literature a n d sociology. Critical theory, as associ ated with the Frankfurt Sch ool and Habe r m a s does n o t follow classical Marxism Critical theory "assumes tha t individuals have the capacity to r eflect critically about soci ety and t o take 'purposive' political action" (Wa i t z k i n 1991: 1 8 ) Critical theory vie w s sci e n c e as the perfec t ideology b ecause science c laim s t o b e val u e n eutral, that i s o bjective. Science redefines soci a l problems as diseases tha t are c urable by techno logical intervention. This r e d efinition "de politicizes" those social issues (1991:18). Critical theory also investiga t e d the industria l productio n of culture such a s Hollywood's rol e i n mov i e produc tion, and the potentia l for inde p endent thinking to be m anipulat e d for comme rcial and political ends (Marcus a n d Fisch e r 1986:119). C u r r e n t critical medical anthropology i s a collectio n o f persp ecti ves combining w orld econ omy/underde v elopment t heories, cultural critique and critical theory w ith the

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traditional anthropological theme of holism, 38 and the representation of the ernie perspective. While CMA theorists have published mostly macrolevel analyses, Scheper-Hughes (1984:544) calls for greater attention to the private level manifestations of the public sphere. Anthropologists must research the connections between peoples' "private troubles and larger social issues" ( 1984:544) Bibeau ( 1985, 1988) proposes a model of critical analysis that synthesizes micro and macrolevel phenomena (Figure 2). More than synthesis, Bibeau (1988:410) says that CMA must use "thick thinking" to reconstruct a multi-layered reality, then investigate the "interconnectedness between phenomena." Bibeau's model has three dimensions. The first dimension, the politico-economic dimension should be examined by asking the question, "Is economic development organized in order to satisfy the basic needs of the whole population (nutrition, housing, education, health), or is this development for the benefit of a limited group of privileged people?" (Bibeau 1988:412). The second dimension, the socio-cultural, investigates forms of social organization, demographic variables, and cultural variables. The third dimension, the individual and collective dimension, contains the "immediate context in which individual persons and family groups have to adapt and in many cases to survive (Bibeau 1988:412). All three dimensions are interdependent.

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"' > I Ll ..., ...J ...J 0 u "() c .. ...J : 0 > 0 :z: Figure 2. Bibeau's Tridimensional Model o f Analysis political oryanilallon and economic "' c 0 "C c 0 u ,, dependance m ode 1; endogenous mode 1 'co s ocial equity : basic needs; quality o f lif e "" .. .., .., ... .., .. > .., ""-0 '" '" eo o "' "' "' >. .,. c 0 41 \. .. Reactions o f lite p opulation pUJ>Uhr supp ort f o r Usc c uurotry's p o l ldes OPJ>OS It I oro yroups Socl o l oy i c a l c lta r a c t eris lics o f U s e courolry demographic structure uruanizatlo n rate social organization: private, sector, p uullc i a 1 secur lly sys tcm 39 0 u o.ou 0 "0 ::;) .. c "' > "' r-------------------t ___________________________ + > .. u "' '-.. ::;) =>-"0 .., -"' 0 > c u "0 c From: Bibeau 1988. Cultural cltaracterlstlcs o f lite country p revalence o f W estern pallerns cu llur a 1 aulhcntl city m odernization processes SOClO-CULTUI!lll OJH(IlS IOil

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40 Researching the micro, mid, and macrolevels of a phenomena would be the lifetime work of one anthropologist. Bibeau planned his model for multidisciplinary work, intending the framework to accommodate the viewpoints of many disciplines, including anthropologists, epidemiologists, and historians (1985:7). The model is a framework, where social scientists can locate their area of study and compare analyses that may use different explanatory models, such as systems theory or adaptation. As such, Bibeau demonstrates that CMA is one perspective among many that can be used to explain sociocultural phenomena. Because of its focus on inter-relatedness and its ability to accommodate multiple perspectives, Bibeau's model was used as the organizing framework for this exploratory study. Research concentrated on two dimensions of Bibeau's model: the Politico-Economic Dimension and the Socio-Cultural Dimension. These two dimensions were selected for several reasons. Completely documenting explanatory data in all three dimensions would require years of participant observation. The data obtained from this study was intended to be applied to policy formation and legislation affecting midwifery practice and education. Therefore, the most important data to document was the formal midwifery culture: that which is codified i n statutes, rules, regulations, standards, and curricula. This study forms a data base comparing British and American midwifery that can be used in subsequent studies about

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41 individual and collective experiences in midwifery and the relationships between dimensions of analysis. Bibeau's socio-cultural dimension was applied to midwifery education and practice to yield the following variables for investigation: cultural characteristics: history of midwifery cultural support for midwifery midwifery practice midwifery education Sociological characteristics: social movements supporting midwifery social security systems supporting midwifery Bibeau' s politico-economic dimension was applied to the investigatio n of constructions of midwifery to isolate these variables: Political variables: state certification of midwifery state regulation of midwives effect of the Commonwealth on midwifery effect of the European Economic Community on midwifery immigratio n of midwives Economic variables: system of health care equity in the provision of health care midwifery professional organization midwifery unionization influence of nursing on midwifery competition from physicians malpractice liability employment opportunities for midwives salary levels and hours

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42 summary: Chapter 2 Chapter 2 reviewed the history and development of critical medical anthropology. Bibeau's Tridimensional Model of Analysis was introduced as the framework used in designing data collection. Chapter 3, Methodology, explains how data were collected and organized for analysis.

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CHAPTER 3 METHODOLOGY 43 Chapter 3 describes the methods used to collect the qualita tive data generated by this study. The study consisted of k e y informant interviews a n d participant observation experie nces by a single investigator in the United States occurring b etween August 1989 and August 1993 The interviews of British key informant s other British midwives, and participant observatio n in British midwifery education and practice were completed in E ngland and Scotland from July 7 1992 through August 2 1992. Collection of American Data As a certified nurse-midwife with 10 years of practice experience in Florida, the investigator had direct knowledge of the cultural constr uction of A merican nurse-midwifery practice. During the time of the study, the investigator was the Legislative L iaison for the F l orida Chapter of the A merican College of Nurse-Midwives and a m ember of the Colleger s Pol itical and Economic Affairs Committee positions requiring detailed knowledge o f the political regulati o n of

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4t midwifery and the economic issues affecting midwifer) practice. The investigator's work as a midwifery cl inicaJ instructor for the University of Florida Midwifery EducationaJ Program gave her a working knowledge of the cultural characteristics of the American nurse-midwifery educational system. In August 1989, the investigator became the Clinical Coordinator for a precertification program, a program that prepared foreign educated nurse-midwives to take the national certification exam of the American College of Nurse-Midwives. This 6 month educational program was offered at the Tampa General Hospital under the auspices of the Frontier School of Midwifery and Family Nursing of Hyden, Kentucky. Between August 1989 and April 1993, the investigator taught and preceptored 21 foreign educated nurse-midwives as they prepared for American certification. Nineteen of the precertification students were British educated midwives. A journal was used t o record observations from these experiences. In September 1990, in Tampa, The Frontier School of Midwifery hoste d a meeting of precertification teachers from the United States. Representatives included two teachers from Dallas, Texas, two from N e w York City, one from Los Angeles, two from Boston, two from Hyd en, Kentucky, two from Tampa, and two foreign educated nurse-midwives working in the Tampa area. The group discussed the differences in the educational

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45 backgrounds of American and British midwives and methods for enhancing the adaptation of British educated midwives to American practice. The same group minus the practicing midwives met in May 1991 in Minneap olis at the annual convention of the American College of Nurse-Midwives to continue investigating the transition of British educated midwives into the American nurse-midwifery system At this May 1991 convention, the investigato r met with the Ad Hoc Committee on Precertification of the American College of Nurse-Midwives f o r the first time. The Ad Hoc Committee had been formed by two British educated nurse-midwives and a former precertification teacher for the F rontier School of Midwifery. The Ad Hoc Committee contended that British practice was equal and in many ways superior to American midwifery and that most foreign educated midwives s hould have certification reciprocity instead of being forced to undergo a precertification process. T h e investigator was a llowed to observe an hour long meeting between two m embers of the Ad Hoc Committee on Precertification a n d Margaret Brain, the President of the Royal Colleg e of Midwives, who was also attending the convention. The Ad Hoc Committee members were pursuing closer ties with British midwifery organizations to gather regulatory and educational documentation that would support their position that British midwives should enter American practice without precertification. The investigator

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46 continues to work with the Ad Hoc Committee on Precertification. In March of 1992, the investigator attended a workshop sponsored by washington, the D.C. ACNM Certification The workshop Corporation (ACC) in taught how the ACC certification exam is constructed and how to construct midwifery exam questions. The workshop was attended by more than 30 nurse-midwifery educators from across the United States. Three of the educators had special knowledge of British midwifery. One was a British educated midwife who immigrated to the United States for nursing work and became certified for American nurse-midwifery practice. One was an American nurse who traveled to Scotland for midwifery education prior to 1975 and entered American practice through Booth Memorial's precertification program. The last was an American educate d nurse-midwife, who worked as a midwife in England for two years while her husband worked there. All were interviewed to elicit their perceptions of the differences between American and British midwifery education and practice. Collection of British Data To seek data that would be most revealing about the relationships and differences between politico-economic and socio-cultural variables in the British and American constructions of midwifery, site consideration was narrowed to

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47 united Kingdom countries that educated British midwives who have practiced midwifery in the United States. Yates' (1983) description of the Booth Memorial Precertification Program provided the only quantified data about country of education for foreign educated nurse-midwives who sought certification by the American College of Nurse-Midwives prior to 1983. In the Booth sample, 78% of the precertification midwives were educated in England or Scotland. No other country educated more than 5 % of the Booth students (Yates 1983: 15). This predominance of midwifery immigration from the United Kingdom indicates a link between British and American midwifery that has persisted since the Frontier Nursing Service adopted the British midwifery model in 1925. B ecause n o precertification midwives w ere educated in Wales or Northern Ireland, those two regions were not selected for data collection during this study. Wales was also excluded because Welsh is spoken in Wel s h hospitals and many midwifery classes. This would have prevented in depth observation by the investigator, who did not speak Welsh. Key Informant Interview and Participant Observation in the United Kingdom The key informants consisted of British midwives involved in midwifery regulation, professional organization, and midwifery education. Expert informants were used so that the

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48 maximum information possible could be gathered in a short time span (Crane and Angrosino 1974:52, Spradley 1979:47). Key Informant and site Selection At the time of initial site selection, the Royal College of Midwives, The Scottish National Board, and the United Kingdom Central Council were the only British midwifery organizations known to the investigator. The Royal College of Midwives, as the largest professional organization of midwives in the world, is internationally known to practicing midwives. The investigator wrote to these organizations requesting information on British midwifery and requesting their participation in a study of British midwifery. Corresponding members of the Royal College of Midwives, the Scottish National Board, and the United Kingdom Central Council in turn suggested that the English National Board, the Welsh National Board, the British Health Department, and the Association of Radical Midwives be contacted. The correspondence period lasted from April of 1991 through June of 1992. During that time, the governing boards of the organizations contacted selected their own representatives to serve as key informants. The professional and legal organizations that participated in data collection were: The Royal College of Midwives, London Headquarters, London, England The English National Board, London, England

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49 The United Kingdom Central Council, London, England The British Health Department, Elephant and Castle, London The Scottish National Board, Edinburgh, Scotland The Association of Radical Midwives, Hamp shire local chapter, Winchester England Inclusion of these organizations in data collection was critical to forming a data base of the politico-economic variables shaping the construction of British midwifery. In the United Kingdom, midwifery educational programs are closely linked with the hospitals providing clinical sites for the midwifery students. Visiting educational programs and their associated midwifery wards was planned to investigate the socio-cultural variables affecting the con struc tion of British midwifery. The sociocultural variables reflect the day to day implementation of the politico-economic basis for midwifery practice and education and the strategies used to resist or overcome barriers to midwifery practice. The April 1991 l ist of the 68 midwifery educatio n a l programs accredited by the E nglish National Board was obtained, as was the September 1991 lis t of 1 1 Scottish midwifery programs accredited by the Scottish N ational Board. In June of 1991, letters were sent t o the following Britis h midwifery programs requesting that the investigator be allowed to interview key faculty members and observe student educational experiences: Luton College of High e r Education, Luton, Engl and St. Mary s and Harrow College of Nursing, Midwifery, and

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50 Health Sciences, London, England Queen Charlotte's Faculty of Health Care, Southall, England St. Bartholomew's College of Nursing & Midwifery, London Portsmouth Royal Naval and Isle of Wight School of Nursing and Midwifery, Portsmouth, England Dorset and Salisbury College of Midwifery & Nursing, Dorset, England Basingstoke and Winchester College of Midwifery, Winchester, England Newcastle College of Health Studies, Newcastle, England Leeds College of Nursing and Midwifery, Leeds, England York-Scarborough College of Midwifery, York, England Sixteen British educated nurse-midwives residing 1n Florida were interviewed to gather background information about potential educational sites. Educational site selection took into consideration the size of the educational program's faculty and student body, the age of the educational program, and the program's reputation for producing quality midwives. Dorset and Salisbury College, for example, is located in the rural southwest of England. American informants who had attended this school described it as a small school that produced conservative, "by-the-book" midwives. Portsmouth graduates described it as an academically tough program that was committed to research-based practice. Prior to 1979, when British midwifery became united under the United Kingdom central Council, midwifery programs were under the control of the local health boards. The midwifery

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p:roqram t;>f that f'l WI' to th formt" nuriftq proqrlm in of currioull, lftd loell It Wl thlt progrom miqht h\V t"qional va ril tion in tJurrieul a nd elinioll th to ite @6mpliftq firound OUth@t'ft E ng llftd1 th llnd Mul t ampl Wl desired to i ty of dltl by the probability t hfit Wl idioynerltie (Miles 1904:l!H) I with pot@ntill th@ that all Britih midwit@ry proqrlm hld bft joind to or thfit e urrieul hld through th@ ftfitioftl l To mot time tu d y e v e n t ually limited to Engllnd \nd scotland. Fund i ng for midw if@r y t h roug h British N8tional ml\\kinq program & government institutions. All for h a d to b e on by the bo ardm of directors of Four colleges agrQed to serv e aa T h e London Colloge o f Nurming and London The Solent School of Health studies Ports mouth, England King Alfred's College Division of Health Studies, Winchester, E ngland

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52 (These institutions changed names shortly before the time of data collection reflecting the consolidation of midwifery education into British college centres. These sites were known as St. Mary's and Harrow College of Nursing, Midwifery, and Health Sciences, the Portsmouth and Isle of Wight School of Nursing and Midwifery, and the Basingstoke and Winchester College of Midwifery when correspondence was initiated.) Colleges refusing visitation cited upcoming programatic changes that were taxing faculty. The same correspondence process was completed for Scottish midwifery educational programs. Requests visitation were sent to: Argyll and Clyde College of Nursing and Midwifery, Ayrshire and Arran College of Nursing and Midwifery Fife College of Nursing and Midwifery Glasgow Eastern College of Nursing and Midwifery Lanarkshire College of Nursing and Midwifery Lothian College of Nursing and Midwifery, Edinburgh, Scotland for Once again, programatic changes were cited as reasons for denying visitation. Only the Lothian College of Nursing and Midwifery in Edinburgh agreed to be a study site. During data collection in Scotland, the "taxing" programatic changes were explained. All the colleges contacted, with the exception of Lothian, were dropping the connection between nursing and midwifery. Following directives from the Britis h National Health Service and the National Boards, colleges were

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53 instituting three year, non-nursing, midwifery educational programs, called pre-registration programs. Pre-registration education is discussed in Chapter 4, Findings. The study also used participant observation to view British midwives in educational settings, in professional organizations, and in practice. Much of the British research was passive observation (Chenitz and Swanson 1986:55). Midwifery licensing laws and practice regulations prevented active participant observation. Observation days approximated 8 hours: a standard midwifery school day or a standard midwifery shift. Chenitz and Swanson (1986:58) recommend that observations done in institutions that operate 24 hours a day include observations on more than one shift. The study included an evening labor and delivery shift at the Simpson Memorial Pavilion in Edinburgh and an evening labor and delivery shift at St. Mary's Hospital i n Portsmouth. Because the government and academic offices w ere open only weekdays, most interview hours w ere limited to weekdays. The site Schedule Site visits were adjusted to accommodate the dates of the Royal College of Midwives annual general meeting and the availability of midwifery faculty, who were taking the Britis h July and August summer holidays The dates of the site visits were:

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07/06/92 07/07/92 07/08/92 07/09/92 07/10/92 07/14/92 07/15/92 07/16/92 07/17/92 Royal College of Midwives, London, England Winchester-Basingstoke sites, England Winchester-Basingstoke sites, England Portsmouth sites, England Portsmouth sites, England Lothian College of Nursing and Midwifery, Edinburgh, Scotland Simpson Memorial Pavilion Hospital Midwifery, Edinburgh, Scotland Simpson Memorial Pavilion Community Midwifery Service, Edinburgh, Scotland Scottish National Board, Edinburgh, Scotland 07/21/92 Annual General Meeting, Royal College of Midwives, Nottingham, England 07/22/92 Annual General Meeting, Royal College of Midwives, Nottingham, England 07/23/92 Annual General Meeting, Royal College of Midwives, Nottingham, England 07/27/92 Library Royal College of Midwives, London, England United Kingdom Central Council, London 07/28/92 Library Royal College of Midwives, London, England Department of Health, Elephant and Castle, London, England Her Majesty's Stationers Office, London 54 07/29/92 Royal College o f Midwives, Welsh Board, London English National Board, London Foyle's Book Store, London 07/30/92 NorthWest London College, St. Mary's Paddington, London British Key Informant Interviews A total of 102 interviews were completed in the United Kingdom. Four informants were government administrative

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55 midwives. Eleven were elected leaders of professional organizations. Forty-six informants were practicing midwives. Four informants were faculty department heads. Fifteen informants were midwifery tutors. Twenty-two informants were midwifery students. The study informants listed by site are: The Royal College of Midwives: Director of Education Senior Tutor Director of Industrial Relations Membership Manager Professional Officer RCM Welsh National Board King Alfred's College Winchester-Basingstoke: Head of Midwifery Education 3 midwifery tutors 2 community midwives 3 midwifery sisters Royal Hampshire County Hospital 9 midwifery pre-registration students, Basingstoke campus 2 midwifery sisters Basingstoke District Hospital l community midwife Bramley Surgery Solent School of Health Sciences, Portsmouth: Head of Midwifery Education Senior Midwife Teacher 9 post-registration midwifery students 1 midwifery sister (senior clinical tutor) Course Leader, Pre-Registration Midwifery Education Programme Diploma Higher Education Course Leader, Post-Registration Midwifery Education Programme Diploma Higher Education 1 post-registration student from America Lothian College of Nursing and Midwifery: Head of Midwifery Education Department Senior Midwifery Tutor Midwifery Teaching Team-5 tutors Simpson Memorial Pavilion:

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Supervisor of Midwives/Director of Midwifery Charge Midwife Labour Ward 4 staff midwives 1 senior student midwife 2 midwifery sisters 5 community midwives Scottish National Board: Midwifery officer Royal College of Midwives Annual Meeting, Nottingham: 8 midwifery lecturers 17 hospital and community midwives attending as delegates United Kingdom Central Council: Professional Advisor Midwifery Health Department: Senior Nursing Officer, Midwifery NorthWest London College of Nursing and Midwifery: Acting Department Head, Midwifery Education 2 midwifery tutors 3 midwifery students English National Board: Professional Advisor Midwifery 56 Formal key informant interviews done in the UK were allotted a minimum of 1. 5 hours. This allowed time for introductions, tape recorder adjustment, and allowed the informant to speak without becoming fatigued (Chenitz and Swanson 1984:72). Gordon's "inverted funnel" interviewing technique was used to stimulate conversation between the investigator and the key informant (Chenitz and Swanson 1984:74). In the inverted funnel technique, the researcher

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57 begins with a broad question and continues with increasingly specific questions. For example, the researcher would ask, "Tell me about the methods the faculty uses to organize the students clinical rotations during their first year of study." After the informant responded, a more detailed question was asked, such as, "As I hear your clinical divisions, the first year is divided into hospital midwifery and community midwifery. Are there other divisions or subdivisions within those rotas?" The inverted funnel approach is useful when the investigator is exploring, when the investigator hopes for unanticipated responses, and when the investigator attempts to avoid imposing her biases on the informant ( Cheni tz and Swanson 1984:75). Participant observation experiences occurred at each of the educational sites. Although licensing laws prevented the investigator from practicing as a British midwife, the investigator was able to follow midwifery educators, students, and practicing midwives through their usual work. Observational experiences included: observation of King Alfred's College faculty teaching and tour of educational facilities at Winchester campus tour of Royal Hampshire County Hospital midwifery wards, observation of labour ward and neonatal nursery midwives, Winchester, England observation of King Alfred's College faculty meeting and tour of educational facilities at Basingstoke Campus discussion and interviews with King Alfred's College pre-registration midwifery students

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58 tour of Basingstoke District Hospital midwifery wards antenatal clinic staffed by community midwife tour of educational facilities at the Selent School of Health Studies, Midwifery Department, Portsmouth tour of St. Mary's Hospital midwifery wards, observation of labour care and midwifery attended births, Portsmouth observation of midwifery suturing class and participation in teaching the students suturing, Selent School observation of a district faculty meeting that included members from King Alfred's College and the Selent School of Health Studies, held at the Selent School, Portsmouth tour of midwifery educational facilities at the Lothian College of Nursing and Midwifery, Edinburgh, Scotland observation of community midwifery lecture, Lothian College observation and participation in midwifery faculty meeting, Lothian College -observation of labour ward midwifery, midwifery attended births, and postnatal midwifery wards at the Simpson Royal Pavilion, Edinburgh observation of the Simpson Pavilion Community Midwifery Service including staffing meeting and daily visits observation of the Simpson Pavilion midwifery managed antenatal testing ward tour of midwifery educational facilities at the NorthWest London College of Nursing and Midwifery Praed Street campus observation of labour ward midwifery and postnatal care St. Mary's Hospital, Praed Street The longest continuous observational experience occurred during the Annual General Meeting of the Royal College of Midwives held in Nottingham from July 21-24, 1992. The annual meeting is the largest gathering of midwives in the United Kingdom. Attendance allowed the investigator to observe

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59 elected branch delegates and governors debate 19 issues related to current midwifery practice, to observe British maternity care products at vendor stalls, and to observe midwifery continuing education offerings. The investigator also discussed midwifery informally with branch delegates during meals and tea. Field notes from the key informant interviews and observational experiences were written on 5-1/2 x 8-1/2 lined pages. An average of two hours was spent at the conclusion of each day for review, completion, and preceding of field notes. Continual note review and preceding during fieldwork enabled the researcher to critique perspective and instrumentation and showed any gaps in data collection before leaving the site (Miles and Huberman 1984:63, Ragguci 1972:488, Chenitz and Swanson 1986:57). Contact summary sheets were completed at the end of each day (Sample Contact Summary Sheet, Appendix 1). Contact summary sheets allowed the researcher to see if the desired information was being obtained, what main themes were being discovered, and gave direction for future contacts (Miles and Huberman 1984:50). One to two days each week were spent in reviewing notes and memo writing (Chenitz and Swanson 1986: 59) Study sites were entered into a log book and numbered in chronological sequence. Each informant and any setting variations within a site were identified in the logbook using a letter designation. Site and informant numbers were used to

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60 cross-reference each field note page. All documents obtained were given numeric codes in a separate document log. The document log was organized by site of origin using the same site number that was used in the site log. Documents that were essential to a particular site were filed with other data from that site. Documents with broad applicability were photocopied and filed under pertinent codes. Original field note pages, transcriptions of tape recordings, and documents were placed in files by site. Literature related to British Midwifery is difficult to obtain in the United States. The Library of the Royal College of Midwives (RCM), at the RCM's London headquarters, was a major source of British midwifery literature. Special permission was obtained from the RCM Board of Directors to use the library facilities. Literature review was done at the Royal College of Midwives on July 6, and July 27 through August 2, 1992. The Royal College Library has the largest collection of literature on midwifery in the world. The Library has two full-time librarians and photocopy machines available to any midwifery scholar permitted access by the Board of Directors. The newly published catalogue, Books for Midwives, (Sweet 1992), was also a source of midwifery literature. Published by Haigh and Hochland with the cooperation of the Royal College of Midwives, the catalogue lists all midwifery textbooks, books related to the practice of midwifery, and historical and

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61 economic texts related to midwifery or the British Health Service. Over 1, 000 titles are stocked. Key sources were purchased at the Haigh and Hochland display at the annual general meeting of the RCM on July 22, in Nottingham. Pamphlets, booklets, and sample journals related to midwifery were purchased and collected at the Annual General Meeting of the Royal College of Midwives in Nottingham from July 21 through July 24, 1992 from the vendor and government displays. British midwifery texts were also purchased at the medical book store of the University of Edinburgh and Foyles, London. Field notes and pertinent parts of documents were photocopied before coding. Coding was done by underlining key phrases on the photocopies and writing the appropriate code in the left hand margin of the page. The prefield code list (Appendix 2) was expanded during coding to yield a postfield code list (Appendix 3) that included unanticipated domains and domains of British midwifery that are not found in American midwifery, such as neonatal nursery midwifery. Once pages were coded, the pages were photocopied once for each code written on the page. Pages were then sorted and filed in folders for each code. The codes were sorted and collapsed into the study variable categories (Postfield Codes by Study Variables, Appendix 4) Documents that were essential to a particular site were filed with other material from that site. Documents with broad

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62 applicability were cross-referenced on contact summary sheets and filed in document files. Validity Validity in qualitative research does not involve accuracy in measurement. "Validity in qualitative research refers to gaining knowledge and understanding of the true nature, essence, meanings, attributes, and characteristics of a particular phenomena under study" (Leininger 1985:68). Validity was tested in several ways. First, the site research goals and the prefield code list were reviewed for face and content validity by six British educated nurse-midwives working in Florida, three American nurse-midwives involved in nurse-midwifery education, and the five membe r doctoral researc h committee (Brink 191983: 126-132). Their comments about wording and topic areas were incorporated into the instruments. Validity was enhanced through the process of triangulation. Triangulation uses multiple sources of data to corroborate each other (Miles and Huberman 1984:235). This study assembled data about British midwifery from British educated nurse-midwives residing in the US, American nursemidwives educated in the UK, British midwives, American precertif ication instructors, and American and British midwifery literature, and participant observation experience.

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63 The number of interview repetitions and the use of participant observation enhanced reliability and validity (Brink 1989: 132). Increased validity avoids problems with two factors inherent in cross-national research (1) the tendency to make one's country appear better compared to others and (2) value judgements related to social policy (Nowick 1977:5,6). For example, belief in the British National Health Service as an efficient method of universal health care could bias a researcher toward ignoring the problems of British midwives. Limitations The data include more information on the ideal culture of midwifery than on the manifest culture. Individual sites and districts can be expected to have divergences from the ideal culture. For example, the English National Board recommends that each student midwife suture three episiotomies before graduation. In application, few students complete this requirement. Even large midwifery services such as that of St. Mary's Hospital used by the Portsmouth Program perform so few episiotomies, many students do not have the opportunity to observe an episiotomy repair much less complete one before program graduation. Key informants revealed differences between ideal and manifest cultures. Data obtained from informants have varying degrees of reliability. Informants may follow a manifest culture while

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64 misunderstanding the rules of the ideal culture. The memories of informants may be unreliable or informants may boast to make themselves or their practices seem more important. Whenever possible, key informants who were part of the ideal culture were used. Using key informants also decreased the likelihood of inflated accounts because key informants had cultural status that did not need inflating. Using numerous key informants, varied sites, and supporting documents increased confidence in the reliability of sources when testimonies agreed. Midwifery in the United Kingdom has undergone rapid changes since 1970. The data from this study could not be applied to programs prior to 1990. The initiation of preregistration as the entry l evel for midwifery study will reshape British midwifery again. These data will have limited applicability once the majority of British midwifery program graduates are not also registered nurses. Data Analysis Data analysis was accomplished using coding, categorization, and memo writing techniques from Glaser and Strauss's grounded theory method (Chenitz and Swanson 1984, Miles and Huberman 1984, Brink and Wood 1989, and Stern 1985). Interview transcriptions, field notes, and photocopies of relevant parts of documents were reviewed for coding. Field

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65 notes and pertinent parts of documents were photocopied before coding. Coding was done by underlining key phrases on the photocopies and writing the appropriate code in the left margin of the page (Chenitz and Swanson 1984:103-108). Memo writing, also done in the left margin, was used to document unfolding ideas and analysis of concepts. Words were used as codes in place of numbers. Words helped to retain the context during qualitative analysis and to keep the researcher focused on the research questions (Miles and Huberman 1984:54-56). When pages were coded, the pages were photocopied once for each code written on the page. Copies were then sorted and filed by code. The codes were sorted and collapsed into the study variable categories (Postfield Codes by Study Variables, Appendix 4) summary: Chapter 3 Chapter 3, Methods, summarized the processes of site and informant selection. Chapter 3 listed the study sites, types of informants, and study experiences. Validity of the data and the initial phases of data organization and analysis were described in Chapter 3. Chapter 4, the Ethnographic Context of Midwifery, describes the historical and socio-cultural matrices of British and American midwifery, then gives detailed descriptions of the study sites.

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66 CHAPTER 4 ETHNOGRAPHIC CONTEXT OF MIDWIFERY Chapter 4 begins with descriptions of the historical and sociocultural variables that form the underlying context for the practice of midwifery, then continues with a description of the study sites. Descriptions within Chapter 4 provide background information about Bibeau' s socio-cultural dimension applied to midwifery. The History of M i dw ifery in The United Kingdom and the United States Two key factors differentiate the history of British midwifery from the history of American nurse-midwifery. First, the recognition and organization of British midwifery preceded that of organized nursing. Second, British midwives were never replaced by physicians to the extent that American midwives were. British records from the middle 1400s contain cases of Bishops' Court proceedings that censored midwives believed to be practicing witchcraft (Donnison 1977:4). The first formal arrangement for controlling midwifery carne from the 1512 Tudor government (Donnison 1977:5). Licensing of midwives during the

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67 Tudor era was delegated to the ecclesiastical courts. Midwives swore to the Bishop that they would assist the poor as well as the rich, refrain from abortive procedures, incantations, the substitution of children, or false attribution of paternity. British midwifery grew as government involvement in health and welfare grew. Watkin (1975:1) credits the Poor Law Amendment Act of 1834 as being the starting point of current British health and welfare. Also known as the Victorian Poor Law, it embodied a coherent set of beliefs about the nature of society and the nature of man ... the principles of 1984 have a continued relevance ... most of our existing arrangements in the field of health and welfare have their roots either in the Victorian Pool Law, or in reaction against it (Waktin 1975:1). The Poor Law acknowledged that pauperism caused illness. Treating pauperism would relieve suffering and make people work eligible. Conversely, sickness was the chief cause of pauperism. If sickness were treated, pauperism would be reduced. The societal responsibility to care for the impoverished supported midwifery. Under the Poor Law, lying-in wards were established for poor women's births. Instead of helping women, the wards became centers of puerperal sepsis. When obstetricians and general practitioners refused to attend women who could not pay for their services, a system of out-door (domiciliary) attendance by midwives was established in many areas. A report to the Registrar General in 1876 estimated that if this practice were instituted nationwide,

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68 maternal deaths related to childbirth would drop by 65% (Dennison 1977:93). Although France and Prussia had national education and regulation schemes for midwives by 1840 (Dennison 1977:53), England resisted licensing midwives through the end of the 19th century. Dennison (1977:123) attributes this to fears that if midwifery were licensed, nursing would soon follow. Florence Nightingale, in attempting to professionalize nursing, sought to have midwifery included with nursing, so that the numbers of practitioners to be 1 icensed would be stronger (Dennison 1977:123). The professionalization of nursing and midwifery made them occupations sui table for respectable women (Webb 1980:404). British women were denied entrance to medical schools during the 1800s (Webb 1980:404). Nursing and midwifery were career alternatives. The first British Midwives' Act was passed by Parliament in 1902 giving midwives legally independent practice. Midwifery was included as an independent profession in the British National Health Service formed in 1944. During the Victorian era, one-quarter of the population of the earth lived in British colonies (Haigh 1985:317). British colonial administrations and missionaries exposed the colonials to the British construction of midwifery. Many former British colonies maintained midwifery and biomedical schools following the British models.

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Unlike British almost disappeared midwifery, midwifery in the Unites States. 69 as an occupation During the 19th century American physicians added midwifery into their practice of medicine. They promoted their use of midwifery combined with medical instrumentation by claiming increased safety through science (Wertz and Wertz 1979:46-47). Many midwives were immigrants with variable fluency in English making it easy for formally-educated physicians to wage antimidwifery campaigns (Ehrenreich and English 1973:34). American physicians competed for midwifery patients because midwifery provided a stable income and poor midwifery patients could provide learning experiences for medical students (Wertz and Wertz 1979:48, Ehrenreich and Englis h 1973:33-34). American midwifery received a stay of execution when Mary Breckinridge brought British midwives to staff the Frontier Nursing Service of Hyd en, Kentucky in 1925 (Dammann 1982:17}. Breckinridge had seen the work of British and French midwives during World War I relief projects and envisioned a corps of midwives providing health service to rural Kentucky. After studying midwifery in England, she imported the British constru ction of midwifery to the mountains of Kentucky (Breckinridge 1952:122-157). Between 1930 and 1960, the profession of nurse-midwifery grew slowly. Nurse-midwives were used to staff areas of critical health shortages: inner city areas, such as New York City, and rural areas such as the Mississippi Delta. American nurse-midwifery received a boost

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70 during the second wave of American feminism as women were moved to take control of their health. Nurse-midwifery, however, continued to experience its largest growth in areas of poverty where physicians would not work. When Breckinridge revitalized American midwifery, she needed a recognized role to gain people's trust. She chose nursing, calling her health center the Frontier Nursing Service 1 not the Frontier Midwifery Service. In 1928 she helped form the American Association of Nurse-Midwives (Breckinridge 1952:305). In most states, nurse-midwifery has been tied to nursing since the 1940s. The return of professional midwifery in the United States was strengthened by the 1932 formation of the Lobenstine Midwifery School of the Maternity Center Association (MCA) in New York City. The MCA worked to combine the skills of American obstetric nurses with the role of the European midwife (Varney 1987 :25). Because there was no American midwfery educational experience 1 the MCA use d "the British curriculum as a guide (Maternity Center Association:1955:22). This was the first professional school of nurse-midwifery in the United States. O nce again, midwifery was aligned with nursing.

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71 Cultural Variables Affecting Midwifery Practice and Education Age of Culture The United Kingdom has four strong national traditions: the English, the Welsh, the Scottish, and the Irish. Each has oral traditions and customs that precede written history. In London, Winchester, Portsmouth, and Edinburgh many of the buildings I lodged in or worked in were more than 100 years old. Midwives at the new health sciences schools in Winchester, Portsmouth, and Lothian were quick to point out that their schools were "purpose-built." In a country where land was limited and the economy was depressed, to be purposebuilt was a treasured exception. Many corner mailboxes were marked "VR" for Victoria Regis indicating placement during Queen Victoria's rule. Bridal shops in Scotland had window displays of the groom and attendants dressed in traditional kilts instead of tuxedos. In 1992, 81.5% of the population of the United Kingdom was English, 9.6% was Scottish, 2.4% was Irish, 1.9% was Welsh, and other immigrant groups comprised 3.8% of the population (Famighetti 1994:819,820). The United States, once a British colonial frontier, still has areas of population growth and new building. Native Americans settled the North American continent prehistorically. The largest population growth followed colonization by the Spanish, French, and English beginning in

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72 the early 1500s. Few American buildings predate the colonial revolution from Britain that started in 1776. American popular culture and marketing sell fashion rather than tradition. Midwifery, an ancient profession, may be more accepted in the United Kingdom where people move past the relics of the ancients every day. Religion Anglicanism was the state religion of England. It was the religion of its public schools and public ceremonies. The Presbyterian Church was the state church of Scotland. So strong were state ties to religion, that the Queen changed religion as s h e crossed borders between England and Scotland. The British way of doing things extends deeply into daily living. The opening ceremony of the 1992 Annual General Meeting of the Royal College of Midwives was an Anglican Prayer Service that included traditional references to a male God and singing Anglican hymns. This was a sharp contrast to the opening ceremonies of the annual meetings of the American College of Nurse-Midwives. American College of Nurse-Midwives ceremonies were opened with prayers that contained general wording acceptable to many religions, reflecting American religious tolerance. In ceremonial prayers God was represented as gender neutral and sometimes female. The prayers were followed by a secular

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73 speech about women's health care. Religious tolerance was a founding principle of the American republic. Religious tolerance was a reaction against religious persecution in England (Lerner 1987:13). The result of American religious tolerance wrote Lerner (1987:705) was an American religious tradition which is at once deeply individualist, anti-authoritarian, concerned with sin and salvation, yet secular and rationalist in its life goals. Class and Status The nations of the United Kingdom have hereditary noble families. With global trade and industrialization, wealthy farnil ies entered the highes t social classes. The British categorize workers into professionals, craftsmen, tradesmen, and domestics. The British class system is rigid and formalized. Social classes are explicit and are used in the budgeting and planning of Britis h social programs. Thomas (1985:282) wrote that British adherence to tradition sterns from the "horrors of the French revolution" that overthrew churc h and aristocratic control. Feeling vulnerable to reaction against church and aristocratic control, the British entered an era of conformity and romanticism (Thomas 1985:283). The United States was founded as a classless society. Lerner (1987:467) described four American principles borrowed from other European societies: "hatred of privilege, the

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74 religion of equality, open channels of opportunity, and rewards based on achievement and not on birth or rank." Lerner (1987:469) further wrote: The meaning of "classless" in American usage is different from the European. It does not, in the American ideal, mean an absence of rank, class power, or prestige. More exactly it means a class system that is casteless and therefore characterized by great mobility and interpenetration between classes. Technology Although the number of telephones and televisions per capita was comparable between the United Kingdom and the Unite d States in 1992 (Table 1), the British used less home technology, such as dishwashers, than Americans did. The highe r cost of technology in Britain and lower British salaries were two causes for the limited use of home technology. In 1992, the British per capita gross domestic product amounted to $15,900 (Famighetti 1993:819). In traveling through the U nited Kingdom, I did not see microwaves and other countertop appliances in kitchens as were seen in American homes. The bed and breakfast establishments and families that I stayed with hung laundry outdoors to save on the electricity that a dryer would use. Many homes were one to two hundred years old. They lacked the electrical wiring to support the number of appliance typically found in American rooms. For example, in several of my rooms, I was unable to

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75 Table 1. The 1992 Demographics of the United Kingdom and the united states. Square Miles Population Population Density Government Defense % of GNP Per capita GOP Miles of Railroads TV setsjperson Telephonesjperson Female life expectancy UNITED KINGDOM 94,226 57,797,800 613/square mile constitutional monarchy 4.3% $15,900 23,518 1/3 1/1.9 at birth 79 years Births/1,000 14 Infant mortality/1,000 births 8 Physicians 1/611 people Compulsory Education 15 years Literacy rate 99% UNITED STATES 3,618,770 256,561,239 70/square mile federal republic 5.7% $22,470 144,000 79 1/404 16 1/1.3 1 /1.9 years 14 10 people years 97% From: The World Almanac and Book of Facts 1994, Famighetti, 1993, Funk and Wagnalls Corporation, Mahwah, New Jersey.

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76 use my lap top computer. The rooms had only one electrical plug and that plug served the single lamp for the room. The cost of cars and petrol and the lack of parking in ancient cities pushed Britains into a well-integrated public transportation system. The United Kingdom had approximately 1 mile of railroad track for every 4 square miles (Table 1). Lode (1991:168) wrote about the difficulty in establishing a rural midwifery service in Powys, Wales, in the 1970s, when several of the midwives did not know how to drive cars. The libraries at the Royal College of Midwives, st. Alfred's College in Winchester, and the Lothian School of Midwifery each had only one photocopy machine. Photocopying was seen as too expensive to be used by students to the degree that it is in the United States. None of the hospitals visited during the study had air conditioning. During the days when the heat approached 80 degrees Fahrenheit, the hospital wards opened their windows. These portals for insects would have been considered unsanitary in the United States. At the annual general meeting of the Royal College of Midwives, many midwives carried folding paper fans to cool themselves. A sales representative from the Corometrics Company, a manufacturer of electronic fetal monitors told me during the annual general meeting of the Royal College of Midwives that the British would not buy monitors like the Americans would. He had been to a corporate meeting in the United States and was astonished at the number of hospitals using a central

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77 monitoring system (one that displays the monitor pattern from 5-12 rooms in one central location) The price of the equipment and British comfort with intermittent auscultation of the fetal heart tones were the reasons given by the sales representative for Britain's lesser use of technology. The only central monitor system he knew of in the south of England, was one located in the affluent university town of Chester. The hospital in Chester had a central monitor display in the midwive's station, the doctor' s sleep room, and the tea room. In England, midwives took the time and maintain the skill to lis ten to fetal heart rates with Pinnard stethoscopes, wooden or plastic bell-shaped instruments approximately 8 inches long. I observed staff midwives us1ng Pinnards in Winchester, Basingstoke, and the Royal Infirmary in Edinburgh. The antepartum ward sister at the Royal Infirmary explained that Pinnards were less intrusive to the mother (as opposed to wearing the two elastic belts of continuous fetal monitoring) and less costly than electronic monitoring. Technology surrounded Americans. Except 1n large urban areas, public transportation was generally underbuil t The United States had only 1 mile of railroad track for every 25 square miles (Table 1). It was unusual to find American housing or buildings more than 100 years old. Homes and workplaces generally had central heat and aircondi tioning. Many labor saving machines were available from dishwashers to

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78 pasta makers. Americans had higher incomes to spend on home technology. The American per capita gross domestic product was $22,470 in 1992. Boorstin (1973:157, 161, 163) described the United States as communities of consumption where holidays such as Christmas and Mother's Day had become rituals of consumption. The abundance of American technology extended into health care. Temperatures, blood pressures, and labor contractions could all be monitored mechanically. In American hospital settings, it was rare to see those measurements done manually. American nurse-midwives did know how to use Pinard or De Lee fetal stethoscopes. However, many routinely used electronic stethoscopes for their speed. Electronic stethoscopes broadcasted the fetal heart tones enabling the mother and family to hear. Nurse-midwives thought that this reassured the mother and increased her prenatal bonding with the fetus. Physicians did not trust the accuracy of nonelectronic stethoscopes. Midwives were encouraged to used electronic fetal monitoring that generated a printed record of the fetal heart rate. Pace of Life The pace of British life wa s slower tha n urban American life. I never saw any 24 hour film developers or drivethrough, fast-food restaurants. Although McDonald's and Burger

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79 King could be found in cities they were not patronized to the degree they were in the United States. One day in London, during the last week of my stay, I was walking toward a Burger King and decided to see if English Burger King food tasted the same as American Burger King food. A Whopper with cheese cost 1 pound 99, small onion rings cost 1 pound 9, and a small diet coke cost 74 pence. The exchange rate at the time was 1.98, making the Burger King meal cost me $8.04 American. Price put fast-food meals into the luxury category for many Britains. More often, meals out were taken at local pubs that served British food for noon and evening meals. Most pubs also included a family room where children can dine with parents and fenced, outdoor playgrounds for the children. Even in hospitals, the pac e of work could be interrupted. In Winchester, Basingstoke, and Edinburgh, I was on the maternity wards at 4 p.m. At 4 p.m., the student midwives were sent to prepare tea and toast or snacks in the break room. Unless a woman were giving birth, a midwife was sent room to room. She knocked on the door, poked her head in the room, and said something to the midwife in the room like, "Jane, Mrs. Jones in room 2 is fully (dilated) and needs you." Each ward had similar phrase to signal that the tea was ready. Nothing, except a birth or an emergency, could interrupt the tea break. In the United States, nursing staffing was based to provide minimum coverage for the average needs of the patients on a ward. This was the most cost effective staffing. The

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80 safest staffing would have been to have sufficient nurses on duty to comfortably handle problems or emergencies. In the 1970s, hospitals staffed for safety. As the cost of health care rose during the 1980s, the ratio of patients to nurses increased. Hospitals staffed for cost effectiveness. In units where demand fluctuated, s uch as emergency rooms and labor wards, nurses had t o prioritize routine request s s u c h as reques t s for snacks to safely handle problems. In these units, nurses and midwives may not h ave had time for res t and meal breaks. British midwives interviewed during the study found the pace of American work "uncivilized." During a midwifery staff meeting at one American hospital, following the collapse of a stude n t who hadn' t eaten i n 12 hours I requested that the clinical preceptors remember to give the students rest and meal breaks during t h e i r 14 hour shifts Staff m embers argu e d that t h e students had to learn t o endure the long hours. The staff midw ives explained that they were afraid to leav e the ward during their 14 hour shifts, fearing that a resident physician might order or apply some technological intervention during the midwive' s absence. Popular Support of Midwifery While slowed in London traffic o n e day, I heard a radio drama that contained a h ome birth scene dramatizing the Britis h way of giving birth. As the woman recognized her

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81 labor, she had her husband call the district midwife. While waiting for the midwife, the husband also summoned the neighbor and his mother-in-law. All were anxious to see the new baby, yet no one questioned the wisdom of a home birth or the capability of the midwife to manage the birth. Upon arrival, the midwife introduced herself cheerfully to the household, asked to have the family wait in the kitchen, and calmly examined the laboring woman. She reassured the woman that the labor was progressing well, then, returned to the kitchen to inform the household how long she thought they might wait for the baby. She telephoned the district hospital to let them know she was attending a labor. When the father seemed at a loss for what to do, the midwife set him to preparing tea. My mind contrasted this radio scene with American television portrayals of birth where women are grunting and grabbing their abdomens, then scrambling to get to the safety of the hospital. Personal Safety England has suffered from Irish Republican Army terrorist attacks. Signs of terrorist threats were everpresent in urban England. In Great Britain in 1992, my luggage was thoroughly searched before being accepted onto the airplane. I was questioned about carrying gifts or packages for other people. On July 27th, while taking the subway home, the platform

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82 speaker system announced, "The King's Cross Station has been closed due to security reasons. Please change trains at other stations. I asked a nearby commuter what security concerns might be. He looked at me incredulously and said, Bomb threats. 'appens all the time." Thirty minutes later while awaiting another connecting train, the speaker system announced that King' s Cross Station had been reopened, "Security concerns are cleared." Traveling home the evening of July 31st, King's Cross Station was once again closed for security reasons. Date Notation The British wrote dates differently than Americans. In the United Kingdom, the third day of October, 1994, was noted as 3/10/94. In the United States, the day and month were reversed. The same date was written 10/3/94. This transposition of date and month forms a special problem for midwifery. One midwifery task was the calculation of expected date of birth (also called expected date of confinement, expected date of deli very) This was done most accurately using Naegle's rule: lst date of last menstrual period, minus three months, plus seven days. Using the British date of 3/10/94, the expected date of birth would have been 12/17/93. With the American notation 10/3/94, the expected date of birth would have been 7/10/94. Incorrect calculation of expected

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83 dates of birth could lead to unnecessary sonographic testing and unnecessary hormonal inductions of labor. Midwives changing from British to American practice learned to change date notation methods. The different styles of noting dates became a problem when British midwives took American midwifery exams. Under stress, they often reverted to their primary method of writing dates. This caused a miscalculation of the expected date of birth and an exam failure. Language Small differences in language use occurred between British and American midwifery. These differences deserved mention not because they exerted a strong effect on the construction of midwifery, but because they add stress when midwives attempted to move between the two countries. British midwives coming to the United States had to change language and spelling to have their written notes understood. Their use of British phrases may not have been understood by readers grading the American national certification, thereby lowering the points accumulated toward a passing score. The words used by British and American midwives were all English words, but their different applications were confusing. For example, the British "The newborn cots are up the lift on the first floor, 11 means in American English, "Take the elevator to the nursery on the second floor. 11 On immediate

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84 hearing, the American English speaker understands all the words, then has to replay the sentence and translate its words into American English for full understanding. One afternoon in Edinburgh, the Simpson midwives sent me from a room on a ward errand. I nodded in agreement and walked out the door of the room. Just outside the door, I realized I d idn' t know what the midwives had asked. I replayed the phrase in my mind. "Could you go for a tin in the sluice room?" Not wanting to seem the American dolt, I was determined to figure this out for myself, but what was a sluice room? Since we were preparing to bathe a baby, I assumed a tin was a wash basin. But, in my mind, a sluice was a chute of fast moving water used by goldminers to separate gold from streambed rocks. "Fast running water, I thought. "Hoppers (large porcelain pedestalled sinks used for washing bedpans) have fast runn1ng water." I had seen a hopper in the dirty utility room. Walking past the front desk I saw the hopper in the utility room. I paused in front of the utility room doorway. A midwife at the front desk looked up from her paperwork. "Sluice room?" I asked hopefully. She nodded, "Aye." During the research period in the United Kingdom I was 5 months pregnant. Like all pregnant women my bladder capacity was limited. On my first morning at the Royal College of Midwives, I stopped at the receptionist' s desk and asked for the restroom. Pausing, the receptionist gave me a puzzled look and replied, "What, need a rest, dearie? Need to put your feet

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85 up a bit? Well, there's the library ... I tried again, saying, "No, I mean the bathroom." This was followed by an even more puzzled look from the receptionist as I searched my memory for what I had heard British midwives calling a restroom. Remembering, I said, "I mean the ladies', the 'loo." This brought instant recognition from the receptionist. "Oh, yes," she said, "Just before Mrs. Tichner's office on the landing." Common English words were used to name different objects in the United Kingdom and the United States. While doing home visits with a community midwife in Edinburgh, we stopped at a low income high rise apartment building to do a postpartum exam. The apartment and furnishings were unrepaired and worn but as clean as a mop and rag could make them. The new baby was the third child of the family, having a 6 year old sister and a 5 year old brother. The children were hom e from school for the summer break. Their cousins, 5 year old and 4 year old sisters were visiting for the day. I put my purse down n ext to the living room sofa as the community midwife and I sat to talk with the family about the mother and baby' s health. We examine d the mother and baby in the mother's bedroom using her bed as a n exam table. The children followed u s like a line of ducklings. As we went to leave, I asked one of the children, "Would you please hand me my purse?" The children doubled over in giggles. Finally, the oldest girl said, "Nay, tha's yer bag," in a thick Scottish accent. The community midwife, English by

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86 birth, said, "We call them handbags." "Oh, 11 I answered exaggerating facial surprise for the children, "Where I come from, we call them purses. 11 Another round of giggles followed. The oldest girl spoke again, "Nay, a purse is wha' a man puts his money in." Exaggerating again, I shook my head "no" and countered, "Where I come from in America, a man puts his money in a wallet." Another round of preschool giggles, followed by another correction by the 6 year old, "Nay, a wallet is a woman s 1 Suddenly, the father, who had been silently watching television rose to his feet and said with disgust, "Does n o matter wha' ye call it. There's na' work and na' money to put in it." In describing these scenes to British midwives working in the United States, they told of a period after arrival, when the words were known, but to understand them was tiring work. One British educated midwife related this story about her early work on an American labor and delivery unit. She entered a room to serve a postpartum meal. As s h e set-up the meal tray, the woman asked for a napkin. T h e midwife went to the supply closet and brought her a perineal pad, a sanitary napkin. The woman was asking for a table napkin. In the midwife' s postpartum eating. experience, a napkin vaginal bleeding; a was used for catching serviette was used while Many British uses of English could be understood from surrounding context. For example, I had never heard or read

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87 the term "rota" before study in the United Kingdom. It was immediately obvious from the conversation about midwifery work hours, that "rota" was used instead of schedule and that it most likely came from rotation, as changes in shift duty are called in the United Kingdom and the United States. Medical and anatomical words being concrete instead of abstract tended to have the same meanings on both sides of the Atlantic. There were exceptions to that rule. While in England, the midwives described the use of a prostaglandin pessary to ripen the uterine cervix before inductions of labor. In the United States, a pessary was a piece of semi-rigid, molded plastic that fitted within the pelvic bones to provide support for the uterus when its suspending muscles were prolapsed. Pessaries were use d b efore the popularity of surgery to repair pelvic musculature. They continue to be used infrequently for women who could not endure pelvic surgery. Pessaries were being used in family planning research. Several models of pessaries saturated with slow r eleasing progestins to prevent pregnancy were under investigation. As the British midwives explained the use of prostaglandin pessaries to me, I imagined a disposable silastic pessary saturated with slow-releasing hormones. It was a full year later in the United States before another British midwife explained to me that pessary was the word the British use for a vaginal suppository. The British

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88 Table 2. Common British Midwifery Terms and American Analogues. BRITISH antenatal cot resident cervical sweep pessary theatre liquor cardiotocograph sister teat nappy cot death siting a line sticky eye take a swab parentcraft theatre clothes surgery bleep barrier care booking rota creche fully winding the baby Vontouse spend a penny AMERICAN antepartum crib registrar stripping membranes vaginal suppository surgical suite, operating room amniotic fluid electronic fetal monitoring no exact analogue, a senior midwife or nurse pacifier diaper Sudden Infant Death Syndrome placing an intravenous catheter conjunctivitis do a culture childbirth/parenting preparation scrubs, scrub clothes doctor's office beeper, pager isolation care first prenatal visit schedule (rotation) isolette incubator completely dilated burping the baby vacuum extractor urinate

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Table 3. Spelling variations in British and American Midwifery Terms. British labour paediatrics foetal centre primiparae multiparae dysmenorrhoea gonorrhoea practise oestrogen anaesthetics American labor pediatrics fetal center primiparas multiparas dysmenorrhea gonorrhea practice estrogen anesthetics 89 prostaglandin pessary was the same as an American prostaglandin suppository. Table 2 and Table 3 list language and spelling variations in English use encountered during the study. Social Movements Supporting Midwifery National Childbirth Trust The British had s everal organizations supportive of midwifery that were unparalled in the United States. Towler and Bramall (1986: 250) wrote that by the early 1960s many British health authorities were providing mothercraft and relaxation classes. This was followed by the formation of The National Childbirth Trust (NCT) an organization dedicated to

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90 childbirth and parentcraft education. Because m idwives taught most British parentcraft classes, the NCT indirectly supported midwifery. Like the American Society for Prophylaxis in Labor (ASPO-Lamaze) and the International Childbirth Education Association (ICEA) in the United States, the NCT certified lay childbirth educators, researched childbirth preparation methods, and distributed childbirth and parenting literature. Unlike the ASPO and the ICEA, the NCT had national trust status. Trust status gave the organization the stamp of government approval. Trust status was a partnership between the private organization and the government. The trust did not pay taxes and received national funding when needed. To have the National Childbirth Trus t support midwifery effectively gave British midwifery the stamp of government approval. Iolanthe Trust T h e Iolanthe Trust was formed in 1983 when the Central Midwives Board located in the Iolanthe House was dissolved. The money from the sale of the house was put into "advancing and promoting training, education, professional development and research in the field of midwifery, and disseminating the useful results of s u c h research (Iolanth Trust Annual Report 1991:1} The A. C.N.M. Foundation, Inc., was incorporated separately from the American College of Nurse-Midwives to

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91 support nurse-midwifery education and p ublic recognition. The Foundation gave six scholarships each year and sponsored special projects such as a video depicting American nurse midwifery but had nowhere near t h e status of a national trust. Green Movements A s enior lecturer a t the Royal College of Midwives credited the Europea n Green Movement as supporting midwifery. The movement was best known for buying meadows to protect and sponsoring coppicing projects. The Greens promoted pla net stewardship. This thinking was extended into avoiding unnecessary med ical treatm ents and supporting natural living, such as "natural childbirth." T h e Green's political publicity kept their p olitical agenda for a low technology lifestyle i n the public mind. Rooks (1986:19) included the American natural foods moveme n t of the 1960' s as a cultural movement that supported the growth of American nurse-midwifery. Great Britain had a strong vegetarian movement that was m o r e v isible t h a n American vegetarian groups. Adds for organic and vegetarian foods we r e seen regularly on British prime time television. The menu of each restaurant or pub visited durin g the study contained a vegetarian selection section with 3 4 meal choices. Peopl e w h o took measures to control their own health, s uch as following a vegetarian diet, were supportive of health care

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92 philosophies, such as midwifery, that gave control to the consumer. Complimentary Therapies The annual general meeting of the Royal College of Midwives included an educational program on complimentary therapies. Helen Spivey, Registered Midwife, defined complimentary therapies as "natural products, like Green products, that work Complimentary therapies by increasing included aroma general therapy, health." massage, acupuncture, moxibustion, and hypnotism. To add a complimentary therapy into practice, the English National Board required that the midwife be certified in the therapy. The English National Board did not consider water birth to be a complimentary therapy. It was considered a method of birth within the scope of midwifery practice. Spivey claimed there was increased demand for British midwives to combine complimentary therapies with midwifery techniques. Because British midwives tended to use complimentary therapies more than other medical professionals, the professional organizations of complimentary therapists were supportive of midwifery, producing an organizational symbiosis within British health movements. American nurse-midwifery had no organized requirements for the addition of complementary therapies. Many nurse-

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93 midwives studied herbal remedies, hypnosis, and oriental therapies such as accupressure and moxibustion. However, the 1994 American College of Nurse-Midwives national convention program contained 60 continuing education lectures or workshops. Fifty-nine of the 60 sessions presented midwifery or biomedical topics, including the use of vacuum extractors for vaginal births and the use of colposcopy. Only one session, titled "Enhancing the Birthing Experience: Healing Touch," presented a complimentary therapy. Consumerism The British consumerism movement of the 1 980s was viewed by some as a forc e that increased market competition within the National Health Service, thereby increasing economic efficiency. Initially, the British were assigned to the services of a health district. Using the consumerism movement, the National Health Service has allowed people to choose services outside of their districts. This forced the districts to compete with each other by offering more hospitable or more cost-effective services. Wolmouth (1992: 29) s aw consumerism as a method of "overturning the inherent paternalism in the health service." Consumerism was a recurrent theme in my talks with British midwives. The senior tutor at King Alfred's College cited the changing of midwifery to meet the demands of women as one of the foremost challenges of midwifery. In her

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94 a ddress to the 1992 annual general meeting of the Royal College, Margaret Brain, t h e President, said that, "Consumerism must be integral to all activities: clinical, managerial or research." Ian Chalmers, MD, in his address at the annual general meeting, described how the Royal College of Midwives, the Royal Society of Obstetricians, and the Health Department used consumerism to design a study of chorionic villus sampling. The study was to yield data on the cvs procedure. cvs gives genetic analysis by taking a sample of preplacental tissue at 8 -11 weeks of gestation. Knowing this would be a controversial subject, the British professional organizations approached the consumer organizations, such as the National Childbirth Trust and the Spastics Society, soliciting their ideas on how the research should be designed, including suggestions for the treatment of women and the language to be used in the consent forms The success of this approach has made it common Health Department research practice. Soci a l Security Systems Supporting M i dw ifery Complying with European Community standards strengthened the maternity leave entitlement for British women Women in the United Kingdom were entitled to six weeks leave at 90% of their pay (generally started at 28 weeks gestation), followed by a flat rate payment for 12 weeks. To qualify for the

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95 Maternity Benefit, British women must have worked two years in full-time or five years in part-time employment. Although the Equal Opportunities Commission complained that the British criteria for the maternity benefit were so stringent that one woman in five did not receive any benefit (Beecham 1992:980), the maternity benefit allowed many wome n to rest during pregnancy and purchase foods appropriate to prenatal nutrition. In addition, British women on Income Support or Family Credit with savings of less than 500 pounds ( $985 American in July of 1992) received a lump sum payment of 100 pounds ($197 American in July of 1992). Between 1990-91 and 1991-92, the number of Maternity Paym ents awarded in Great Britain rose by 41,000 to 230,000, giving at least 3 0 percent of British families additional maternity support (Maternity Action 1992: 8). A rested and well-nourished woman is less prone to prenatal complications such as pre-eclampsia. State maternity benefits, therefore, enhanced Britis h midwifery's support of the uncomplicated pregnancy and birth process. The European Community agreed to a minimum levels of maternity leave and pay in October of 1992. The Economic Community directives guaranteed women 14 weeks maternity leave with pay at the minimum rate of their country's statutory sick pay regardless of the length of time in employment (Beecham 1992: 980). This significantly increased the maternity leave available to British women

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96 While pregnant women in the United States were guaranteed prenatal and birth care through the Medicaid program if their income fell below the Federal poverty level, pregnant working women received no wage support. It was not until the 1993 Family Medical Leave Act that some pregnant women received job security. Under the Family Medical Leave Act, workers were guaranteed 12 weeks of leave without pay after the birth or adoption of a child, or to care for sick relatives. Workers were guaranteed return to a position of equal pay and rank, but not the same position. The Family Medical Leave Act, however, applied only to organizations with greater than 50 employees. This means most American working women still did not have guaranteed maternity leave. This partial government support for maternity forced most American middle class women to continue working until labor begins. Not only did American wome n have to work to continue their incomes, most continued to work to have insurance benefits for birth because there was no American national health. The community midwife at the Bramley Surgery contrasted the British "res pect for pregnancy" with the way American women at the n earby American airbase had to work until they give birth. "We pity them," she commen ted. Lack of maternity support made American women choose between impoverishment and midwifery advice to obtain adequate rest and nourishment. These choices had the potential to harm both fetal and maternal health.

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Figure 3. The United Kingdom and British study sites. c:: co Q) u 0 u .-l .w c:: co ,.., J.J < Orkney Islands E ngland SheLl a n d Js]ands co Q) VJ .c J.J I.. 0 % 97

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98 Descriptions of study Sites Located in England Figure 3 shows the nations of the United Kingdom: England, Scotland, Wales, and Northern Ireland, and the cities visited during the British research. The United Kingdom is shown in relation to France, England's closest neighbor on the European continent. The United Kingdom includes 94,226 square miles. In 1992, the population of the United Kingdom was 57,797,800. The population was 90% urban with a population density of 613 people per square mile (Famighetti 1994:819,820). Scotland and Wales are independent nations. Scotland occupies the upper 37% of the British Island (Famighetti 1994:820). Scotland has its own legal currency. While the Scottish speak English, only 20% of the Welsh speak English and Welsh. Approximately 32,000 speak Wel s h only (Famighetti 1994: 820). London London is not only the capital of the United Kingdom but one of the capital cities of the industrialized world. The 1992 population of London was 6 735,000. The Houses of Parliament for the United Kingdom are located in London as are most government administrative offices. London is also the capital city for British midwifery. The Royal College of Midwives, The United Kingdom Central Council, the English

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99 National Board, and The International Confederation of Midwives are all located in London. The United Kingdom central council The offices of the United Kingdom Central Council (UKCC) were located two city blocks from the Royal College of Midwives. The United Kingdom Central Council regulated nurses, midwives and health visitors. Before 1979, 9 separate governing bodies did this work. They were fused into the UKCC i n 1983. Beginning in 1992, the UKCC will have 60 members. The UKCC had three main functions: 1) to make and improve standards for clinical practice and education, (2) to set and improve standards of professional conduct, and (3) to maintain a central registry of nurses, midwives, and health visitors. In 1992, the central registry had over 600,000 practitioners listed. In its registering and disciplinary functions, the UKCC was most like an American state board of nursing that regulates nurse-midwifery. The English National Board The English National Board (ENB) was one of the four national boards (England, Wales, Scotland, and Northern Ireland) that formulated standards for nursing and midwifery education and certification in the United Kingdom. The United

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100 Kingdom Central Council sets broad standards for the United Kingdom. The national boards applied those standards to the individual countries and were responsible for their implementation. T h e ENB validated midwifery courses, approved (accredits) midwifery programs, and organized continuing education experiences for supervisory and administrative midwives. In t hese functions, the ENB was analogous to the American National League for Nursing. The E N B was responsible for the national midwifery certification examination. Starting in 1990, the ENB worked to devolve the national examination into programs of continuous assessment within each midwifery educational program. The Department of Health Each of the four United Kingdom countries had a Department of Health. The functions of the Departments of Health were to: -monitor the National Health Service, manage policy for nursing and midwifery, -commission research about health practices and health needs issue information about the country' s health needs and health practices, -write and implement the details to Acts of Parliament concerning health, and -to interact with the European Economic Community.

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101 The UKCC and the ENB were statutory bodies. The Department of Health was a government body. As statutory bodies, the UKCC and the ENB could not interact with the European Economic Community (EEC). All work with the EEC was channelled through the Department of Health. The Head of the Department of Health reported to the Secretary of State and the Prime Minister. Although not directly related to the practice of midwifery, the Department of Health (DOH) had an impact on midwifery. The DOH sets the government health priori ties. Britain's health priorities have long included reducing maternal and infant death and supporting family planning. The DOH commissioned and funded research related to midwifery. For example, the DOH was studying the 1979 and 1983 graduates of midwifery educational programs. This longitudinal study would yield data on career patterns, mobility and retention, and educational patterns post-midwifery registration. Using this data, the National Health Service would make decisions about future needs for midwives within the NHS. The DOH also had grant money for voluntary organizations that supported the work of midwifery, such as the Stillbirth and Neonatal Death Society. Each of the 4 United Kingdom countries had a Senior Nursing Officer, employed by its Department of Health. The Nursing Officer was charged with managing policy for nursing and midwifery within the National Health Service. The English DOH had 40 administrative nurses. Six were also midwives.

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102 Other countries had smaller Departments of Health. Wales, for example, had only 1 nursing officer, who was also a midwife. Because of the smaller budgets of other countries, the English DOH most often funded research and the writing of pamphlets and books. Products of the English DOH were used by the other Departments of Health, such as those of Scotland and Wales, imprinted with their names. The Royal College of Midwives The Royal College of Midwives (RCM) was the professional organization for more than Midwives Institute, formed 35,000 in 1881, British became Midwives. The the College of Midwives in 1941, and received royal patronage in 1947. The aim of the RCM was, "to advance the art and science of midwifery and to maintain high professional standards (RCM Organizer 1992:4) .11 The RCM Board of Directors and employees advised and negotiated with the government on all matters related to the NHS maternity service and the employment of midwives. Acting in this capacity, it was a legally recognized union for midwives. Its union functions distinguished the RCM from its American counterpart, the American College of NurseMidwives. American professional organizations have maintained a philosophy against collective bargaining and strike action. The RCM also sponsored educational programs for midwives. The RCM maintained a lending/reference library about midwifery

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103 and promoted midwifery research. The RCM maintained offices in London, North England, Wales, Scotland, and Northern Ireland. It was governed by an elected council that met 6 times each year. The Council contained the RCM officers and a Board for each of the member countries. Council members were elected by local branches. The British research period coincided with the annual meeting of the Royal College of Midwives in Nottingham from July 21, 1992 through July 24th. This meeting was the largest annual gathering of midwives in the United Kingdom. The annual general meeting (AGM) consisted of parliamentary motion making and voting using the representative democratic government of the RCM, annual awards to distinguished midwives, a trade show, and a continuing education day. Permission to attend the meeting as a special observer had to be approved by the Board of Directors of the Royal College of Midwives. Unlike American professional conventions, which were most often held in scenic or resort areas, the AGM was held at the University of Nottingham. Midwives stayed in dormitory rooms that were empty for the summer. Meals and tea were served in the dormitory cafeterias. The parliamentary sessions were held in the Midlands Conference Center auditorium of the University. Because National Health Service hospitals did not pay for trips to the annual general meeting, the meetings have always been held at schools or universities to limit costs. Attendance at the conference for three nights residence, three

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104 meals and tea each day, and all conference sessions cost 170 pounds ($333.20 American at the time). Attendance permitted observation of the formal structure and current goals of the Royal College of Midwives. Branch delegates debated and voted on issues such as women's right to maternity pay, separating midwifery pay from nursing pay, midwife/client ratios, and midwives prescribing rights. Attendance also allowed the opportunity to select practicing midwives from parts of the United Kingdom located outside of the itinerary as informants. Spradley (1972:73) recommended finding informants who were not part of the main observational group to increase data diversity. I was able to sit and talk with practicing midwives at meal times tea, and during exhibition times. St. Mary's Paddington In March of 1990, three schools of nursing and midwifery; St. Mary's Paddington, Northwick Park and Central Middlesex Hospital, were united under the NorthWest London College of Nursing and Midwifery. The office of the A cting Department Head of the Midwifery Educational Programs was in St. Mary's Paddington. St. Mary's was a turn of the century hospital surrounded by a neighborhood of professional and executive families. St. Mary's was a city hospital with no surrounding park or lawn. Its building complex was continuous with the

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105 businesses around it; its entrance on the Praed Street sidewalk. St. Mary's was a District center with specialized maternity clinics for high risk pregnancies and a neonatal intensive care unit. Northwick Park Hospital was located in a London suburb. Central Middlesex Hospital wa s an industrial area not favored by students. The NorthWest London College (NLC) had nine full-time faculty members: four at St. Mary's, four at Northwick Park, and one D epartment Head. Central Middlesex was primarily a clinical site. The midwifery program had two intakes of 25 students a year, April and September. Eight students were assigned to St. Mary s nine to Northwick Park, and eight to Central Middlesex. Central Middlesex slots were sometimes unfilled. A staff of 45 midwives at St. Mary's attended 2 ,500 births p e r year. St. Mary's a lso h a d a community midwifery staff of ten. Northwic k Park has 3 500 births per yea r and Central M iddlesex had 2,000. In the past, the NorthWest London College had to recruit from abroad to fill its midwifery student positions. Forma l advertising wa s done in Northern I r eland. M any of the NorthWest London midwifery students still came from Northern Ireland. Marketing was done by word of mouth between these students and friends Hospital housing accommodations w e r e provided to all students. Students had to begin their midwifery education by living in student housing. Many c hose a roommate and moved t o a n apartment after t h e first term.

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106 Winchester-Basingstoke Winchester is an ancient capital of England, a county seat, and a Norman cathedral city. Lying 65 miles southwest of London, it lS also home to the 600 year old Winchester College, one of England' s prestigious boy's preparatory schools. Surrounded by meadows, Winchester sits between England's two best trout streams, the Itchen and the Test. Winchester was a wool center in the Middle Ages. Current commerce centered on the college and county administration. Basingstoke is 20 miles northeast of W i nchester. It is a small town, surrounded by old farms with bramble and fuschia hedgerows. Basingstoke was a n agricultural center that also provided services to families from a nearby airbase. The Winchester-Basingstoke Midwifery Program was part of King Alfred' s College. The program had classrooms and hospital clinical sites in both Winchester and Basingstoke. Until 1989, Winchester and Basingstoke were separate midwifery programs. Then, like many other smaller, hospital-based midwifery programs, Winchester and Basingstoke becam e college based. They joined the nursing program at King Alfred' s College to become the Division of Health Studies. The WinchesterBasingstoke Program admitted its first cohort of preregistration midwifery students in March of 1991. They will graduate in 1994 after three years of midwifery studies.

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107 The Royal Hampshire County Hospital in Winchester provided clinical experiences for 24 midwifery students each year (eight from each of three overlapping cohorts). The Basginstoke District Hospital provided clinical experiences for 18 midwifery students each year. Being a smaller hospital, it took six students each year from the three overlapping cohorts. The Bramley Surgery, located in the country outside of Basingstoke, was "purpose built" by the District in approximately 1988. The old surgery (clinic) was a back room of the general practitioner's horne. The new surgery contained a computerized front office, four exam rooms, and two offices. Patients were assigned to the general practitioner and his junior partner by the National Health Service. Two community midwives rotated From Basingstoke District Hospital to antenatal clinics at the surgery twice a week. When not in antenatal clinics, the midwives were on-call for births at the hospital. Portsmouth Portsmouth is the harbour city of the Royal Navy. It is located 70 miles southwest of London next to a natural harbour on the Solent shore. Because of Irish Republican Army terrorist precautions, Portsmouth did n o t look like a naval city. Sailors did not wear uniform off ship, nor was their

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108 hair closely cropped. The port and the Polytechnic were the major industries. "I wasn't born yesterday;" said one of the Portsmouth midwifery tutors, "I know many of our students choose Portsmouth so they can meet one of Her Majesty's men!" Like other British midwifery programs, Portsmouth accepted students from overseas. Most overseas applications carne from British Commonwealth nations. The British government provided scholarship money for these students. Commonwealth Nations are listed in Table 4. The Isle of Wight partially protects Portsmouth from the English C h annel. The Isle covers almost 20 square miles. Scheduled ferries and helicopters connect the Isle with Southampton to its west and Portsmouth to the northeast. The Portsmouth and Isle of Wight Midwifery Program opened i n 1967 when British midwifery study was divided into two, six month sessions. In 1981, those session s were consolidated and the program joined the Selent School of Health Studies of Portsmouth Polytechnic. The School of Health Studies also offered nursing, radiology assistant, and dental assistant programs. Health studies students shared core courses, s uch as anatomy, in mixed classes. The Portsmouth midwifery students used St. Mary' s Hospital in Portsmouth as their main clinical site. The St. Mary's Hospital complex was adjacent to the Selent School of Health Studies. St. Mary's was a large regional hospital that was chronically underfunded and behind on renovation. Its physical

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109 appearance and problems were similar to those of large American tertiary level hospitals such as Tampa General Hospital and Jackson Memorial Hospital in Miami. St. Mary's had maternity clinics with obstetricians specializing in high risk pregnancies and a regional neonatal intensive care unit. st. Mary's also had the usual maternity and newborn services that a smaller district hospital would have. The So lent students rotated to three maternity homes: Bishops Waltham, Petersfield, and Fensham. The maternity homes were wings of small rural hospitals, similar to level one hospitals in the United States. Many women made a 30-40 mile journey into St. Mary's Hospital to give birth nearer to St. Mary's specialized neonatal nursery. Then, they left St. Mary's the day after birth and spent another three to four days resting with their newborns in the local maternity homes. Students from the Isle of Wight did their community midwifery on the island. They helicoptered to Portsmouth for classes. One midwifery faculty member lived on the Isle of Wight and also commuted by helicopter. Transport was often delayed due to storms over the channel. Portsmouth had a post-nursing, or registration, midwifery program and a preregistration program that started in 1991. Portsmouth was be one of the few British midwifery programs that would continue both nursing and nonnursing entry levels. Portsmouth, one of England's largest schools of midwifery, also offered a bachelor's degree in midwifery, a master's

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110 degree 1n midwifery, and continuing education programs for midwives. The midwifery faculty at Portsmouth taught the maternity nursing component of the nursing program offered at the School of Health Sciences. Descriptions of Study Sites Located in Scotland While occupying 37% of the main British island, only 4,957,000 people, 8.5% of the British population resides in Scotland (Famighetti 1994:820). Large portions of Scotland are barely habitable mountains or moors. The Scottish lowlands, a 60 mile wide area on the English border contains 75% of the Scottish population (Famighetti 1994:820). Edinburgh, the capital city of Scotland had a 1986 population of 439,000 (Famighetti 1994:821). Scotland's production is mainly agricultural. It is known for wools and hardy breeds of cattle and sheep. Whisky is its largest export (Famighetti 1994:821). Although a member nation of the United Kingdom, Scotland, is a separate country with its ow n legal system and currency. While the state religion in the England is Anglicanism, most Scots are Presbyterians. Lying on the same latitude as Moscow, Scotland is known as the cold north and a place for sheep. The Scots are renowned for their fierce independence. The Scottish National Party, founded in 1928, still works for full independence from the United Kingdom (Harvie 1990:305). The Scottish National Party has promoted and initiated devolution

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111 from English control since its inception. The Scottish National Party gained power during the 1970s when Scottish North Sea oil boosted the ailing British economy (Harvie 1990:306). When discussing midwifery trends in Scotland, a senior midwifery tutor from Lothian College remarked, "We Scots are a cautious lot by nature. We sit back and let the English make their mistakes during demo programs. Once they've got the kinks knocked-out-and spent the money to do it-, then we give a go in Scotland. We're just small enough to start a good idea all at once, all over Scotland, instead of implementing it district by district." The Lothian College of Nursing and Midwifery The National Health Service, Scotland, was divided into 1 5 Health Boards. Midwifery administration for these boards and midwifery education was centered in the capital city of Edinburgh. In 1975, Scotland took its midwifery educational programs from District supervision and consolidated them into colleges of nursing. That created 21 Scottish midwifery programs, 16 remain. The Lothian College of Nursing and Midwifery in Edinburgh was the largest school of midwifery i n Scotland. It provided nursing and midwifery education not only for the Lothian

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112 Health Board, but for the entire Highland Region and the Western Isles, a population of approximately 974,000. Edinburgh has been the capital city of Scotland since 1450. It was at once medieval with castles and modern with fax machines. The Lothian College of Nursing and Midwifery stood in contrast to the Victorian and Edwardian neighborhoods surrounding it. It was purpose built in 1989. Students came to Lothian from all over the United Kingdom and the Commonwealth nations. Twenty-one hospitals provided clinical experiences for the Lothian midwifery students. At the time of data collection, Lothian had 80 postregistration midwifery students, and was accepting 20 preregistration students into their new preregistration program each year. The simpson Memorial Pavilion The largest midwifery clinical site for the Lothian College was the Simpson Memorial Maternity Pavilion of the Royal Infirmary in Edinburgh, founded in 1879. The Simpson, as it was known, was named after Dr. James Young Simpson, who developed the Simpson style forceps and was the first British physician to apply the use of ether to midwifery. His use of an anesthetic to ease labour pain was widely denounced from Scottish and British pulpits but accepted by Queen Victoria for the birth of her eighth child (Dewhurst 1980:177-78).

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113 Only the Simpson Pavilion and the Eastern Infirmary in Edinburgh had maternity units. The Simpson was a formidable Victorian stone edifice. To enter the second floor antenatal and labour wards, one climbed a wide stone staircase. Even the Cesarean section suites retained their Victorian look. Called theatres instead of operating rooms, the surgical table stood in the middle of the room. One wall had four-tiered stone steps that were used as seats by students in the early days of obstetrical surgery, when an operating room was a theatre. While preserving Victorian midwifery skills, the Simpson midwives were able to offer the latest technology to women, including inhalable anesthetics and transcutaneous nerve stimulators for pain relief. The Simpson staff had 20 senlor midwives (sisters), 26 staff midwives, and 19 midwifery tutors, who together attended 6,500 births each year. There was a controlled bustle of activity on the Simpson labour unit. With 6,500 births per year, the unit was continuously occupied. As a National Health Service hospital, The Simpson provided services for families with no incomes other than government support to Edinburgh' s most affluent families. With so much traffic through maternity, the midwives cautioned visitors not to leave personal items unattended. Like the midwifery locker rooms of many American inner city hospitals, the Simpson midwifery locker room had a locked door with padlocked lockers.

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114 The Simpson Community Midwifery Office The Simpson's Community Midwifery Office was on the pavilion's first floor. The Community Office had a staff of n1ne full-time midwives and two midwifery sisters. These community midwives provided postnatal horn e visits for the mothers and infants attended by the hospital midwives. They also attended horne births in Edinburgh south of the Princes Street line when women request. The Simpson community midwives saw 1,500 to 2,000 postnatal women each year with an average of five home visits each. (Other mothers giving birth at the Simpson were seen by community midwives based at other hospitals depending on the locatio n of their residence in the Edinburgh.) The neighborhoods served by the Simpson community midwives ranged from upper middle class townhouses to high rise, government low-income housing. The government high r1ses while plain, did not have the graffiti, broken glass, or trash that was often seen in American government high rises. The Scottish National Board The offices of the Scottish National Board (SNB) for Nursing and Midwifery were located in downtown Edinburgh. The SNB forms policy about nursing and midwifery education 1n

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115 Scotland. It was responsible for the standardized content of midwifery educational programs, and the course validation (evaluation) of midwifery programs, and the approval (accreditation) of midwifery programs. The SNB ensured that midwifery education was consistent with European Community Council Directives, British midwifery statutes, and the directive of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. The SNB's aims in relation to midwifery for 1992 were: To introduce a three year programme of study for the preparation of midwives which will meet the requirements for standard, kind and content and which will, in particular, ensure that the depth, nature and general arrangements for study are such that the criteria for the award of a diploma at higher education level are met. To have the award evaluated with a view to establishing its credit rating within a credit accumulation and transfer scheme and in particular to achieve assessment of experience derived learning. To facilitate the development of an education led, research and practice based curriculum while at the same time exploiting the opportunities which, given full student status, are now available for meeting criteria in relation to academic rigour and vocational utility. One midwife worked with a team of nurses and clerical staff at the SNB. SNB midwifery and nursing representatives were formerly appointed positions. Starting in 1992, those representatives were to be elected by the government.

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116 Descriptions of Study sites Located in the United states The federation of the United States began with the Declaration of Independence from Great Britain in 1776. Territorial wars with France and Spain and additional land purchases followed. The current 50 sovereign states of the federation occupy 3, 618,770 square miles (Famighetti 1993:822). This is roughly 38 times larger than the United Kingdom. The 1993 population numbered 256,561,239 with a population density of 70 per square mile (Famighetti 1993:822). Compared to the population density of the United Kingdom, 613 per square mile (Famighetti 1993:819), the United States is sparsely settled. The Tampa General Hospital The Tampa General Hospital was located in Tampa, Florida. Florida is the southeastern most state in the union. Tampa is a port city, being located on a large natural bay. Tampa's climate is semi-tropical. During the 1800s and early 1900s Tampa had a thriving cigar rolling industry with many Cuban and Italian immigrants. In 1992, Tampa was a corporate center with many tourist attractions. Tampa was located in Hillsborough County. Hillsborough County had large agricultural interests in the southern half of the county, producing oranges, tomatoes, and other vegetables. Tampa's

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117 1990 population was 290,900 while Hillsborough County had a population of 834,054 (Times Books 1991). The Tampa General Hospital was a private, not for profit, 1, 000 bed tertiary care center that provided care for the medically indigent of Hillsborough County. Until the fall of 1992, Tampa General was the only one of three county labor and deli very units that would accept women who did not have private health insurance. Approximately 7, 500 women gave birth at the Tampa General Hospital in 1991. Its 12 labor-deliveryrecovery rooms were continually full. Women often waited in the five bed triage room until a labor bed was free. The Tampa General Hospital was affiliated with the University of South Florida College of Medicine. Medical students attended labor and delivery rotations at Tampa General. The labor and delivery unit was staffed by more than 75 registered nurses and surgical technicians, 16 obstetrical residents, and four perinatal fellows in 1992. Beginning in 1986, there were insufficient residents to attend all the laboring women. Private physicians could not be attracted to Tampa General to share in the care of med ically indigent women. The faculty of the University of South Florida Department of Obstetrics formed a nurse-midwifery service to care for women with uncomplicated pregnancies. The Service started with one nurse-midwife ln 1985 and had 11 full-time nurse-midwives in 1992 with an additional three part-time nurse-midwives. At the Service' s peak in 1991,

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118 the nurse-midwives attended more than 2,500 births. It was common for a nurse-midwife to attend 5-6 births in one 14 hour shift. More than 90% of the women attended by the nursemidwives received prenatal care in the Hillsborough County Public Health Departments. Their prenatal care was provided by nurse-practitioners and the University of South Florida obstetrical residents. The nurse-midwives provided prenatal care and gynecological care to women 48 hours each week at the Genesis Center, a women's and children's clinic owned and operated by Tampa General Hospital. Medicaid eligibility screening, Women, Infants, and Children's (WIC) Nutritional Services, and social work support were provided at Genesis. Medical and surgical consultation for the nurse-midwives was provided by the faculty physicians of the Department of Obstetrics University of South and Gynecology. The Florida ethnic backgrounds of the women seen at Genesis and Tampa General by the nurse-midwives were similar to the State of Florida: 83.1% White, 13.6% Black, and 12.2% Hispanic (Famighetti 1993:636). Many of the Hispanic women were migrant agricultural workers. The nurse-midwives of the Tampa General Service received their midwifery educations in seven different American programs. One nurse-midwife was a British educated midwife. The nurse-midwives of the Tampa General Service were clinical faculty members of the University of Florida's Nurse-Midwifery Program and the University of South Florida College of

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119 Medicin e Depart me n t of Obstetrics. University of Florida nurse-midwifery s tudents had c linical rotations with the Nurse-Midwifery Service. The nurse-midwives taught the U niversity of South Florida medical students the labor process and suturing and served as their clinical preceptors on labor and delivery. The Frontier School of Midw ifery a n d Fam ily Nursing The Tampa General Hospital became a clinical site for the Community Based Nurse-Midwifery Educational Program (CNEP) of the Frontier School of Midwifery and Family Nursing in Hyden, Kentucky in 1988. Midwifery students attended general orientations and lectures in Hyden, did modular study, then attended clinical rotations in their local communities. The Frontier School opened a precertification program in 1989 to provide foreign educated nurse-midwives preparation for the certification exam of the American College of NurseMidwives. The Tampa General Hospital Nurse-Midwifery Service provided lectures and served as a clinical site for the precertification program. Between 1989 and April of 1993, 21 foreign educated nurse-midwives completed the precertification program at the Tampa General site. The principle investigator, who served as the Tampa precertification program coordinator, traveled to Hyden, Kentucky, in June of 1991 and reviewed the records of foreign

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120 educated nurse-midwives who attended former precertification programs at Frontier and Booth Memorial Hospital in Philadelphia, Pennsylvania. Womencare WomenCare was a privately owned women's health practice located in northeast Tampa near the University of South Florida. Nurse-midwives and nurse-practitioners provided gynecological and family planning services to approximately 20 women each day. Medical consultation was provided by the family practice physicians of the University of South Florida College of Medicine. The owners o f WomenCare paid the physicians for consultations. Most women paid cash for their treatment, although WomenCare did participate in several managed care programs, such as the Blue Cross/Blue Shield preferred provider network. WomenCare provided care based on feminist principles. Nurse-midwives and nurse-practitioners most ofte n dressed in street clothes to symboliz e parity with the patients. Examinations and treatments were explained in detail. Health education for wellness and continued self-care was provided to all women. WomenCare served as a student clinical site for the Frontier School of Midwifery Precertification Program.

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121 East Pasco Medical Center East Pasco M edical Center was a primary level, 88 bed hospital located Zephyrhills, in Pasco County approximately 20 miles north of Tampa. Zephyrhills was primarily a retirement community w hose population quadrupled i n the winter when northern retirees came south for the milder weather. East Pasco Medical Center had 300 t o 400 births a year. When local obstetricians refused to provide care t o medically indigent women in 1990, East Pasco Medical Center employed two foreign educated nurse-midwives t o form the Sunlight Obstetrical Services. By 1993, six nurse-midwives were employed by the hospital. Five of the s1x nurse-midwives were British educated. The hospital paid one physician to provide medical consultation. Two additional communit y physicians rotated night a n d weekend call hours to provide con sul t a t ion a n d s urgical ser v ices. The wome n recei ving care at Sunlight Obstetrical Services were approximatel y 80% Ca ucasian, 1 5 % B lack, and 5% Hispanic. summary: Chapter 4 Chapter 4 presented data on t h e historical and sociocultural contexts of midwifery in the United States and the United Kingdom. Although the original American constructio n of midwifery was imported directly from the United Kingdom in

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122 1925, it was imported into a country with a different historical and socio-cultural matrix. Chapter 5, Findings, presents the current constructions of midwifery in the United Kingdom and the United States by examining philosophies of midwifery, midwifery practice, politico-economic variables affecting midwifery practice, socio-cultural variables affecting midwifery practice, and midwifery education.

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123 CHAPTER 5 FINDINGS Chapter 5 describes study findings. Data from key informant interviews and participant observation are organized into models of midwifery practice and models of midwifery education i n the United Kingdom and the United States. Models of Midwifery Practice Midwifery Philosophy of Practice The philosophy of the Royal College of Midw i ves includes alms of the midwifery profession, functions, needs of the profession, values, professional beliefs, and professional assumptions. The philosophy defined the work of a midwife but does not clearly distinguish that work from the practice of medicine. According to the Royal College the midwifery profes-sion intended to: empower women during their childbearing experience provide holistic care maintain professional credibility be proactive and sensitive to social change and changing patterns of health relevant to the profession (Royal

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124 College of Midwives 1992:3) The philosophy of the American College of Nurse-Midwives used the perceived deficiencies in biomedical practice to define the beliefs and work of nurse-midwifery: ... We further support each patient's right to selfdetermination, to complete information and to active participation in all aspects of care. We believe the normal processes of pregnancy and birth can be enhanced through education ... Nurse-midwifery care is focused on the needs of the individual and family for physical care, emotional support and active involvement of significant others according to cultural values and personal preferences ... The practice of nurse-midwifery encourages ... non-intervention in normal processes ... (American College of Nurse-Midwives 1989). Sweet (1990:CS-2l-02) reduced British midwifery ideology to three basic concepts: normality (of pregnancy and birth), continuity in care, and the responsibility for practice in the midwife's own right. The philosophy of the American College of Nurse-Midwives included the concepts of normality, continuity in care, and the social importance of birth. American midwifery's concepts of normality and continuity in care are a British heritage. The written history of the first twenty years of the New York city Maternity Center Association, a site of early American nurse-midwifery practice, described the philosophy of the Maternity Center: As in England, the concept that childbearing is a normal process was the dominant philosophy. Pregnancy was regarded as more than a 9 month segment of life: its foundations were laid far in advance and its effects extended into the next generation (Maternity Center Association 1953:23).

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125 M idwifery Practice British midwifery practice has been divided into two domains: hospital midwifery conceptual midwifery. Hospitals became the usual site practice following the 1970 Peel Report. and community for midwifery Peel urged the building of sufficient hospital beds for all pregnant women thereby almost abolishing the domiciliary birth system (Pratten 1990:43). Prior to Peel, only women with pregnancy problems or inadequate housing gave birth in hospitals. The remaining domiciliary births and postpartum care for the mother and n ewborn continued to be managed by the District Midwife. The Peel Report additionally recommended that hospital and district midwifery practices be integrated. District Midwives moved into the hospitals to provide staff attendance for normal births This shift placed them into a role that contains some elements of the role of the American labor and delivery nurse However, the labor and delivery nurse accepts a patient from a physician and follows his orders for care. The labor and delivery nurse does not deliver the baby unless the woman gives birth before the physician can arrive. When a British woman has pregnancy problems i n labor, the r o l e of the British midwife overlaps that of the American labor and delivery nurse. For example, the midwife provides labor support and assists while forceps are applied by the

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126 physician. When there is a medical problem in labor, such as insulin dependent diabetes, the midwife contacts the physician. The midwife implements the physicians orders for care. However, unlike the labor and delivery nurse, even if there is a medical problem, the midwife will deliver the baby unless forceps or surgery are needed. The British community midwife is affiliated with a hospital. The community midwifery staff of a hospital focuses on care that is provided outside of the hospital, including: -pregnancy "booking," completing the prenatal history, most often done in a woman's home (Mudge 1990:408, Cronk and Flint 1989:9-11) -antenatal care in local surgeries or clinics -home visits for pregnant women on bedrest -domiciliary births -postpartum exams for mother and newborn for a minimum of 10 days Unlike hospital midwives, who generally w orke d a 40 hour week, community midwives in the study averaged a 40 hour week, but also were responsible for rotating on-call time so that one community midwife was available continually by phone and for home births. With a domiciliary birth rate of less than 2%, community midwives attended few births compared to the hospital midwives. Some hospitals had programs that rotated their hospital and community midwives so that midwives retained skills in both practice areas.

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127 American nurse-midwifery practice was divided into five domains: -antepartum management -intrapartal management -postpartal management -newborn management -interconceptional management (gynecology and family planning) These management areas define practice terri tory for American midwives. During the study, nurse-midwifery management domains were defined according to Varney: antepartal period-The antepartal period covers the time of pregnancy from the first day of the last menstrual period (LMP) to the start of true labor, which marks the beginning of the intrapartal period (Varney 1987:63). intrapartal period-The intrapartal period is not specifically defined in Varney. It is, however, the period of labor, which Varney (1987:229) defines as, "those processes that result in the expulsion of the products of conception by the mother ... (labor has) true labor contractions, as evidenced by progressive cervical changes, and ends with the delivery of the placenta. newborn period-The time between 28 weeks gestation and 28 days after birth (Varney 1987:411). postpartal period-The postpartal period is the time from the delivery of the placenta and membranes (marking the end of the intrapartal period) to the return of the woman1s reproductive tract to its nonpregnant condition ... This period is also called the puerperium ... The puerperium lasts approximately 6 weeks (Varney 1987:475). interconceptional period-... the interconceptional period covers the period of time between the delivery of the products of one conception and the occurrence of the next conception ... In practice health care during the interconceptional period has come to mean the primary health care of women who are between menarche and menopause as it relates to the reproductive system (Varney 1987:533).

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128 The five domains used to divide Varney' s textbook NurseMidwifery became the conceptional domains of midwifery learned by American nurse-midwifery students. American midwifery students have separate classes and clinical practicums in each of these areas. American nurse-midwifery's tendency to reduce a woman's health into discreet areas of clinical care may stem from the absence of an American cultural construction of midwifery as nurse-midwifery expanded during the 1950s and 1960s. Medical textbooks, such as William's Obstetrics (Pritchard and MacDonald 1980) were used for midwifery education, glvlng American nurse-midwifery the reductionist tendencies of the medical model of health care. The American domains of midwifery may have been a heritage from the original British midwifery domains. the publication of Varney' s Nurse-Midwifery in 1980, Textbook for Midwives, a British midwifery text Until Myles' first published ln 1953, was used for American nurse-midwifery education. The 1975 edition of Myles divides midwifery into domains that encompass both the normal process models and the biomedical illness models of pregnancy and birth: -pregnancy -abnormalities of pregnanc y -normal labor -abnormal labor -the puerperium -the newborn baby (Myles 1975:xv-xvii)

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129 Hospital Midwifery Midwifery care During Labor and Birth. As pregnant women were moved into the hospital system, British midwifery specialized within the hospital to fill a number of roles. Midwives provided labor and birth support, managed recovery in the postpartum areas, and cared for the newborns in nursery areas if the newborns were separated from their mothers. All this management was done independently by the midwives. A woman could enter the hospital in labor and leave with her newborn without ever being seen by a physician or needing a physician to authorize her care. In the United Kingdom, by statute, a midwife must be present at every birth, even Cesarean births. A midwife may attend a birth without a physician present, but, a physician must have a midwife present at any birth. In the United Kingdom, the midwife brought the labouring woman into the labor area, decided what care is needed, then provided that care herself. If a labouring woman needed a type of pharmacological pain relief, she and the midwife decided on a suitable medication. If Entonox gas was decided on, the midwife went to the medication room to get the Entonox cylinder and mask equipment. The midwife explained the use of the Entonox equipment and continued to administer the medication. When the birth was imminent, the midwife brought in a trolley containing the equipment needed for birth. The midwife assisted the mother during birth, then helped the

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130 mother view the child and initiate breastfeeding. Following a short period of recovery, the midwife fetc hed tea and toast for the mother. Tea wa s followe d by a bed bath and change of clothing for the mother. The mother and n ewborn then were moved to a postpartum room. The average length of s tay following birth was 48 hours. During those 48 hours, the mother and newborn w ere cared for by other midwives who staffed the postpartum units. The role of the British midwife was divided into a t least four separate roles in the United S t ates : the lab o r nurse, the physician, the anesthesiologist, and the postpartum nurse. First, a registered nurse settled a laboring woma n into a labor room. T h e nurse evaluated the progress of labor by measuring t em p erature, pulse, respirations, and blood pressure by doing vaginal exam s to measure cervical dila t ation, and by recording the fetal heart tones. If the woman needed pharmacological pain reli ef, the nurse telephoned the physici an, requested the medication, and took the physician' s order for which med ication should b e administered. In the United States, epidural analgesia was used more often than inhalable gasses. Fee for service health care in the United States paid the most for the most complicated care. Even though inhalable gasses were safe and cost effective, American physicians had learned t o use the analgesia with the highest reimbursement, epidural analgesia, when patie nts have

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131 private funding. Women covered by public funds most often received injectable narcotic analgesics. Epidural analgesia is achieved by placing a local anesthetic between layers of membranes surrounding the spinal cord. The anesthetic is placed between the membranes by inserting a needle through the cartilage between the bony vertebrae. This procedure was most often performed by a separate specialist, the anesthesiologist. In some cases, a nurse-anesthetist placed and managed the epidural catheter. The decision to give medication was never the decision of the labor ward nurse. It was a specialist's decision-a specialist who had not been with the woman during the labor. In the absence of labor complications, the labor nurse communicated the woman's status to the physician by phone, summoning him only when the birth was imminent. The physician performed the mechanics of supporting the baby as the mother gave birth, removed the placenta, and sutured any lacerations of the birth canal. The work of cleaning the mother and putting away the soiled instruments was left to the nurse. There was no standard for how long a physician should stay with a woman following birth. Most left as soon as the placenta was removed and any suturing was completed. In the United Kingdom, statute dictated that the midwife remain with the mother and newborn for a minimum of one hour. In the United States, the mother and baby usually recovered for an hour in the labor area. American staffing

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132 patterns dictated that a nurse could be assigned to another laboring woman once the first woman had given birth. This staffing prevented women from receiving a postpartum bed bath. Selectively applying the pregnancy as a normal process model, American nurses washed the perineum and legs of a postpartum woman, then encouraged her to shower as soon as she was able to walk and care for herself. In this use of pregnancy as a normal process, there is little need for postpartum nursing care because the mother is not sick and can care for herself and the newborn. After asking if I could help during a change of shift in Edinburgh, I was assigned to do the postpartum bed bath for a woman that I had accompanied for several hours. As the midwife left the room, I remembered with a small panic that I had not done a bed bath in more than a dozen years. I had to search a cerebral attic for bed bath technique facts: have the patient test the water temperature, wash clean parts first, dirtiest areas last, keep the patient covered for privacy, use a bath blanket underpad to keep the bed dry. As I began to wash, the mother said, "Ah, this is the best part." "The best part?" I asked. "Yes," she explained. "It's the only time people really take care of you. This is the best, to have someone do your bath." In the United States mothers and newborns generally have an hour's recovery together. Mother and newborn then were moved to separate areas: the postpartum unit and the nursery

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133 where separate nurses care for the mother and the baby. Some hospitals did have postpartum units where mothers and babies room together and were cared for by one nurse. The physician visited the hospital each day and wrote orders for how the nurse was to care for the woman. A separate physician, the pediatrician, visited and examined the baby each day, then wrote orders for the baby's care. Midwifery Care in Neonatal Intensive Care Units. British midwives filled a role not staffed by American nurse-midwives that of the neonatal intensive care nurse. When medical technology became sufficiently sophisticated for nurseries to specialize in the care of premature newborns, British midwives became the professionals who provided around the clock staffing of the intensive care nurseries. Medication and therapy orders were written by neonatologists, then implemented by midwives explained this expansion paediatricians and the midwives. British of a low technology profession into a high technology environment by claiming that the midwife was the provider best educate d to teach the necessary parenting skills for preterm infants and the best provider to facilitate breastfeeding. In the United States, intensive care nursing was provided by registered nurses who implemented the medication and therapy orders of neonatologists. When American neonatal intensive care units were expanding during the 1960s and

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134 1970s, American nurse-midwifery was refining the concepts of normal, uncomplicated birth and low technology care while the American College of Nurse-Midwives worked to define a construction of American midwifery. During the study, no American nurse-midwives interviewed worked in neonatal intensive care units. Community Midwifery The community midwives are descended from the district midwives, formerly responsible for the domiciliary birth service. The Cranbrook Committee Report of 1950 did not see a need to unify the domiciliary and maternity service, but did recommend that 70% of births take place in hospitals. Women who had three or more children were targeted for hospital birth. This 70% was achieved by 1965 (Watkin 1975:163). Since the late 1970s, the community midwives have been deployed through hospitals instead of the district health service. Community midwives formed the vanguard of the British health visiting service. During 1992 each mother was entitled to 10 days of postpartum visits from the community midwife. That could be lengthened to 28 days postpartum by the midwife without a physicians approval. The Bramley and Simpson community midwives averaged 5 home visits per postpartum patient during the time of the study. The community midwifery staff was

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135 notified of all births by a unit clerk or the hospital midwives. During postpartum visits, the community midwife took the mother's blood pressure, measured the involution (shrinking) of her uterus, and assessed uterine bleeding and perineal healing. She examined the newborn for jaundice, cord healing, weight gain (using hand held scales), and alertness. The mother's ability to care for her baby and her coping skills were assessed. A variety of social service agencies could be contacted by the midwife to provide help if the mother were unable to appropriately care for herself and the newborn. The midwife answered questions about postpartum recovery, newborn care, and breastfeeding. The community midwife carried ergotamine tablets and injectable syntocinon to decrease heavy postnatal bleeding, suppositories and enemas for constipation, and antibiotic creams for infant cord care, but no analgesics. Instead of being seen by a paediatrician, the normal newborn's immediate postnatal health was followed by the community midwife. In addition to antenatal care, (childbirth preparation groups), and parentcraft postpartum classes visits, community midwives provided domiciliary birth services. The Basingstoke community midwives averaged one to two home births each year between 1985 and 1991. Following the February 1992 Winterton Report from Parliament calling for the increased autonomy of midwives and an increase in the number of home births (House of Commons 1992:xciv, xcv; Lawson 1992:129), the

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136 Basingstoke unit had 6 requests for domiciliary births between March and June. Although these were small numbers, the domiciliary requests increased the birth work of the community midwives in the study by 300%. Reported one community midwife, "We were so unnerved we had a minirefresher on domiciliaries and had to redo our scheduling." Concerned about the increasing hospitalization of women and the increasing push for technologies used by physician specialists, many British community midwives had revised their practices and staffing to strengthen midwifery care by having teams of community midwives provide prenatal care, be on call to attend the births of their patients, then provide postpartum home visiting. In these schemes, sometimes called Domino schemes for Domiciliary In and Out, women returned home at approximately 6 hours after birth (Davies and Evans 1990; Kearns 1989; Flint, Poulengeris, and Grant 1988, Meeran 1988, Mudge 1990, Domadia 1990). The archetypal scheme developed by Flint, Poulengeris, and Grant was called the K now Your Midwife" scheme. The continuity in care provided to Know Your Midwife (KYM) patients produced fewer antepartum hospitalizations for complications, reduced labour analgesia, subjectively reported decreased pain in labour, shorter labours, and fewer episiotomies (Flint 1989:7). The Rhonda Valley of Wales embraced the KYM scheme for its 2,000 annual births. Ninety-eight percent of Rhonda women are attended by KYM midwives (Davies and Evans 1990).

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137 Interconceptional Care: Primary care, gynecological care, and family planning The core competencies of American nurse-midwifery practice contained three areas of management not included in British midwifery practice: 1) primary care including women s annual health screening, 2) management of gynecological problems, and 3) provision of family planning services. American nurse-midwive s provide a range of women s health services from breast exams to Norplant insertion. Gynecology and family planning curricula were added into nurse-midwifery programs beginning in the middle 1970s. British primary care, family planning, and routine gynecology work was provided by general practice physicians. summary: Types of Midwifery specializations in the United Kingdom and the United States Figure 4 summarizes the types of midwifery specializations in the United Kingdom and the United States. Midwifery specializations in the United Kingdom depended on workplace location for categorization. British hospital midwives did not provide antepartal care. Antepartal care w a s provided by community midwives. British neonatal intensive care units were staffed by hospital midwives. Both hospital and community midwives had a scope of practice that was narrowed by job specifications. The United Kingdom had educators that

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138 specialized in midwifery. The United Kingdom also had thousands of midwives who specialized in administration. These midwifery administrators managed hospital maternal-child health nursing, midwifery or public health. Administrative midwives were referred to as midwives. American nurse-midwifery categorized its specialties by the breadth of scope of practice. A nurse-midwife in fullscope practice routinely performed antepartal, intrapartal, postpartal, and gynecological tasks. While some full-scope nurse-midwives also provided care for the newborn, this was more the exception than the rule. The British community midwife comes closest to matching the scope of practice of an American nurse-midwife in full scope practice. American nursemidwives in limited scope practice performed tasks in one or more areas of practice. For example, a nurse-midwife may have been employed in a Planned Parenthood clinic to provide gynecology and family planning care but not to provide antepartal care. There were nurse-midwives who specialized in nurse-midwifery education. The United States did not have large numbers of nurse-midwives who were administrators. American nurse-midwifery has been focused on producing nursemidwives for clinical practice. When an American nurse-midwife did administrative work without clinical practice, the nursemidwife was said to be "not in midwifery."

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139 Figure 4. Types of Midwifery Specialization in the United Kingdom and the United States. UNITED KINGDOM UNITED STATES /HOSPITAL .L--COMMUNITY "\ EDUCATION \ Intrapartum Postpartum (mother & newborn) -Neonatal Intensive Care _......._....Antepartum -.: Intrapartum -,"-..Postpartum (mother & newborn) ADMINISTRATION FULL SCOPE /Antepartum / Intrapartum Newborn FamilyPlanningjGynecology LIMITED SCOPE Antepartum Intrapartum Newborn Postpartum Family Planning Gynecology EDUCATION

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140 variations In Midwifery Practice Prenatal Care. At the Bramley Surgery, the community midwife examined prenatal patients for the same data tha t a n American nurse-midwife would: feeling of maternal well-being, appetite, fetal movement, fetal growth, fetal heart tones, and maternal blood pressure. The m anner of data collection had a low technology atmosphere Instead of measuring growth of the uterus by applying a centimeter tape measure t o the abdomen, as would be done in the United States, the community midwife palpated the position and size of the fetus transabdomaninally. She judged subjectively, based on experience, that the fetus was an appropriate size for gestational age. Instead of using an electronic, doppler fetal heart monitor to listen to the fetal heart, the midwife used a Pinnard stethoscope. The Pinnard stethoscope was made of hard plastic; some are wooden. In the United States, a handheld fetal heart tone doppler unit cost approximately $500; a Pinnard $15.00. Said one British midwife, "We know the mechanical errors of the machines. We'd never trust them (the machines) over our ears." Subtle differences existed in prenatal advice given in the United Kingdom and the United States. In the U nited States, midwives advised pregnant women against changing cat litter because of the risk of toxoplasmosis, an infection that can cause fetal malformations. In the United Kingdom, the focus

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141 was not on cat litters but on preventing pregnant women from participating in the spring lambing. The ewes and lambs could carry Chlamydia psittaci, implicated in spontaneous abortions and fetal deaths. One midwife in Edinburgh advised a woman not to work in the lambing shed unless she was brewing tea. A British midwife explained the lack of focus on domestic cats as toxoplasmosis vectors by saying, "In the United Kingdom litter is a luxury, cats are turned outdoors." Iron deficiency anemia was the most common pregnancy complication in the United States. In the United States, pregnant women were urged to eat liver regularly for its iron content. Most often in the United States, organ meats were made into cat or dog food. In the United Kingdom, where meat was expensl ve, organ meats were eaten regularly. British midwives advised pregnant women not to eat liver, pate, or liverwurst, fearing that while using prenatal vitamin supplements, the women would ingest too much Vitamin A (concentrated in liver) and cause fetal deformities. An observed difference between British and American prenatal care routines was that the British midwives did not routinely measure antenatal weight gain at each prenatal visit. One woman 32 weeks pregnant, at the Bramley Surgery wanted to check her weight gain because she did not have a scale at home. The midwife showed her the scale in the corner and encouraged her to satisfy her curiosity. When asked about recording prenatal weight gain, British midwives replied that

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142 as long as the fetus grew appropriately, there was no need to fuss after the mother about eating. All midwives said that if mothers appeared to be edematous during the pregnancy, they would initiate weekly weight recordings. Funds for supplemental food for pregnant women are available in the United Kingdom based on maternal income n o t health status. In the United States, the Women, Infants, and Childrens' Supplemental Food Program (WIC) was available to pregnant and lactating women based on financial need (Dwyer and Freeland 1988:277) WIC Programs received federal funds that were matched by the states. In Florida in 1992, WIC was not fully funded. Financially eligible women received supplements only if they had a health problem. Nurse-midwives had to look for a health problem, such as anemia or inadequate weight gain (approximately less than one-half pound gain each week during pregnancy) to obtain assistance for women. Medical Records. The most striking difference between British antenatal practice and American practice seen during the study, was that the written British prenatal record, called the book, was carried by the pregnant woman. The woman gave the book to the midwife at each prenatal visit. The midwife recorded her findings and returned the book to the woman. The pregnant woman controlled her record. The midwife did not have a copy of her findings on file. She did not need to produce copies of records for insurance companies or supervising

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143 physicians. The British system assumed t h e midwife completed her work. The woman presented the book to the hospital midwife at the time of labor, giving the hospital midwife a written record of the pregnancy course. The Portsmouth book used carbonless, self-copy paper to make a copy of the initial pregnancy visit history and physical exam. The copy was sent to the district maternity unit to be placed on file for labor. This procedure notified t h e hospital uni t months in advance how many births to expect for the month. In the United States, women who received prenatal care 1 n the public health departments carried a copy of their records to the hospital. This prevented files from being lost at the hospital. The health department clinics kept medical record files with the origina l prenatal records. American women with 1nsurance coverage did not carry copies of their medical records. Physicians and hospitals claimed ownership of the medical record. In some states, such as Florida, legal rights t o the medical record were defined by law. Patients could obtain a copy of their medical records but had to submit a request in writing and could have been required to pay up to a dollar per page for the copies. Labor Admission. In each of the units visited: Winchester, Basingstoke, Portsmouth, and Edinburgh, women and their companions were free to stay overnight in antepartum units if they thought they were in early labor. If, in the morning,

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144 contractions had stopped or slowed, the women returned home until they felt it was time to return. In the United States, women were not allowed hospital admission for healthy pregnancies until they have achieved four centimeters of cervical dilatation or if the amniotic membranes (bag of waters) had broken. For liability reasons in the United States, any woman entering the hospital had regular nursing assessments. A woman couldn't pick a room and go to sleep as in the United Kingdom. Food and Fluids During Labor. In the four British labor units visited, women ate and drank as they desired during labor. Tea and toast were available in each of the units. When queried about what women actually ate, midwives replied that women stop eating when the labor is really active. The decision to stop eating was left to the laboring women. Oral fluids were never restricted unless surgery were being considered. A 1984 study by Garcia and Garforth (1989:156) surveyed 220 British maternity units. Fifty percent of the units surveyed responded that food and drink were allowed only in early labor. Food and oral fluids were restricted for most American women in labor. This was based on the possibility that a woman might need a surgical birth, vomit under anesthesia, aspirate the stomach contents, and die. In actual practice, to restrict food and fluids during labor dehydrates a woman and robs her of her energy supply. Dehydration can weaken and stop regular

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145 labor contractions and cause fetal acidosis (Ludka and Roberts 1993:203). In place of oral calories and fluids, American physicians used intravenous fluids. Wome n typically received 125 cubic centimeters of 5% Dextrose solution intravenous liquids (21 calories) each hour during labor, an inadequate energy supply for pregnant women who require approximately 80 calories each hour for baseline metabolic needs. Intravenous fluids do not lubricate the mouth or throat. Women were given ice chips to s uck with the caution, "Don't drink too much of the water from the ice. You might vomit." This caution sometimes became a self-fulfilling prophecy, m aking women feel nauseated. midwives did not site (insert) intravenous catheters. Intravenous fluids were not used in uncomplicated British births. Said the labour ward midwifery sister at the Simpson Memorial Pavilion, "If a woma n is sick enough for a drip, she' s sick enough for a doctor." At the time of the study, some British hospitals had added intravenous line insertion into the job descriptions of midwives. In most settings, American nurse-midwives could forgo the use of intravenous lines during labor and give oral liquids. In settings where intravenous lines were hospital pol icy American nurse-midwives have a variety of ways to resist the imposition of medical routines on normal labors. One method is to delay the diagnosis of labor. T h e Tampa General Hospital was the only site for uninsured women to give birth i n

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146 Hillsborough County during 1992. The Nurse-Midwifery Service was charged with the triage of all laboring women who had received prenatal care at the county health departments; over 2 200 women. Triage, originally a military term, 1s the sorting of care into those who critically need help and those who can wait. Women who had achieved four centimeters of cervical dilatation were admitted to a labor bed. In 1992, four British midwives were working with the service to study for the American certification exam. They were appalled to find that the staff nurse-midwives manipulated the findings of their cervical exams. If a nurse-midwife examined a woman who was five centimeters but comfortable, she would say, "You're three centimeters. This is a good start to labor. You seem very comfortable. Why don't you walk around the hospital? Go down to McDonald's and get a drink if you want. Don't get a diet drink. Get something with calories. You'll need the energy later. I'll check your cervix again in an hour or two or earlier if you want. Come back any time you need me." Women left this interaction with a perception of normalcy and were able to spend the largest part of their labor in control of their movements and positions. Another method of resisting the taboo on oral liquids was to bring the woman a clear liquid with calories, such as 7-Up, disguised in ice chips. The midwife would say, "You might think this ice tastes like 7-Up. But, I assure you, this hospital has a policy against women drinking during labor, so

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147 these are just 1ce chips." Women, desperate for food and drink, were quick to grasp the nurse-midwife's meaning, and conspired with them to hide the drink from the nurses and physicians. Assessing Progress of Labor. midwives performed vaginal In the British study hospitals, exams to measure progressive cervical dilatation no more often than every four hours. They were surprised to hear that American physicians expect hourly 1ncreases in dilatation and do routine cervical exams at least every two hours. In the experience of those British midwives, many wo men had periods of several hours where they had little change in dilatation. Bothering women with transvaginal cervical exams only added to labour anxiety. Women were expected to resume dilatation after a rest period and, in the experience of the British midwives, they did. British midwives interviewed prided themselves in being able to assess progress in labor from a woman's nonverbal signs, such as mood changes and muscle movements. At the Simpson Pavilion, performing more than five cervical exams during a labour was considered abnormal and put the woman at risk for uterine infection. Women who received more than five cervical exams had culture swabs taken of the cervix to rule out infection. Labor is expected to be an unfaltering progressive process in the American biomedical illness model. Average dilatation rates for first and subsequent labors were

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148 researched and quantified by Friedman (Varney 1987:230,231). In the United States, if women s labors didn't progress hourly according to Friedman's average values, nurse-midwives were pressured by physicians to use intravenous pitocin to augment the strength and speed of the uterine contractions. Nursemidwives attentive to a woman's labor had techniques for resisting the imposition of pitocin. Seeing that a labor was slowing, the nurse-midwife could underreport cervical dilatation so that the woman's subsequent lack of dilatation progress wouldn't be noticed for one to two hours. This bought the nurse-midwife time to use midwifery techniques to restore the labor contractions. These midwifery techniques included: having a woman walk to the bathroom to empty her bladder, giving her oral fluids, having her rest on her left side to improve uterine blood flow and contraction strength, relieving any pain, and having the woman rest. During the four British births observed, the midwives listened to the labouring woman's decision about what stage of labour she was experiencing. When labouring women said, "I need to push," or "The baby's coming," the midwives took their words and encouraged them to get comfortable and start pushing the baby out. In the United States, labor nurses told women not to push until they had been examined and assured that the

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149 cervix was completely dilated. If women followed their physiological urges and continued pushing, they were exhorted by the nurses to stop for fear they would rip the cervix. This prohibition against pushing before complete dilatation was said to prevent cervical tears. Although not documented in the midwifery literature, it was conventional midwifery wisdom that women should be allowed to follow the physical urges of their bodies in labor. Women who follow their physiologic urges and gently push before complete dilatation gradually pushes the cervix open. This technique was observed in use by Mexican mothers accustomed to home births as they supported their laboring daughters. Electronic Fetal Monitoring. In the United Kingdom, electronic fetal monitoring machines were set to run the paper recording at one centimeter per minute. The recording speed was standardized to three centimeters per minute in the United states during the early 1980s. Printing the fetal heart pattern at one centimeter per minute uses less paper and is, therefore, less expensive. This slow speed elongates the heart rate pattern making the pattern look less reactive than patterns at three centimeters per minute. British midwives working in the United States could be falsely reassured by American printouts as they see speeds faster than those to which they are accustomed that make the heart rate seem more reactive.

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150 Cesarean Birth. The overall Cesarean birth rate for England in 1985 was 10.5% (Dowie 1991:5.5). The British labour units studied had Cesarean section rates ranging from 7% to 13%. The Royal Hampshire Hospital in Winchester had the 13% Cesarean section rate. The midwifery faculty was embarrassed by this rate. The English National Board judged midwifery educational sites and had the authority to close a site to midwifery students if the Cesarean section rate was too high. The Winchester faculty had received a warning from the English National Board that their surgical birth rate should !::>e scrutinized and lowered. The British Cesarean rates were compared to those of Tampa General Hospital, which averaged 15% during the 1980s and early 1990s, considered t o be a low American rate. During the same time period, Tampa General's Nurse-Midwifery Service, which attended the healthiest women, had a Cesarean section rate of 4%. A 1993 American Hospital Association survey found the national Cesarean section rate to be 21% (American Hospital Association 1993:5). Episiotomy. British midwives did not routinely perform episiotomies (a surgical incision to enlarge the vagina at the time of birth). Following the physiologic process, the assumption was made that the vaginal tissue would stretch around the baby's head. Until the mid-1980s, suturing to repair an episiotomy was not included in British midwifery programs. British midwives had to b e skilled at supporting the

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151 emerging fetal head while preventing lacerations of the vagina-repair of a laceration required calling for the obstetrician. European Economic Community midwifery standards now require that suturing be taught 1n British midwifery programs. Episiotomy incisions have been routine practice by American physicians since the 1930s based on the theory that a surgical enlarge m ent of the vagina instead of muscle stretching a t birth preserved the strength of the perineal muscles. American nurse-midwives, inheriting the British model of birth as a normal process avoided the routine use of episiotomies. To be skilled at maintaining a n intact perin eum was especially important for rural nurse-midwives where finding a physicia n to suture wa s difficult. Labor Complications and Emergencies. Another sign of midwifery' s independence from biomedicine in the United Kingdom was the response to labour ward emergencies. In Winchester, a midwife called for help when a monitor indicat e d fetal distress. The mother was being monitored continuously because h e r previou s baby had been stillborn. In Edinburgh, when the student midwife and the staff midwife were unable to extract a baby' s shoulders, the emergency button wa s pushed. In both cases, the midwifery sister, the most senior midwife o n duty, responded and took over management of the problem until it was resolved. In Edinburgh, minutes after the baby

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152 was born the registrar physician walked into the room. "Rotten luck," he said. "I was hoping to see the sister undo a stuck. I've never seen one done." In the United States, nurse-midwives were expected to call a physician for help. It was rare for two nurse-midwives to be on duty at the same time so that one could assist the other. More than this the definition of physicians as managers of pregnancy complications forced nurse-midwives to summon physician help in order to practice within the standard of care. To pass the emergency management questions on the A C N.M Certification Council's national certification exam, a midwife had to write that one of her first steps was to summon a physician. British midwives who took the American College of Nurse-Midwives certification exam said that they often failed those questions because they were not in the habit of calling a physician for help in labour emergencies. In the United Kingdom, according to the midwives interviewed, a birth is a birth," regardless of presentation. Midwives independently attend breech births, twin births greater than 35 weeks gestation, post-term pregnancies (those lasting longer than 42 weeks gestation) and preterm births generally more than 32 weeks gestation. In the United States, however, these presentations and variations in gestational age have been defined as abnormal by biomedicine and are usually outside of the scope of nurse-midwifery practice.

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153 In many American nurse-midwifery practices, the nursemidwives technically co-manage complications such as preterm labor and pre-eclampsia with physicians. In actuality, the nurse-midwives work from protocols, giving standardized medications for these problems without the physician ever being present. In the United Kingdom, midwives would never order intravenous fluids or the necessary medications to treat pregnancy or labor complications. The physician consultant would order the necessary medications and insert the intravenous line The physician might be present for the birth, but the midwife would perform the labor support and hand maneuvers. Newborn Care. British newborn care was less technological than A merican care. Babies did not go to centralized nurseries, not even for brief observation periods. Newborns stayed with mothers during postnatal recovery and left the labour unit in their mothers' arms. Newborns stayed i n open cribs a t their mothers bedsides. When midwives moved newborns, they carried newborns in their arms. In the United States, for liability reasons, a nurse or midwife moving a baby was ordered by policy to move the baby in a crib on wheels. A midwife carrying a baby might drop it.

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154 Infant Feeding. The assumption was made in the United Kingdom that mothers would breastfeed, even though the midwives at Winchester, Portsmouth, and Edinburgh said at least 40 percent of the mothers chose formula feeding. Formula samples were not available in the hospitals. Formula feeding mothers were expected to bring formula from home. Breastfeeding rates at the British sites were comparable to those of Florida hospitals. In the U n ited States, formula manufacturers supplied hospitals with free samples. Since 1990, American formula manufacturers have mailed discount coupons directly to the homes of expectant parents in spite of World Health Organization and American Academy of Pediatrics prohibitions against the direct mail of formula coupons. Length of Postpartum Stay. At the British study sites, women could stay one to five days postpartum. British midwives encouraged primiparous women to stay five days postpartum to rest and establish a breastfeeding pattern. In the United States at the time of the study, women with public funding were sent home within 24 hours following birth. Women with insurance coverage could choose to stay 48 hours By July of 1993, even women with insurance coverage were being sent home within 24 hours of birth. Women who had Cesarean births were discharged 36-48 hours regardless of coverage type or age. Having no system of community follow-up care like the British, American women were left to the care of their families. If

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155 family members worked, the woman cared for herself and the new baby. In October of 1993, a British midwife visiting Florida reported that the National Health Service was encouraging midwives to send women home within 48 hours of birth to help contain costs. Political Variables Influencing Midwifery Practice State control of midwifery in both the United Kingdom and the United States contained two processes: certification and registration. Certification is the process of testing basic midwifery knowledge upon entry into the profession. Registration is the process of annual registration by midwives who are in active practice. A midwife who was certified in 1950 and wished to retire in 1990, would retain her certification, but would no longer register to practice each year. Certification. British midwifery certification was controlled directly by the state. British midwifery certification had been by examination since the 1902 Midwives Act. The Central Midwives Board was charged with making rules and regulations for the training and examination of midwives. The first courses of training were short, hospital based with a written and oral examination at the end of the course, conducted by doctors. The pass rate for those entering the profession was approximately 50%. The tight central control exercised by the Central Midwives Board and the influence of doctors who enjoyed a high profile

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156 within the Central Midwives Board, set the tone for the training and examination of midwives for almost 100 years. Alongside this there was the unsubstantiated belief that central control over all matters maintained national standards for those wishing to practice midwifery (Naisbi tt 1990:430). By the 1970s, the examination committee consisted of one obstetrician, one practicing midwife, and six midwifery educators. Each student took a written examination followed by an oral examination based on the graded written examination. The examination was given four times each year. The process of developing the examination was described by a Departmental Head, who had been a member of the examination committee for a number of years. The examination committee met twice each year. At each meeting, the committee selected questions for the upcoming examination and half of the following examination. Examination questions were written on index cards filed in a shoebox. Committee members "randomly" selected questions for the exam. Because the same questions were used year after year, students had an idea what topics and questions were covered on the examination. Study books listing sample examination questions and ideal answers were also available to purchase. The written examination was given three hours one day and three hours the next. Examinations were given on the same day all over the United Kingdom and were proctored by examiners from the midwifery program. The oral portion of the examination was given two weeks later after the papers had been graded. Three committee members administered the oral

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157 portion of the examination. The oral portion was meant to review portions of the written examination that needed clarification. The Winchester faculty shared a copy of the British national examination. Exam proctors at each school received extra copies of the examination that they posted after the oral portion of the examination was completed. A copy of the examination was posted on the bulletin board for students to review. Copies of old examinations were kept at the schools for the students to use in studying for their examinations. The exam copy reviewed contained five long essay questions. Students were instructed to choose three out of the f ive questions to answer. They were advised to take approximately 4 5 minutes to answer each essay question. The exam also contained 10 short answer questions that were intended t o take 10 minutes each to answer. All the short answer questions had to be completed. There was n o charge to British midwifery students to take the natio nal certification exam. American certification of nurse-midwives was controlled by the profession's national organization, the American College of Nurse-Midwives instead of the government until 1993. In 1993, certification control was assumed by the A.C. N. M. Certification Council, separately incorporated from the American College of Nurse-Midwives. The American College of Nurse-Midwives Certification Council (ACC) used a restricted, multiple answer essay format for its national certification

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exam. 158 The ACC had five to seven active forms of the examination that were administered randomly. Examinations were retired after several years. Each month, preferably the second Saturday of the month, somewhere in the United States, the ACC exam was administered. Rarely, it was administered at two separate locations on the same day. The ACC examination questions were made by an examination writing committee. Committee members donated their time to this work. Topic areas were selected from areas of current midwifery practice as determined by annual American College of Nurse-Midwives task analysis membership surveys (Fullerton 1987). In this manner, new areas of expertise, such as care of the HIV positive woman, were added into the examination. The ACC examination was a six hour written examination. It was glven in three, two hour sections written in one day. Examinations averaged 25-30 questions. There were no revlew books available to prepare for the exam as were available for other American professional exams, such as nurslng, law, medicine. Because the examination coples were re-used, proctors and students took a written oath to preserve the "security" (secrecy) of the examination. Nurse-midwives in practice before 1971 were automatically certified without passing the ACC certification exam. The original exam contained both written and clinical components until 1974, when the clinical component was discontinued (Foster 1986:15). The clinical component was replaced with a

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159 written certificate of clinical competency issued by the basic educational or precertification program. Until 1989, the exam was a norm-referenced exam. In norm-referencing, examinations were graded on a curve and the lowest ranked failed the exam (Fullerton, et al:1989:72,73). Since 1989, the ACC exam is criterion-referenced. Exam questions were weighted according to their importance to maternal and infant safety and their potential frequency of use in nurse-midwifery practice. For example, a question about the management of a postpartum hemorrhage was weighted more than a question about treatment for bacterial vaginosis. Weighting and scoring details were kept confidential by the ACNM Certification Corporation. A national change ln British midwifery certification occurring during data collection in the United Kingdom was the devolvement of the national exam. Naisbitt (1990:430) writes that the process of devolvement began in the 1970s. Groups of midwifery tutors wrote the Central Midwives Board regarding the examination, "which they considered unfair, rigid and did not reflect current midwifery practice or current educational and examination systems in comparison to other professions." When the United Kingdom Central Council and the English National Board replaced the Central Midwives Board in 1983, the time was ripe to change the examination system. The United Kingdom Central Council (UKCC) was responsible for standards of education and professional conduct. The National Boards of each country were responsible for approving (accrediting)

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160 midwifery educational programs and conducting and approving midwifery examin ations. At the time of the closure of the Central Midwives Board, British nursing n o longer used a national e xam, but a process called continuous assessment. British midwifery educators lobbied to use this process for midwifery certification. Even though midwifery training for registered nurses increased from 52 to 78 weeks during the 1980s to meet European Economic Community standards, the pass rates on the national examination remained approximately 75%. In response, the United Kingdom Central Council issued new Midwives Rules in 1986 that contained eight competencies all midwives should achieve during training and a provision for the national examination to be held in parts (Naisbitt 1990:430). As the devolution process began, the United Kingdom Central Council introduced these changes: ( i) (ii) (iii) ( i v) (v) (vi) (vii) (viii) (ix) that the central file examination would be retained in the short term that the written papers would reflect current midwifery practice that the obstetrician s were no longer required as examiners that a moderating committee be established that midwife teacher examiners would be formally prepared for their role ... the examination to register as a midwife would be devolved to the training institution s the course programmes from the institutions would be required to reflect the change that the preparation of all staff, especially clinical midwives, would be required to have a mentor assessor role that continuing assessment of theory and practice was introduced (Naisbitt 1990:431).

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161 Wales was the first United Kingdom nation to adopt continuous assessment in 1987. All students enrolling in English and Scottish midwifery programs after July 1, 1992, were examined using the continuous assessment process, not the national examination. At the time of the study, the Northern Ireland National Board had not yet implemented continuous assessment. The continuous assessment process removed physician control from midwifery evaluation. Midwifery students were assessed by midwifery educators, those who best know their knowledge base and clinical performance. In continuous assessment, a manual was given to each midwifery student at the program start. The manual outlined each assignment, exam, and project that was part of the continuous assessment process. Students had two attempts to pass each exam. Midwifery schools had the latitude to develop their own assignments, exams, and projects. These continuous assessment components were validated by an external examiner assigned to the school by the National Board. For example, King Alfred's College has an external examiner assigned by the English National Board. The Lothian School of Nursing and Midwifery has an external examiner assigned by the Scottish National Board. The external examiner also visited the school a t the end of each term to review the exams and written work contained in each student's portfolio. Self-assessment by the students was incorporated into the continuous assessment process. For example, students at King

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162 Alfred's College were encouraged to keep a learning diary and to discuss learning needs and achievements with teachers regularly. The NorthWest London College used summative and formative exams at the end of each semester in its continuous assessment process. A summative exam was an exam of multiple questions covering specific topics. A formative exam was constructed to reveal the student's application of knowledge base and principles. The formative exam might have been a paper written "Discuss the over a six week period. A sample topic was, social services available to you in the X District to aid an unmarried, unemployed pregnant woman." Students would have learned the available social services and would have worked with those services durinq their clinical work. Students at the NorthWest London College received written exam questions six to eight weeks in advance of the semester's final exam period. They picked four questions to complete. The final exam was administered as two written papers, each allocated three hours writing time. Students were expected t o master the current literature on question subjects and to write from memory. The Solen t School of Midwifery did not assess midwifery students in their first period. The faculty wanted the student t o learn to explain care to the mother and to support the mother instead of studying facts for exams. The Solent faculty also refrained from assessing students during night duty rotations.

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163 The Lothian School of Midwifery was phasing-in continuous assessment and planned to use the Scottish National Board exam until approximately 1995. Lothian used the continuous assessment process to assure that students' clinical skills were correct before they entered antenatal clinic or hospital ward rotations. The Lothian faculty arranged 12 stations in the school's clinical laboratory area. Each station had a clinical skill to be demonstrated and a faculty member to assess that skill. The students moved from station to station and were "signed-off" by the faculty as they demonstrated skills correctly. Students had to correctly demonstrate 10 of the 12 skills. For example, the clinical examination might contain a station where the student was expected to take an obstetrical and medical history from a faculty member, a s t ation where the student had to correctly demonstrate Leopold's maneuvers for determining fetal position, and a station where the student had to demonstrate the correct hand maneuvers to facilitate atraumatic birth of the fetal head. The Lothian faculty based their objective, structured clinical examination on Assessment of Clinical and Practical Skills, written by the Dundee University Centre for Medical Education ln 1985. To increase the standardization of midwifery curricula and the continuous assessment components, midwifery tutors from neighboring programs formed curricula advisory groups. During the study, the faculty of the Solent School of

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164 Midwifery in Portsmouth, had a faculty meeting attended by a member of the King Alfred's College School of Midwifery. The faculty members shared problems and solutions to clinical teaching, departmental budgeting, and assessment of student s progress. Independent Practice. British midwives have been independent practitioners since the 1902 Midwives Act. The work of British midwives did not have to be authorized, signed or examined by a physician. Since 1936, British midwives have been abl e to use anesthetic gases or injections, even in domiciliary work, to relieve pain. Britis h midwives did not need a physician's signature to obtain these medications, as did American nursemidwives. In Florida, a nurse-midwife had to file annually a written agreement signed by a licensed physician that outlined what procedures and medications the midwife could use. The nurse-midwife then had prescriptive privileges for those medications. To obtain physician cooperation, nurse-midwives worked as the employees of physicians or organizations employing both the physicians and the nurse-midwives. Two groups of nurse-midwives were incorporated and paid physicians to be available for consultation. British midwives did not have prescriptive privileges, they were exempt from the pharmacy /prescription laws. To obtain medications, they completed standardized requisitions that were filled by the local chemist (pharmacist). British

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165 midwives were able to obtain analgesics, including narcotics and inhalable nitrous oxide, and oxytocic drugs without physician permission. Unlike nurse-midwives in Florida, who prescribed a variety of antepartum and postpartum medications under protocol, British midwives were limited to analgesics and oxytocics. At the Bramley Surgery near Basingstoke, a community midwife taught a woman about the effects of anemia on pregnancy. She discussed the pathophysiology and reviewed necessary changes to increase the intake of dietary iron to prevent increased anemia. She the n instructed the woman to call the surgery 1 s general practitioner (physician) for a prescription for iron tablets and explained the dose and correct use of the tablets. In Florida, a nurse-midwife would have written the prescription for iron, saving the woman another trip to the office, thereby increasing the likelihood that she would obtain the prescription and use the iron. The British community midwife said that iron is available without a prescription in the United Kingdom, as it is in Florida. Without a prescription, the woman would have been required to pay for the iron. With the prescription, the National Health Service would pay for the medication. The 1986 Cumberledge Report recommended that the Department of Health form a limited list of medications and items that could be prescribed by nurses and midwives (Midwife Health Visitor & Community Nurse 1991:23) .The members of the Royal College of Midwives

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166 voted to petition Parliament for the right to prescribe medications related to pregnancy, childbirth, and family planning during the 1992 annual general meeting. In the United States, the Joint Commission on Accreditation of Health Care Organizations has a standard that requires physical examinations, medication orders, and progress notes written by nurse-midwives to be co-signed by a physician, unless the hospital is located in one of several states where nurse-midwives have legally independent practice. The work of British midwives is not signed by physicians. British midwives do not have to file written agreements with physicians. Registration and state Control of Midwifery. Following certification, a British midwife registered to practice. Registration began the process of state control of practice. Registration of midwives has been the responsibility of the Unite d Kingdom Central Council since the 1979 Nurses, Midwives and Health Visitors Act repealed the Midwives A cts of 1902, 1918, 1926, 1936, and 1951. Each March, midwives intending to practice must register with the United Kingdom Central Council. The notification is sent to the local District Supervisor of Midwives instead of the London United Kingdom Central Council office. In the United States, registration of nurse-midwives was done at the state level. Registration, called licensing, was

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167 managed by legislatively mandated practice boards. Licensing of nurse-midwives was done by state boards of nursing, state boards of medicine, state boards or healing arts, or state boards of midwifery. The trend since 1990 has been to consolidate nurse-midwifery and licensed, direct entry midwifery into one board of midwifery that holds a single standard for the practice of midwifery. New York, Alaska, and New Mexico are among the states that have legislated boards of midwifery. The District supervisor of Midwives. Some British midwives practiced in more than one health district. Therefore, they had to notify each District Supervisor of Midwives of their intention to practice midwifery within the Supervisor's district. Two examples clarify this process. In the first example, a midwife was employed in London. Her husband took a new job in Portsmouth and the family moved with him. The midwife found a new position as a community midwife in Portsmouth. She was employed by the National Health Service as a community midwife of St. Mary's Hospital, Portsmouth. The District Supervisor of Midwives was a position outside of the National Health Service. The midwife had to notify the District Supervisor of Midwives that she intended to practice in her area. The United States has no position analogous to the District Supervisor of Midwives. A nursemidwife registers with the state and does not register

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168 locally. In the United States, state registration is called licensure. The second examples concerns a British independent midwife. The United Kingdom had approximately 100 independent midwives in 1992. Independent midwives were not National Health Service employees. They provided prenatal care in women's homes and attended births in homes or hospitals. Even though independent midwives were self-employed, they had to report to the District Supervisor of Midwives. Independent midwives were not reimbursed by the National Health Service. Families paid cash for independent midwifery services. Women choosing independent midwives were seeking increased continuity in care or wished to give birth at a hospital outside of their district. Because few people could afford independent midwifery, independent midwives often worked in areas as large as 150 square miles. These areas could have included several health districts. The independent midwife had to notify the Supervisor of Midwifery in each district where she cared for women. The District Supervisor of Midwives assured that independent midwives had access to hospitals and the services of an obstetrician when the midwife thought her patient needed those services. The District Supervisor of Midwives assured that independent midwives had hospital access by giving them "honorary contracts" to work within the district hospital (Cronk and Flint 1989:150). A nurse-midwife in Florida who was

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169 unable to find a physician who would sign a written practice agreement with her would not have been able to practice within a hospital. The nurse-midwife had to search for a sympathetic physician, then do the work of applying to join the hospital medical staff. In the United Kingdom, the midwife simply wrote a letter to the District Supervisor of Midwives requesting her help. Cronk and Flint's Community Midwifery (1989:228) contained a sample letter to the DSM that says, I am writing to ask you to send me a notification of intention to practice please as I have today booked Mrs. Janet Baker, 24 Swallow Square, Wrigtown for delivery at home in October with myself acting in an independent capacity. Nearer the time could you also send me a Birth Notification Form and a Guthrie Test Form. I have written to Mrs. Baker's GP, Dr Floris of 63 Manning Grove to ask her if she is willing to provide medical cover for the delivery. If she is not willing I will inform you and in the case of any deviation from the norm in the health of either mother or baby I will refer the mother or baby to the registrar on call for obstetrics or paediatrics at Buckton Hospital. In addition to insuring the ability of midwives to practice, The District Supervisor of Midwives (DSM) was responsible for advertising study days (continuing education programs) to all midwives within the district and providing clinical expertise and support to other midwives. The position of DSM was not necessarily a fulltime position. In many areas, the DSM was also the manager of a hospital midwifery unit. The example of the midwife who moved to Portsmouth illustrates this point. She had to notify the DSM that she intended to practice within the district. In this case, the DSM was also

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170 t h e manager for the Community Midwifery Unit of St. Mary' s Hospital, Portsmouth. The distinction between the two roles, supervisor and manager, became most important when considering t h e last f unction of the District S upervisor of Midwives. T h e DSM assured the quality of p ractice by overseeing the Midwives' Rules of the UKCC. The Midwives' Rules included requirements for notification of intention to practice, specifications for the midwife to attend a refresher course every five years, reasons why a midwife can be s uspended from practice, and procedures for preventing the spread of infection (UKCC Midwives' Rules 1991). If a midwife is practicing i n a manner that jeopardizes the safety of mothers and babies the DSM reported the midwife to the n ational board' s investigating committee (for example, t h e English National Board). The DSM could initiate proceedings that would remove a midwife from the UKCC register, thus making her unable to practice midwifery. The midwifery manager of a hospital unit could o nly discipline a midwife for infractions of organizational rules. A manager could discharge from employment a midwife that habitually broke a hospital' s rules about record keeping, but that midwife could seek employment at other institutions. Once the DSM notified the investigating committee of a practice problem and the committee completed its investigation, it had four options:

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171 No action -Referring the practitioner to the code of practice and saying that they consider that professional misconduct could have occurred but is not proven. -Referral to the professional conduct committee -Referral to the health committee (Cronk and Flint 1989: 136). The professional conduct committee contained five members of the UKCC and a lawyer. The committee held formal hearings and had the power to subpoena witnesses. The professional conduct committee could take four actions at the conclusion of a hearing: -Take no action. -Take no action but refer the practitioner to the Code of Professional Conduct. -Postpone judgement until a future date. -Remove the midwife from the UKCC register (Cronk and Flint 1989:137). There was no analogue of the District Supervisor of Midwives in American Nurse-Midwifery Practice. Professional nurse-midwifery conduct in Florida was overseen by 2 mechanisms. First, as advanced practice nurses, unprofessional or incompetent conduct could be reported to the Florida Board of Nursing, a section of the Florida Department of Professional Regulation. The Board of Nursing had statutory power to investigate nurse-midwifery practice and revoke a license. There had never been a nurse-midwife appointed to the Florida Board of Nursing. Therefore, midwifery practice could be judged by advanced practice nurses who had no experience

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172 with midwifery practice. Second, at the hospital level, the medical staff reviewed cases for misconduct or unprofessional practice. Once again, the nurse-midwive's work was reviewed not by peers, but by physicians who were in economically competitive positions. An American nurse-midwife accused of substandard or unethical care could be reported to the American College of Nurse-Midwives. The College had a disciplinary committee that could investigate charges against a midwife The Disciplinary Committee could: -dismiss charges -censure the nurse-midwife -decertify the nurse-midwife. Decertifications were published in the bulletin of the American College of Nurse-Midwives. A method existed for nurse-midwives who had been decertified to petition the Disciplinary Committee for readmission into the College of Nurse-Midwives. Midwifery Access to Hospitals. Nurse-Midwives in the United States did not have guaranteed access to hospital practice. Hospital personnel in the United States were organized into two groups: hospital employees and medical staff. Hospital employees included the nursing staff, housekeepers, cooks, and administrators. The medical staff was comprised primarily of physicians who were self-employed. The medical staff

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173 physicians formed a group or groups of physicians by specialty to govern the practice of medicine within the hospital. The medical staff was meant to oversee the quality of care by reviewing each other's clinical skills and providing continuing education for its members. Any physician wishing to practice at a hospital had to b e approved by the medical staff credentialing committee. Medical staffs also admitted nonphysician health care providers, such as psychologists, dental surgeons, and podiatrists, to the medical staff. Full active staff could admit, care for, and discharge patients from the hospital independently. In Florida, as nurse-practitioners, nurse-midwives applied to be members of a hospital's medical staff. The standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) placed nurse-midwives within a category called Allied Health Provider. Allied Health Providers were supervised by physicians. Physicians were r equired to sign the written history and physical exams of any Allied Health Provide r to comply with JCAHO s tandards. This placed physicians in control of nurse-midwifery hospital practice. The Department of Health. The United Kingdom Central Council and the national boards were statutory organizations. As such, they did not negotiate with the European Economic Community (EEC). That was done by the government. The English Department

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174 of Health, with input from Scotland, Wales and Northern Ireland, was the governmental division that spoke for midwifery at the EEC. The Minister of Health, who headed the Department of Health, reported to the Secretary of State and the Prime Minister. Seven health ministers, three from the House of Commons and two from the House of Lords, a lso directed the work of the Department of Health. Based on the national budget, the British Treasury parcelled out funds t o the Secretary of State for the Department of Health. The Department of Health channelled these funds to the 14 regional Health Administrations of the National Health Service The Department of Health was also responsible for health research and the production of health educational materials. The English Department of Health employed 4 0 nurses; s1x were midwives. Scotland, Wales, and Northern Ireland also had Departments of Health. However, thos e countrie s were so small, their Ministers of Health managed other government areas. For example, the Scottish minister was the Minister of Health and Education. The w h o l e of Scotland was smalle r than the W est Midlands Health Administration that included the city of Birmingham. One section of the Department of Health was responsible for the Maternity Services. The Maternity Services administrative team included an obstetrician, a midwife, an

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175 administrative nurse, a pediatrician and a general practitioner. The Department of Health's Midwifery Officer, estimated that 8 0% of the team' s work week was spent in research to be used for the formation of Maternity Services policy. The Department of Health had grant and contract money for voluntary organizations t o help with its research. The Stillbirth and Neonatal Death Society, for example, received a contract to set the guidelines for bereavement care. The Department of Health also funded the researc h that supported its recommendation that m idwifery education be changed from postnursing registration to direc t entry (pre-registration) The D epartment of Health produced educational literature for patients and practitioners. The Department of Health pamphlet on Cot Death (Sudden I nfant Death Syndrome) was aimed at c h anging the practice of midwives and health visitors from advising that babies sleep on their stomach s to advising that babies sleep on their sides or their back. Department of Health and British manufacturers' handouts list m idwives as primary care providers. Very 1 i ttle information using the designation "nurse-midwife," "midwife," or the neutral "health care provider" is available in the United S t ates Most pamphle t s refer to "your physician only. The Department had previously funded a study that showed t hat infants who placed t o prone t o sleep had higher rates of cot death. The Cot Death pamphlet was given to families to change their infant care.

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176 For many years previously, midwives and health visitors had advised families that babies who slept prone were less likely to choke to death on their own secretions. The research and education done by the Department of Health changes midwifery practice. The small sizes of Wales, Scotland, and Northern Ireland prevented their Departments of Health from doing their own health research. Most often, English work is adapted. The English Department of Health writes pamphlets in a general m anner so tha t the other countries are able to use the same pamphlets marked as produc t s of their Departments of Health. The National Perinatal Epidemiology Unit funded by the Department of Health incorporated social science, epidemiology, and economics findings t o produce Effective Care in Pregnancy and Childbirth (Chalmers, Enkin, & Keirse 1989). The two volume set reviewed all the research available in maternity care, then gave guidelines for effective care. The 732 page, 2 volume set was distributed by the Department of Health t o each maternity unit during 1992. (It's c ost in July 1992 was $443 American.) Effective Care included chapters o n midwifery care. The British Commonwealth and Midwifery. T h e Britis h Commonwealth was formalized by the Statute of Westminster in 1931. Most member states joined the Commonwealth after 1945 (Haigh 1985:318). The r e were no legal or con stitutio n a l

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177 obligations involved in Commonwealth membership, although Queen Elizabeth was acknowledged as the head of the Commonwealth. Of the Commonwealth Nations (Table 4), 28 were republics, five were monarchies separate from the United Kingdom, and 17 acknowledged Queen Elizabeth as the head of state (HMSO 1992:2). Membership in the Commonwealth provided for consultations between governments and cooperative work in the areas such as agriculture, health, law, d e velopment and education. Webb wrote that the relative prosperity of the United Kingdom during the 1950s and 1960s served as a magnet to the poor and ambitiou s in colonies and former colonies in Asia, Africa, and the West Indies: it was said that a quarter of the world' s populatio n wa s eligible to come to live in Britain, because as residents of the Empire they were British subjects and because Britain, unlike almost all other countries, had imposed n o limitation o n immigrants (Webb 1980:617).

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178 Table 4. British Commonwealth Nations. Year of Joining 1931 1947 1948 1957 1960 1961 1962 1963 1964 1965 1966 1968 1970 1972 1973 1974 1975 1976 1978 1979 1980 1981 1982 1983 1984 1990 Country Australia, Britain, Canada, New Zealand India, Pakistan Sri Lanka Ghana, Malaysia Nigeria Cyprus, Sierra Leone Jamaica, Trinidad and Tobago, Uganda Kenya Malawi, Malta, Tanzania, Zambia Gambia, Singapore Barbados, Botswana, Guyana, Lesotho Mauritius, Nauru, Swaziland Tonga, Western Samoa Bangladesh The Bahamas Grenada Papua New Guinea Seychelles Dominica, Solomon Islands, Tuvalu Kiribati, St. Lucia, St. Vincent and the Grenadines Vanuatu, Zimbabwe Antigua and Barbuda, Belize Maldives St. Christopher and Nevis Brunei Namibia From: Britain and the Commonwealth, 1992, Central Office of Information, London: Her Majesty's Stationary Office.

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179 Midwifery scholarships were available through Commonwealth projects during the study. The Commonwealth Nurses Federation 11seeks to promote nursing and midwifery as professions, to foster regional co-operation and education projects, and to provide information among member societies (HMSO 1992) .11 This political cooperation i n midwifery education has spread the British model of midwifery to all Commonwealth Nations. All applications from overseas midwives to have British registration were reviewed by the United Kingdom Central Council. The UKCC registration department collect e d the applications, transcripts, references, and registrations from other countries. All completed applications were reviewed by one midwife. This amounted t o approximately 1,000 applications per year. Most of these midwives did not intend to work in the United Kingdom. Many voluntary service organizations, mission projects, and governments accepted the British midwifery registration as the 11gold standard11 of midwifery practice. Once British Registration was obtained, the midwife was given reciprocity to practice in other countries. To become regis tered in the United K ingdom, the educational background of the foreign midwife h a d to meet all of the European Economic Community Directives for midwifery. If the applicant had clinical deficiencies, those deficiencies had to be corrected by working in the United Kingdom. American nurse-midwives, f o r example, often lacked sufficient medicalsurgical nursing experience to qualify as a British registered

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180 midwife and were required to do 6 months of medical-surgical nursing in the United Kingdom before registra tion. Prior t o t h e introduction of direct entry midwifery, British midwifery students were paid employees. Foreign midwives were able t o receive pay while making-up their deficiencies. Since 1992 British s tudents are supernumerary staff, making a reduction in sites available for foreign midwives. Most foreign midwives were judged by the United Kingdom Central Council to have some experience deficiencies to overcome. It was difficult for the United Kingdom Central Council to compare the independence and community midwifery components of the British midwifery construction to other countries' constructions of midwifery. European Economic community support of Midwifery. The United Kingdom had to change its midwifery educational syst e m in response to the European Economic Community standards. The United Kingdom had the only European midwifery system where the majority of midwives were registered general nurses before entering 18 month midwifery educational programs. In other European countries, students entered 3 year midwifery programs directly. British schools h a d t o implement 3 year, direct entry midwifery education to conform with other Economi c Community countries. These programs also taught suturing and the use of family planning methods to comply with the Economic Community Midwives Directives (Appendix 5)

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181 The United Kingdom had 92 males (. 09% ) qualified to practice midwifery in 1992. Fifty-three (.15%) of those qualified male midwives registered to practice in 1992. For many years, the Royal College of Midwives denounced males in midwifery. In 1987, the European Parliament passed legislation requiring all member states to allow male midwives to work in their hospitals (Elgey 1987:6). Men have had equal access to American nurse-midwifery programs since the 1964 Civil Rights Act. The American College of Nurse-Midwives did not record certification or membership by sex. In the 1987 survey of its membership, 3 5 ( 1. 5%) of its respondent s were male (ACNM 1987). Complying with European Economic Community standards also strengthened the maternity leave entitlement for British women. The Economic Community directives guaranteed women 14 weeks maternity leave with pay at the minimum rate of their country' s statutory s ick pay regardless of t h e length of time in employment (Beecham 1992:980). Britain' s maternity leave was originally tied to length of time in employment. The Economic Community standards opened access to paid maternity leave to all Britis h wome n Economi c Variabl e s Influe ncin g Midwifery Practic e The s uccess of midwifery as an autonomous occupation is closely tied to the structural arrangements for the payment of services (DeVries 1992:4).

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182 Economic factors contribute to the cultural construction of midwifery. These economic factors include the health system, the professional organization of midwifery, the professional organization of nursing, competition between maternity care providers, employment opportunities for midwives, a n d malpractice liability. The Health Care system. In addition to the Poor Laws, Robert Owen s New Lanarkshire Community set health care precedents for the National Health Service (Rose 1985:277). Owen, influenced by Engel' s The Conditio n of the Working Class in England that implicated capitalistic industrialization as a cause of poor health, set out to make the N e w Lanarkshire cloth mills a model community. Private housing was built for the families of New Lanarkshire. Education, including mus i c art and dance, was available t o all even adults. Free health care wa s provided to workers and their families. W ome n were g1ven m aternity leaves and later provided with day care services for the work day. Owen s vision of universal access to health care is cited in the United Kingdom as influencing nineteenth century industrialists and European health planners (Rose 1985:276). Whe n the National Health Service was formed in 1 9 4 8 the United Kingdom had a war decimated population with the beginnings of a postwar baby boom. The British call this the period of austerity. Rationing of fuel, clothing, and many

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183 consumer good continued after the war. Food rationing was not lifted until 1954 (Haigh 1985:325). The National Health Service guaranteed access to health care for all British citizens. Its single-payor, capitation system with hospital ownership, state control of pricing, and state employment of health care workers has been acknowledged as being the most efficient method of providing universal access to care (Hanneman, Hage, and Hollingsworth 1990). British midwifery's relationship with the National Health Service has been symbiotic: Without inclusion in the National Health Service as primary maternity care providers, midwifery in the United Kingdom would have perished. Without midwifery, the National Health Service could not have provided cost-effective maternity services. Most practicing British midwives were employees of the National Health Service. With hospitals and physician practices organized within the National Health Service, British midwives had one organizational culture to learn. Figure 5 illustrates midwifery employment in the United Kingdom and the United States. Many authors including Doyal (1979), McLachlan (1975), and Webb (1980), describe the shortcomings of the National Health Service including understaffing, underfunding, and low morale. Since the inception of the National Health Service, a limited number of private beds were available in British hospitals. Private insurance policies were available for those

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184 who could pay for extra coverage. Private insurance could be used to "que-jump," to obtain services instead of waiting for treatment with the National Health Service. The government moved to eliminate private beds in the 1970s (Webb 1980:614). At the time of this research, private insura nce and private hospital beds still existed in the British system. Whatever the shortcomings of the National Health Service, Webb (1980:614) wrote that, "its centrality in the system of social services is unassailable. The United States did not have a unified national health system. Individual American citizens were responsible for purchasing their own health care within a patchwork of

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185 Figure s. Midwifery Employers in the United Kingdom and the United States. NHS HOSPITAL MMMMMM PUBLIC HOSPITALS /1-----------CNM CNM CNM THE UNITED KINGDOM THE NATIONAL HEALTH SERVICE NHS HOSPITAL MMMMMM NHS HOSPITAL MMMMMM THE UNITED STATES PUBLIC HEALTH UNITS CNM CNM CNM CNM FEDERAL COMMUNITY AND MIGRANT HEALTH SERVICES ARMED SERVICES ....-----1-----CNM CNM CNM UNIVERSITIES -----1-------CNM CNM CNM CNM CNM CNM BUREAU OF INDIAN AFFAIRS -------r----cNM CNM CNM NHS HOSPITAL MMMMMM NATIONAL HEALTH SERVICECORPS CNM CNM CNM HEALTH MAINTENANCE ORGANIZATIONS ------r-----_ CNM CNM CNM PROFESSIONAL ASSOCIATIONS (Physicians) CNM CNM CNM

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186 independent health care systems. Nurse-midwives were employed by a variety of public and private employers (Figure 5). The diversity of nurse-midwifery employers forces nurse-midwives to learn and relearn organizational cultures as they change employment. Even within employment by a single organization, an American nurse-midwife may practice within two or more organizations. Figure 6 illustrates the organizational affiliations of British and American midwives. In the United Figure 6. Midwives' Organizational Affiliations in the United Kingdom and the united states UNITED KINGDOM Employment Organization Hospital of Intrapartum Practice UNITED STATES 1-------------------Employment Organization -------------------r-----------------------1 Hospital of Intrapartum Practice

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187 Kingdom, with the National Health Service as a single employer, even the community midwife providing care at community surgeries and attending births at the district hospital worked within one organizational culture. In the United States, the nurse-midwife could have been employed by one organization while attending births in a second organization. The separate American health care organizations could have conflicting purposes and goals. For example, a nurse-midwife could be employed by a federal community health center, whose goal was to provide health care to all regardless of ability to pay. The same nurse-midwife could attend births at a for-profit hospital, whose goal was to maximiz e profit by admitting only patients with private insurance. The fragmentation of the American health care system uses nurse-midwifery time in learning and conforming to a variety of corporate cultures that could be spent in increased patient care. American health care was provided by two funding sources: 1) private insurance for those who can purchase health care coverage, and 2) public funding for those who are unemployed, disabled, or have insufficient earnings to purchase health care coverage. Private insurance coverage was sold predominantly by profit-making corporations. Insurance policies varied in what services are covered as benefits and which providers would be paid by the policy. Publicly funded health care was provided by many sources such as county health

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188 departments and the National Health Service Corps. American public health funding originated at the city, county, state, or federal levels of government. American nurse-midwives had to collect fees for their services. Whether they billed for their own care or their billing was done by their employers, nurse-midwives had to be fluent in the rules and restrictions of many third party payers. A nurse-midwife not skilled at billing for care could provide care t o women without funding and operate a deficit practice. Table 5 illustrates the contrast in British health care, where funding remains within the Nationa l Health Service. British midwives were salaried employees of the National Health Service and did not have to worry about how their patients would pay their bills. In the United Kingdom, women were give n care regardless of their ability to pay.

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189 Table 5. Funding Sources for M idwifery in the United Kingdom and the Un ited States. UNITED KINGDOM District capitation l NHS salaries UNITED STATES Medicaid Medicare Champ u s Bureau of Indian Affairs Federal grants State grants Private insurers: Blue Cross/Blue S hield Aetna Prudential Managed contracts: Cigna Health Options Prucare Self-insured business: Lykes-Pasco General Telephone Tampa General Hospital

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190 American nurse-midwives did not have a secure place within American health care systems. Nurse-midwives had to legislate the ability to obtain insurance reimbursement state by state. American nurse-midwifery did, however, have strong ties with national health needs. Almost half of American nurse-midwives reported that their primary work site was located in a federally designated health professional shortage area and more than 50% of the work done by nurse-midwives was paid for by Medicaid, Medicare, the Indian Health Service, or other agencies providing free health care (Scupholme et al. 1992:344-347). Professional Midwifery organization. Three professional organizations represent only British midwives: The Royal College of Midwives, The Association of Radical Midwives, and the Independent Midwives Association. The American College of Nurse-Midwives and the Midwives Alliance of North America are the professional organizations representing midwifery in the United States. The Royal college of Midwives. The Royal College of Midwives is the oldest British midwifery organization. Its forerunner, the Trained Midwives Registration Society was formed in 1881, and later changed its name to the Midwives Institute. The Midwives Institute furthered British midwifery by organizing a series of midwifery lectures to improve

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191 midwifery education, forming a midwifery library, and working for legislation that secured practice rights for midwives (Royal College of Midwives 1991). The Institute's midwifery practice bills were defeated nine times, then were successful in 1902 with the passage of the first Midwives Act. The Midwives Institute changed its name to the College of Midwives in 1941. The name mirrors the style of British medical societies such as the Royal College of Obstetricians and Gynecologists and the Royal College of Surgeons. King George conferred the Royal prefix to the College in 194 7 (Royal College of Midwives 1991). The Royal College is the largest organization representing midwives in the world. More than 80% (35,000) of British midwives belong to the Royal College of Midwives. The Royal College represents post-registration and direct entry midwives, midwives employed by the National Health Service and midwives employed independently. The Royal College works with foreign governments and other midwifery organizations to provide expert knowledge on midwifery. For example, during the time the British study itinerary was being arranged, the Director of Education for the Royal College, was in Tanzania advising schools on methods of midwifery education. The Members Services division of the Royal College was divided into five branches: education, industrial relations (union activity), professional, administration, and finance. The director of each department was accountable to the General

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192 Secretary. The General Secretary's position was analogous to that of an executive director of an American professional organization. In 1992, the Royal College had 19 registered midwives who were paid employees of the Royal College and 15 nonmidwife staff members (RCM 1992:6,7). The Royal College had paid staff organizing these divisions: -Professional Affairs -Press & Parliamentary -Industrial Relations -Education -Library -Membership The Royal College of Midwives was governed as a representative democracy (Figure 7). Members were assigned to one of 224 local branches. Branches sent one delegate to the annual general meeting of the Royal College empowered to vote on motions for the branch. Each of the United Kingdom countries: England, Scotland, Wales, and Northern Ireland elected three members to form the 12 person Royal College council. A president and treasurer were elected separately. An additional 12 council members were elected by the general membership of the Royal College. The Council met six times a year and selected its own chairman. Royal College branch delegates were brought into the London headquarters once a year for leadership training. Branches held monthly meetings.

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193 Figure 7. Structure of the Royal College of Midwives Council. President Immediate Past President Honorary Treasurer N. Ireland Wales 1 2 3 England 1 2 3 1 2 3 (elected by branch members in each of the 4 countries) 1 2 3 4 5 6 7 8 9 10 11 12 (elected by the general UK membership) BRANCH MEMBERS Scotland 1 2 3 From: The Royal College of Midwives. Membership. 1992: 2

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194 Association of Radical Midwives. A second, smaller professional organization supports British midwifery: The Association of Radical Midwives (ARM) formed in 1976. A group of midwifery students, perceiving the increased medicalization of British midwifery founded ARM (Towler and Brammel 1986:275). ARM members interviewed in the United Kingdom estimated its membership to be near 400. When asked about ARM, members invariably prefaced their comments by saying, "It's not really that radical ... Radical was selected for its literary meaning, relating to roots and origins, and best expresses the hopes that midwifery could find its way back to a position where midwives' skills were used to the full while still taking full advantage of the benefits of modern technological advances, where these are seen to be in the best interests of the woman and the child. In other words, the hope that the true meaning of midwife ("with woman") will once more be realized (Midwifery Matters 1992:i). The Association for Radical Midwives was a volunteer association with one staff member who was paid for 25 hours a week at the rate of a British E grade post. The ARM was comprised of local groups that centered on the support of midwives, especially those committed to traditional care. ARM published its own quarterly journal, Midwifery Matters. All the midwifery faculty members interviewed in the United Kingdom were ARM members. ARM had the following objectives: 1. To re-establish the confidenc e of the midwife in her own skills. 2. To share ideals, skills and information. 3. To encourage midwives in their support of women's active participation in birth.

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195 4. To re-affirm the need for midwives to provide continuity of careers. 5. To explore patterns of care. 6. To encourage evaluation of development of our field (Midwifery Matters 1992:i). The goals of ARM seemed to be restatements of the goals of the Royal College of Midwives. One British midwife tried to explain the difference by saying, "The Royal College works for itself and the NHS. ARM works for women." Another said disdainfully, "The RCM? They're old stodges. It's an old ladies' sewing circle." The Vision, ARM's 1986 publication, gave a clearer picture of ARM's intentions. The Vision called for: -Informed choice in childbirth for wome n -Continuity in care for all childbearing women Women would be cared for by small groups of midwives. General practice physicians would provide medical care, but generally not antenatal and birth services. Women would retain the option of GP care. Community based care -60-70% of midwives will work in community based groups of 2-5 midwives -30-40% of midwives will be hospital based in teams. These will work with physicians to car e for the 15% of women experiencing pregnancy or birth complications. -Full utilization of midwives' skills -Midwifery will be the entry to care for all women. -Midwifery training will be primarily by a 3 year, Direct Entry course. Post-registration will continue to be an option for qualified nurses (ARM 1986:2-6). The ARM in conjunction with the feminist lobby set-up a working party to promote direct entry midwifery in the 1970s (Towler and Bramall 1986:44). Direct entry midwives, they

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196 hoped, would be less influenced by the medical model of care . None of the ARM members interviewed during the study knew of the American College of Nurse-Midwives. However, they were all familiar with the Midwives Association of North America (MANA), a smaller organization with a membership that includes American midwives of all educational levels. The ARM had sponsored a trip for Ina May Gaskin, the author of Spiritual Midwifery and a founding member of the Midwives of Alliance of North America, to lecture in England. Typical of many MANA members, Ina May learned her midwifery by practice on a rural cooperative during the 1960s. She had been instrumental in organizing granny, lay, and American licensed midwives. ARM members sought to learn Ina May's philosophies of womencentered care and spiritual midwifery to r einforce those philosophies in British midwifery. Independent Midwives Association. The third professional organization that supported British midwifery was the Independent Midwives Association founded in 1985 with the goal to improve support and communication between selfemployed independent midwives (Isherwood 1989:309). The Association was formed with 3 members and had grown to approximately 100 members in 1993, with most of the growth during the 1990-1993 period. All members were midwives who practiced independently. There was no American association or

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197 subgroup within the College of Nurse-Midwives for privately employed midwives. The American College of Nurse-Midwives. With the exception of the midwifery library and union activities, the American College of Nurse-Midwives served the same functions for American nurse-midwifery as did the Royal College of Nurse-Midwives for British midwives. The American College of Nurse-Midwives evolved from the American Association of NurseMidwives formed in 1928. The American College of NurseMidwives was chartered in 1955 with a membership of 124. By 1984, the membership had grown to 2,534 (Varney 1987:11), and was 3 ,936 in 1992 (ACNM 1993:16). Table 6 compares the goals of the British and American midwifery professional organizations.

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198 Table 6. The Goals Of Midwifery Professional Organizations. ROYAL COLLEGE OF MIDWIVES 1. enable midwives to fulfil their role as autonomous, accountable practitioners from the point of registration 2 enable the setting, maintenance, development, evaluation and regulation of standards 3. enable the development of a research-based body of knowledge to underpin practice 4. enable the provision of education to equip the midwife to work in a variety of settings 5. enable professional representation in public debate to promote and support a high quality maternity service 6. enable the provision of an ethical framework for practice and client advocacy where appropriate AMERICAN COLLEGE OF NURSE MIDWIVES 1. to insure the right of practice for every CNM 2. to maintain and enhance the quality of nursemidwifery care 3. to increase the body of knowledge about nursemidwives and nursemidwifery practice 4. to evaluate and promote nurse-midwifery educational programs 5 to increase understanding of nurse-midwifery practice and promote the professional image of the nurse-midwife to consumers, health care professionals, and potential students 6 to promote the ACNM as a national and international leader and resource in maternalchild health 7. to insure the financial stability of the ACNM From: Royal College of Midwives, 1992,. A. Philosophy for Midwifery, and American College of Nurse-M1dw1ves, 1992 Annual Reports.

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199 In 1992, the American College of Nurse-Midwives had 6 nurse-midwives who were a paid employees. One headed the Special Projects Division, a division that seeks funded, midwifery-related projects to provide income for the College. Four were project coordinators for Special Projects and one directed the Division of Professional Services and Support. The American College of Nurse-Midwives had an additional 19 paid staff members (ACNM 1993:10). The American College of Nurse-Midwives had paid staff members to organize membership and professional affairs. Unlike the Royal College, The American College depended heavily on the volunteer effort of its members. Volunteer members chaired and staffed the following ACNM Divisions and Committees: -Division of Accreditation (included educational accreditation site visitors) -Division of Publications (included editors and peer review personnel for The Journal of Nurse-Midwifery) -Division of Research -Committees: Archives, Bylaws, Clinical Practice, Continuing Competency Assessment, Continuing Education, Disciplinary, Education, International Health, Membership, Nominating, Nurse-Midwives of Color, Political and Economic Affairs, Program, Professional Liability, Publicity and Public Relations Ad Hoc Committees:Homebirth, Peer Review, Precertification

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200 Figure 8. Organizational Structure of the Amo :ican College of Nurse-Midwives An..t.ll.w-y o.,.nuau..... AC* found. I ......... AC* CoM. Co.r4.1ll IOMO rr IUJUTOIS Vio. Pr .. lct.nt s.cr.t&rJ r,.........,....r .... l Rep. ... ll Rep. ... Lon lll ...... I V Rop V Rop I -.ion VI Rop. Dlvhlonei'(QIP'IIr&l t t .. 01vh10f.,. Oiv of Aoor.dltation Oiv or P'ubl1o.at1or w Oiv of hee&t"'h h"'ohive n1t ... Cl 'rot1oe on Cd. tont. (duo.aUon Cont. t-. ,._, Dloclpli,_.y Cdvotlon )ntl. HMl tj, w.,.e,rehl p ,.._... o f Color Noain.&tlf'l9 roc. ""'r. U&.b111 ty .. l"'ubllo Relatio n loatlon /1.4 Hoo c.or..J.tt ... From: American Col J.ege of Nurse-Midwives. Membership Directory and Handbook 1992-1993. 1992:22.

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201 The American College of Nurse-Midwives (ACNM) was a smaller organization both in numbers of members and structure than the Royal College of Midwives (Figure 8). The ACNM had seven regions that included the continental United States, Alaska, Hawaii, Puerto Rico, and Guam. Within these regions, local nurse-midwives formed chapters. Chapter formation required a minimum of five members who were ACNM certified nurse-midwives. Florida, for example, belonged to the Southeast Region III. The entire state had one Chapter with approximately 130 members. With more than 300 certified nursemidwives practicing in the state, the ACNM Florida Chapter represented less than 50% of the state's nurse-midwives. The membership of each region elected a regional representative who became a member of the ACNM Board of Directors. The general membership elected a President, VicePresident, Secretary, and Treasurer. Any ACNM member could attend the annual convention and its business sessions. Since 1990, more than 1,200 certified nurse-midwives have attended each convention. Motions were voted on by the general membership during business sessions and referred to the Board of Directors for implementation. Midwives Alliance of North America. The Midwives' Alliance of North America (MANA) was formed in 1982 from the union of state and local midwifery groups that represented licensed, non-nurse midwives. MANA used the World Health

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202 Organization definition of midwifery and accepted into membership any midwife regardless of educational preparation (MANA 1992) The MANA organization worked to maintain a construction of midwifery that is free of control by medicine or nursing. In 10 years time, MANA was able to organize an international structure, organize annual conventions, and develop an international certification exam. MANA conventions have continuing education seminars that include not only updates on technical skills, but sessions on intuitive skills, and complimentary therapies such as moxibustion during pregnancy. The Midwives' Alliance listed these goals: -Expand communications and support among North American midwives; -Represent and respond to the needs of midwives on a regional, national, and international basis; -Assist in the development of core competencies and midwifery educational models that support multiple routes of entry into practice-including apprenticeship; -Establish midwifery care as a quality health care option and assure its accessibility to women and their newborns; -Promote research in the field of midwifery care; -Foster cooperation between midwives and other professionals and non-professionals concerned with improving the health and w ell-being of mothers and babies; and -Affirm eac h women's right, ability and responsibility to choose appropriate health care providers and services (Midwives' Alliance of North America 1992).

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unionization. 203 The United Kingdom had a long history of -unionization. The National Health Service had more than 40 recognized unions. During the 1980s, more than 50% of the British work force was unionized (Carpenter 1988: 76). The British Medical Association negotiated directly with the Government. The predominant unions affecting British midwifery were NALGO, COHSE, The Royal College of Midwives, and the Royal College of Nurses. The National Poor Law Officers Association was founded in 1885 to be the union for poor house m asters, poor law doctors, and poor house nurses. The National Poor Law Officers Association was absorbed into the National and Local Government Officer's Association (NALGO) in 1935 (Carpenter 1988:317). NALGO had a reputation for being a white collar union. It represented governmental professional grades including nursing (S ethi and Stuart 1982:76). The National Asylum Worker' s Union formed in 1910 and became the Mental Hospitals and Institutional Workers' Union (MHIWU)in 1931. The MHIWU merge d into the Co nfederation of Health Service Employees (COHSE) in 1946 (Carpenter 1988:15). Part of COHSE' s strength came from its numbers of nurse members, particularly psychiatric nursing (Sethi and Stuart 1982: 76). A new union, UNASYN, was projecte d to cover 50% of the health care workers in the United Kingdom. During the 1992 annual general meeting the Royal College of Midwives d ebated

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204 a motion to expand its union activities to include health care assistants. At that time, the medical doctors were recruiting surgeons and doctor's assistants to increase their lobbying power. Although some British midwives viewed the inclusion of health care assistants as a method of increasing the membership strength of the Royal College of Midwives, their inclusion would have jeopardized the standing of the RCM with the International Confederation of Midwives. The motion was defeated. The Royal College of Nursing (RCN) had union status to represent nurses. NALGO, COHSE, and the RCN had the potential to affect British midwifery because some of their nurse members were midwives. The United Kingdom had 105,587 qualified midwives in 1992. Only 35,013 registered to practice as midwives. The other 77,574 were registered general nurses who studied midwifery for promotion. The Royal College of Midwives represented midwives exclusively. The RCM claimed to represent 85% of British midwives. An industrial relations officer from the RCM said that the union activities of the RCM were especially important as parts of the NHS were privatized. For example, as hospitals were allowed to choose trust status, allowing them to set their own prices and wage structures, the RCM had to be recognized as the representative of midwives at the local level to prevent wage and work disparities among midwifery positions.

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205 British health unions grew in response to the reorganization of health care during the 1960s. During the 1960s and early 1970s, Britis h health care districts were reorganized, taking health care out of the community and strengthening large district hospitals, s u c h as st. Mary's in Portsmouth. Sethi and Stuart (1982:83) wrote that the management o f the large district hospital s was i mpe rsonal, bureaucratic, and increasingly modeled on private industry. They compared the growth of health service u nion s from "the health factories of the 1960s and 1970s" to the "trade unionism tha t grew out of the indu s trial factories of the nineteenth century" (Sethi a n d Stuart 1982:83). D uring the s tudy, the Simpson Pavilion Community Midwifery Service was l n a turmoil over the planned loss of a room approximately 10 feet by 30 feet. The hospital administration wanted the room for additional office space. T h e room, called the coffee room, was used as the mornlng assignment room It contained a refrigerator for food and the tea stand and a telepho n e for outreach calls. Loss of the room would leave the 14 community midwives with one 30 feet by 30 feet room tha t contained their paper and medical supplies, lockers, two desks and telephones. Loss of the smaller r oom would mean that the staff had no meeting room, no r oom for private telephone conversations with patients, and no room for the refrigerator and tea stand. The community midwives picked a representative from t heir staff to meet with administration

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206 immediately. They also planned to invite the administrators to their regular Monday morning meeting so that the administrators could see how cramped the space was. Then, if they received no "satisfaction," they would contact the Royal College of Midwives. Competition With Physicians. Prior to 1948, the British community midwife was the sole connection between a woman and the maternity services. British physicians had never desired domiciliary practices. Domiciliary practices were time inefficient and involve a large measure of charity care (Donnison 1977:92). As the National Health Service was being formed, general practitioners saw a practice opportunity: they lobbied and won the right to a capitation fee from the health authority for prenatal care. A woman could have a general practitioner attend the birth without paying a fee. Midwives had to be paid separately, leading to a trend away from the use of midwives (Robinson 1989:177). The Briggs report of 1972 called for teams of consultants, general practitioners, and midwives to provide medical and midwifery care for the Maternity Service. Midwives continued to attend most British births, filling the role of the American hospital labor and delivery nurse and the American obstetrician at the time of birth. The Health Services and Public Health Act of 1968 required all hospitals to provide a domiciliary maternity service. Watkin (1975:164)

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207 writes that this was intended to enable midwives to have the benefits of hospital employment and to enable the National Health Service to deploy midwives as most needed. In effect, midwives were brought under physician-directed hospital policies and domiciliary births were discouraged. In addition to the general practitioner, a three-tiered system of obstetricians-gynecologists provides care for complicated cases (Dowie 1991:4-11). Duty doctors or house officers occupied the first level of the medical system and are the equivalent of American hospital residents. The house officers were junior doctors who waited in residency housing until summoned by the midwife for cases needing medical or surgical care. The registrar filled the second level of responsibility. The registrar was most often a full-time contract position with the National Health Service that included academic lecturing and research. Registrars were expected to have a diploma from the Royal College of Obstetricians and Gynecologists. The most specialized of the British obstetriciangynecologists were the consultants, who were accredited by the Higher Training Committee of the Royal College of Obstetricians and Gynecologists (Dowie 1991:9). Much of the consultants time was spent in antenatal clinics, particularly in the early detection of fetal anomalies (Dowie:7-9). The consultant was analogous to the American perinatologist if specialized in obstetrics, and the gyne-oncologist if

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specialized in referral basis gynecology. Con sultant u nits as did American tertiary 208 opera ted o n a care centers. Consultant units averaged 1,500 to 3 ,000 births per year. Employment Opportunities. In July of 1992, the 20 students who had graduated from the Lothian School of Midwifery 1n April had returned to their guaranteed nursing positions o r were "on the dole" because there were n o midwifery openings. Likewise, the majority of Portsmouth graduates had no employment prospects. critical shortage of 1986:1). Yet in midwives 1986, authors warned of a (Massaro 1986:21, Brindle Several factors converged to limit midwifery employment opportunities in the 1990s: Midwives returned to work after marriage and childbirth, wh e n previously they retired from practice. -The National Health Service and the Royal College o f Midwives actively recruited retired midw ives back into practice. -With high unemployment, many midwives continued work to support their families when husbands were unemployed or underemployed. -The British birth rate dropped as the large post-World War II g e neratio n aged-out o f reproduction. Over the years 1983 to 1989, the annual births in England

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209 increased by almost 10%. Then, the rate fell during 1990 (Dowie 1991:91). At the same time, the annual cohort of midwifery students fell by about 21 percent due to the closing of smaller schools of midwifery (Dowie 1991:91). During the shortage of midwives, the National Health Service worked to recruit part-time and retired midwives back into the work force. The Royal College of Midwives worked with eight colleges to offer reorientation to midwifery courses. It was more cost effective to reorient midwives out of practice than to educate new midwives. During the 1980s, the postpartum length of stay decreased from 1 week to an average of 4 days, decreasing the need for hospital midwives (Dowie 1991:20). The National Health Service did not have manpower projections to plan the numbers of midwives to be educated. Therefore, many districts educated more midwives than were needed in practice. The low birth rate of the 1960s and the 1970s coupled with immigration restrictions will keep the birth rate low during the 1990s and past the year 2000. The low birth rate of the 1960s and 1970s was expected to mean fewer applicants to midwifery programs (Redford and Thompson 1988:46). In spite of this demographic self-correction, the Directors of Midwifery Education at Winchester, Portsmouth, and Lothian all expected to see a "rationing" of the numbers of slots for midwifery students to reflect the decreased need for midwives. The Director of the Portsmouth program said that Wessex, the southern portion of

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210 England, may have been overproducing midwives by 300% due to lack of staffing planning. The Midwives Chronicle (1990:82) reported that 13,500 new midwives became qualified between 1984 and 1990, yet the number of midwives in practice rose by only 3,240 between 1980 and 1990. With free education, many registered general nurses studied midwifery to further their nursing careers. "Studies this century have consistently showed that less than 40% of qualifying midwives trained because they wanted to practice (Robinson 1986:25 ) ." An interview questio n when applying to the Lothia n School of Midwifery was, "Do you want to practic e midwifery or have another qualification?" The Senior Midwifery Educator estimated that 50% of nurses interviewing for midwifery educational slots simply desire d to broaden their educations. Midwives interviewed in London, Portsmouth, and Edinburgh cited low pay, low autonomy due to physician control, and organization within nursing as r e a sons for leaving midwifery practice. Laurant (1991) and Rogers (1991) support these reasons for leaving practice. The 1987 survey of American College of Nurse-Midwives membership showe d that 30.6% of the membership responding wa s currently eligible for midwifery practice but wa s not employed as a nurse-midwife (ACNM 1987:7). The top three reasons for not practicing as a nursemidwife were different than the reasons British midw i ves give for leaving practice. American nurse-midwives gave these

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211 reasons for leaving practice: 33.6% wr
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212 Florida women cared for by nurse-midwives by the year 2,000. This would require an estimated additional 600 nurse-midwives (Florida Midwifery Resource Center 1993). Numerous expansions in nurse-midwifery education would be needed to accomplish an increase of 100 new nurse-midwives a year. Salary Levels and Hours. Most practicing British midwives are employed by the National Health Service (NHS) Promotion grades and salaries are fixed by the NHS. Until 1991, District Health authorities were entirely dependent on funds allotted by central fiscal policy (Pratten 1990:60). This led to chronic underfunding of community services in favor of larger medical centers (Prattern 1990:60). While the British maternity wards visited were bright with new paint and wallpaper, the equipment, such as labour beds, was old. The labour beds were crank operated instead of motorized. Every effort was being made to reduce cost. Women brought their own soap, washcloth, and toothpaste into British hospitals. A sign hung over the sink in the St. Alfred's College of Nursing and Midwifery: "Towels cost as much as a pence each. Over a Thousand Pounds a week at Hampshire County. Don't waste even one!" In spite of the fact that British midwives were independent practitioners, they advanced in seniority and pay along nursing levels. In 1992, a British hospital midwife had an annual salary range of 10,230 pounds to 11,720 pounds

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213 ($20,153 -23,088 American). A community midwife's salary ranged from 15,230 pounds to 17,735 pounds ($30,003-$34,937) (Scottish National Board 1992:2). Senior midwives received a pay raise in June 1992 changing their range from 14,380 pounds to 43,120 pounds ($28,472 -$85,377). Midwives in parts of London and 7 rural regions received geographical allowances that added another 6 -10% to their salaries (Midwifery Digest 1992:2). An administrative midwife might need 30 years seniority to approach the top of the pay scale. Hospital midwives and community midwives averaged a 40 hour week with no overtime. Both rotated shifts. Community midwives, however, were on call for domiciliary births and patients needing horne visits 24 hours a day, thus the higher level of reimbursement. Hours worked on-call were not paid, but taken later in the week as compensatory time. In 1992, the salary range for a nurse-midwife in Florida was $35,000 to $65,000. American nurse-midwives most often worked a 40 hour week plus 2-3, 24 hour periods of call time each week. Call time was not compensated. Some nurse-midwives in small practice groups worked a 32-40 hour office week and were on-call every night or every 2nd night, taking 1 or 2 weekends off-call each month. In urban practices with more than 300 births per year, 5 or more midwives worked as a group with work hours approximating 40 hours per week with no oncall time.

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214 Midwifery Malpractice Liability. Although many British midwives interviewed during July 1992 acknowledged that malpractice cases filed against obstetricians and m idwives had increased in the United Kingdom, none knew a midwife who had been sued for malpractice. The Royal College of Midwives offered separate liability insurance. College officers maintained that this was one reason midwives joined the Royal College. They could not name another 1 iabil i ty policy available to midwives. Liability insurance was not required for midwives to practice in the United Kingdom. Unlike British midwives, malpractice liability was a major practic e 1ssue for American midwives. All Florida hospitals reviewed during the research required proof of liability insurance for a midwife to gain access to medical staff status The cost of liability insurance for American midwives ranged from $1,500 to $6,000 per year. Midwifery Practice Model summary Figure 9 outlines the differences i n the models of midwifery practice in the United Kingdom and the United States. If midwifery is defined as care behaviors directed toward periods of physiologic change in a womanrs life, midwifery in the United States has a broader scope of practice. Midwifery in the United Kingdom is limited to care

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215 during reproduction, childbirth, and lactation. Midwifery care in the United States extends from menarche beyond menopause and includes primary care aspects of women's health.

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216 Figure 9. Models of Midwifery Practice in The United Kingdom and the United States. POTENTIAL SCOPE OF PRACTICE <----------><----------------------------------> <-------> menarche r eproduction m enopa use <----------------------------------> pregnancy childbirth lact ation SCOPE OF BRITISH MIDWIFERY PRACTICE <----------------------------------> community mid wifery <---------------------> hospital m i dwifery SCOPE OF AMERICAN NURSE-MIDWIFERY PRACTICE <----------><----------><----------> antepartum intrapartum postpartum care care care <-------------------------------------------------------> g y necological care <--------> family planning <--------> preconceptional care <----------> family planning

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217 Models of Midwifery Education Educational Finance A nurse wishing to become a midwife in the United Kingdom did not have to save money or find scholarship funds to pay for tuition and board. Nursing and midwifery students were rostered. That is, they were counted as staff, were expected to work the wards, and received a paycheck. student dormitories and a living allowance were also available. Student work hours had the aspect of an apprenticeship. Said one British-educated midwife, who had completed an American master's degree in nurse-midwifery, "You Americans don't have a clue about how to make a midwife. In England we lived at the hospital. We lived and breathed midwifery all week. Here (in America), you put-in 6, 8 hours in clinicals, then you go back to the library to read." Although American nurse-midwifery programs rece1ve some state and federal funding, American midwifery students had to pay their own tuition either by savings, scholarships, or loans. In 1992, the cost to complete the midwifery master's degree at the university of Florida was $5,389 for instate students and $15,397 for out-of-state students. Only 21 states had nurse-midwifery programs, forcing many students to relocate for midwifery education and pay out-of-state tuition. since 1980, most American nurse-midwifery programs have

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218 developed part-time tracks to accommodate students who must work to support themselves and family. Lacking national health coverage, many American nurse-midwifery students had to continu e working t o provide health care coverage for their family. structure of Educational system Prior to the 1980s, British midwifery education was unde r the local control of the health districts. The major benefit of this system was that the demand for midwifery services could be met by recruiting from within the district and keeping graduates within the district (Dowie 1991:4.32). Warwick (1992:251) characterized this period of education by saying, "Midwifery schools were very small, courses were somewhat parochial and staffing levels were susceptible to major fluctuations ... issues of accountability and budgetary control were confused." The Briggs proposal addressed these problems by recommending that existing nursing and midwifery schools, faculties, and clinical sites be amalgamated into 200-300 colleges of nursing across the United Kingdom. Scotland comp l e ted its amalgamation of nursing a n d midwifery in 1975, creating 21 Colleges of Nursing and Midwifery. The 1979 Nurses', Midwives' and Health Visitors' Act provided for the National Boards of each country (such as the English National Board) to approve (accredit) and monitor midwifery

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219 courses (Dowie 1991:4.29, Naisbitt 1990:CS-21-03). The United Kingdom Central Council determined what core midwifery knowledge and skills must be taught in midwifery programs. From the 1960s to 1982, most midwives in the United Kingdom were registered nurses who attended a midwifery course lasting 12 months. Until 1970, this course was divided into Part I and Part II. Part I also was studied by all registered nurses who became home health visitors and registered nurses desiring administrative promotions. Following the Brigg's Report, midwifery education was lengthened to 18 months using a modular system of 4 twelve week periods. The modular system was designed to gradually build a knowledge base. Clinical hours were not increased under the modular system but theoretical teaching was. British midwifery students prior to the Briggs report were counted as staff. In order to make the educational process more of a learning process with less staffing, programs were required to have two of each four weeks be dedicated exclusively to classroom learning. Further, students could no longer be assigned more than one-third of their clinical rotations as night duty (Watkin 197 5: 3 31) Ending the roster system and increasing midwifery education to 18 months was also necessary to conform with the European Economic Community midwifery standards. Students completing the 18 month post-registration (post-nursing) midwifery programs used the initials S.C.M., state certified midwife. During the 1970s, two postgraduate courses were developed

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220 to extend midwifery education, the Diploma in Professional Studies Midwifery (DPSM) formerly known as the Advanced Diploma in Midwifery (ADM) and the bachelor degree in midwifery education (BA). The Advanced Diploma of Midwifery was a one year course of study wit h a research focus. It was t h e m i nimum educational level required to teach midwifery. The program s visited during the study each required a registered general midwife to have two years of clinical experience before entering advanced study. The second advanced degree, the bachelor of midwifery education was a two year progra m of study. The first year of the bachelor' s degree was the same as the Diploma in Professional Studies Midwifery. Second year course work included writing ends and objectives, writing and presenting reports, practice teaching, and midwifery research. Salaries for those studying the bachelor' s degree were paid by the national boards. Employment after graduation was guaranteed as the National Health Service must hold the student' s slot and pay grade open for two years. In return, the graduate had to work another two years for the National Health Service. Like British midwifery programs, American nurse-midwifery programs were required to be affiliated with institutions of higher learning. This gave students transferable academic credits and access college learning resources. American nursemidwifery programs could be based in colleges of nursing, medicine, or public health. Nurse-midwifery programs could be

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221 18 month certificate programs or master's level programs. In 1992, there were 32 American nurse-midwifery programs accredited by the American College of Nurse-Midwives through the United States Department of Education. Ten (31%) of the programs were certificate programs and 22 (69%) were master's level. Regardless of level, students studied the same core curriculum and took the same national certification examination. British midwifery educators did not have percentages of British midwives who had higher degrees. American nursemidwifery educational programs have bee n torn between the American Nurses' Association recommendation that all advanced nursing practice programs be at the master's level and the International Confederation of Midwives that does not require nursing as a base for midwifery. The American College of Nurse-Midwives continued to support and accredit certificate midwifery programs. No other country required master's level preparation for midwifery. Students from certificate programs performed as well as master level students on the national certification exam. In the 19 87 American College of NurseMidwives survey of 1,959 members, 46% of the respondents had master's level preparation and 4 6% were prepared at the certificate level. Eight percent were educated overseas (ACNM 1987:12). In 1992, the State of Utah required that midwive s be master's prepared. Several other states proposed similar legislation.

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222 Content of Educational Programs Comparing curricula from school to school within a country was difficult. Comparing curricula between countries was more problematic, but revealed differences in the national construction of a profession. When the curricula from Lothian College and the University of Miami are compared side by side Table 7, several differences 1n educational goals were revealed. Both programs took registered nurses and educated them to practice midwifery in 18 months. The Lothian was a postregistration certificate program and the University of Miami students graduated with a master's degree. In addition to the courses compared, both groups had clinica l rotations. The University of Miami students had an additional minimum of six credit hours in thesis work to complete before graduation. Exact comparison was difficult because of the integrated study used in British midwifery education. British curricula were organized by theme. Lothian's social and behavioral sciences course included concepts from sociology, epidemiology, and psychology. American midwifery programs were organized by shorter, separate courses such as epidemiology and physiology.

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223 Table 7. A Curricula Comparison Between the Lothian College, Edinburgh, Scotland, and the university of Miami, Florida. LOTHIAN COLLEGE Course List Diploma in Higher Education Midwifery Midwifery Practice (application of theoretical knowledge to practice development of midwifery skills) Professional Issues (ethics, accountability, confidentiality, legislation) Social and Behavioral Sciences (sociological, epidemiological and psychological factors related to midwifery practice) Communication and Counseling Research (the application of resear c h to midwifery practice) UNIVERSITY OF MIAMI Course List Master's Science of Nursing Advanced practice nursing roles Theoretical bases of nursing High Risk Family Concepts of transcultural nursing Applied nursing informatics Advanced pharmacology Physiology for advanced nursing practice Advanced health assessment Research in Nursing ------------------------------------------------------------------------------------------------------Education (supervisory & teaching skills, personal development) Perinatal Health Care (IP,PP,NB*) Primary Health Care of Women I (AP,GYN, FP*) Primary Health Care of Women II(AP, GYN, FP*) Nurse-Midwifery Specialty Integration -----------------------------------------------------------------------------------* IP=intrapartum care, PP =postpartum care, NB=newborn care, AP= antepartum care, GYN=gynecology, FP =family planning

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224 Table 8. A curricula Comparison Between King Alfred's College, Winchester, England, and the University of Florida, Gainesville. KING ALFRED'S COLLEGE Course List Diploma of Higher Education in Midwifery Studies Study Skills Introduction to Health Promotion UNIVERSITY OF FLORIDA Course List Master Science of Nursing --------------------------------------------------------------Midwifery Practice Skills Midwifery and Paediatrics Nurse-Midwifery I Nurse-Midwifery II Nurse-Midwifery III --------------------------------------------------------------Community Studies Social Science --------------------------------------------------------------Life Science Physiologic Bases of Nursing --------------------------------------------------------------Behavioral Science Applied philosophy, law and public affairs Seminar/Information technology Research appreciation Counseling skills Health promotion Research appreciation Social Science II Behavioral Science II Life Science II Community Studies II Complementary Therapies Professional and Health Seminar/Service Studies (midwifery models) Counseling Workshops Ethics Workshops Nursing and the Law Nursing & Health Care Policy Nurse-Midwifery Statistical Methods in Nursing Research Research Methods in Nursing Nurse-Midwifery Theoretical Models-Nursing Leadership Roles-Nursing --------------------------------------------------------------

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225 A comparison of the University of Florida and the King Alfred's College curricula, Table 8, revealed the same differences as the comparison between the Lothian and the University of Miami Programs: exact side by side comparisons of midwifery programs were impossible because British midwifery and American nurse-midwifery used different theoretical bases and different conceptual domains. One major difference existed between the King Alfred and the University of Florida programs: King Alfred's curriculum prepared students to be midwives during a three year course. The University of Florida course prepared registered nurses to be midwives in 18 months. What the programs had in common is that both were entry level midwifery education programs. The University of Florida required an applicant to be a registered nurse with a bachelor's degree. Clinical Education In both British and American midwifery education, students had clinical rotat ions where coursework was applied to supervised practice. British midwifery students began clinical rotations during their first term of study. Instead of focusing on one area of practice, students began with a community midwifery rotation. Students followed a community midwife and began to learn all the skills used by a community midwife whether antepartal or postpartal. All the British

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226 programs studied used this method of student deployment with the purpose of having students see pregnant women within their communities and as part of their communities. one faculty head explained, "Bringing a pregnant woman into a district antenatal clinic puts her into a little box that doesn't tell you a thing about her home, her family, all the things that make a pregnancy." She explained further, We send students into the hosp itals last, when they know what a midwife is and what the community is. In the hospital, the temptation is become a nurse. Nurses don't have the independence to be a midwife and all they know is illness. We want our students to know normal process not illness. Before program completion, British midwifery students had to complete statutory clinical requirements. These requirements were set by the national boards and included: -100 antenatal examinations of pregnant women with appropriate advice -supervise and care for 40 pregnant women -receive clinical instruction in the management of labour, including witnessing 10 normal labours -personally manage and conduct the delivery of 40 women under the supervision of another midwife -receive instruction on the indications for, and the technique of, episiotomy, including the safe strength and dosage of local anaesthetics, followed by practical experience -receive instruction on the technique of repairing the perineum and practical experience as appropriate -attendjassist at 40 complicated labors -attend 1 or 2 breech deliveries -during the postnatal period give supervision and care to and personally examine 100 mothers and their newborn babies -have experience in supervision and care of low birth weight, post-term and ill newborn and give appropriate care/advice to their mothers -give care to women with pathological con?itions in the fields of gynaecology and obstetrlcs

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-give care to children from birth onwards with pathological and other problems -give care to adults prior to, during and following surgery for conditions whic h may affect wome n in childbearing years -give care to adults with medical conditions which may affect women in childbearing years -have experience in care of adults with mental illness which may affect women in childbearing years (Solent School of Health Studies 1991:20) 227 In the United States, nurse-midwifery clinical rotations were divided into areas of practice: antepartum, intrapartum, gynecology and family planning, and newborn care. Students often had clinical rotations a t one site for antepartum work, another for intrapartum and newborn care, and another for gynecology/family planning. One rotation wa s done per semester. A final rotation, historically called integration, aimed to place the student with a practicing nurse-midwife so that the student worked as a typical nurse-midwife, using antepartum, intrapartum, newborn, and gynecology skills as needed. American nurse-midwifery programs were required by the Division of Accreditation of the American College of Nurse-Midwives to provide minimum numbers of clinical experiences for students. These requirements included: -15 new antepartum visits -70 return antepartum v isits -20 labor management experie nces -20 d eliveries -40 postpartum visits (05 days) -20 newborn assessments -40 postpartum/family planning/gynecology visits (American College of Nurse-Midwives 1988:8)

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228 A larger document, The Core Competencies for NurseMidwifery, developed by the American College of NurseMidwives, gave a detailed listing of the nurse-midwifery knowledge base and technical skills. Pre-Registration Education Since the first legal recognition of midwifery in the United Kingdom with the Midwives Act of 1902, there have been two entry routes into British midwifery. The original method of entry into midwifery, direct entry into a school of midwifery, was called pre-registration midwifery. The second route uses nursing registration as a prerequisite and was called post-registration midwifery. At the time of the 1902 Midwives Act, most midwifes were pre-registration midwives. Following legal professionalization, British midwifery was pushed into the biomedical system in the short span of 20 years. By 1929, only 10% of British midwives entered midwifery without having nursing registration background (Thompson 1990:CS-20-04). Only 31% of practicing midwives were nonnurses in 1949 and by 1982, only 7.2% of registered midwives were pre-registration midwives (Redford and Thompson 1988:37). Pre-registration midwifery came to be viewed as inferior preparation. The British glossed over the increasing control of midwifery by medicine and nursing by claiming that single qualification preparation for midwives did them a disservice.

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A Government Working Party reported in 1949, . it is almost dishonest to train women, give them a statutory qualification and then use them in a permanent period of inferiority (Redford and Thompson 1988:39). 229 Many administrative promotions required nursing registration, thereby limiting the career mobility of pre-registration midwives. During the early 1980s, the only pre-registration program remaining in the United Kingdom was in Derby, England. Pre-registration midwives had the same education requirements and post-registration midwives and took the same national certification exam. They were regulated using the same system as post-registration midwives. With the start of the fall 1992 academic year, pre-registration midwifery became the method of midwifery preparation in England, Scotland, and Wales. The King Alfred's College pre-registration curriculum, Table 8, summarizes the knowledge base of direct entry midwives. The pre-registration programs of King Alfred's College and Lothian College both taught only midwifery during the first year of study. Students were not exposed to hospital midwifery or biomedical treatment of pregnancy complications until the second year of study. The curricula were planned this way so that the student forms a solid concept of pregnancy and birth as normal processes before having that concept challenged by biomedicine. Several colleges in the United Kingdom, such as Lothian, retained post-registration programs for nurses interested in midwifery.

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230 Direct midwifery exists 1n the United States but has fought a longer, less successful battle to co-exist with biomedical practitioners. By the late 1980s, it was impossible in many states to practice midwifery without being a registered nurse. Non-nurse midwives in states that provided for the practice of licensed midwifery maintained a construction of midwifery that was separate from biomedical practice. Birth was attended in homes. Women were referred to physicians for care when their pregnancies had medical complications or when birth could not be completed at home. Licensed midwives across the United States became increasingly organized during the 1980s under the Midwives Alliance of North America. The first recent professional school for direct entry midwifery in the United States was the Seattle School of Midwifery, opening in 1981. Founders of that school believed that the professionalization of direct entry midwifery would give direct entry midwifery recognition by and cooperation from biomedicine. This recognition would allow direct entry midwives access to hospital practice. After t e n years, Seattle graduates are still largely domiciliary care providers. Experience with direct entry midwives in industrialized Europe and the success of the Seattle School of Midwifery in cost-effectively producing safe care providers led American health policy makers to reconsider nursing as a practice base for midwifery during the late 1980s. By 1993, three additional

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231 states had legislated educational routes and practice for nonnurse midwives: Alaska, New York, and Florida. Ernst (1991) wrote that the re-emergence of direct entry midwifery had polarized American nurse-midwifery. Some nurse-midwives support the profession of midwifery regardless of entry route. Other nurse-midwives think that biomedical fluency is a requirement for safe care. Midwifery Educators Consistent with the British view of midwifery as a practice-based profession, Britis h midwifery educators were largely experienced practicing midwives until the 1950s. The Midwife Teachers Training College, sponsored by the Royal College of Midwives opened in High Coombe in 1950. In 1972 when the Advanced Diploma of Midwifery Studies was started, teaching curricula were standardized into a full year of study ( 3 academic terms) yielding the Midwi ve' s Teacher Diploma (Towler & Bramall 1986:264). In 1992, two routes into midwifery education were accepted: 1) experience and an Advanced Diploma of Midwifery Studies or 2) experience and a master's degree. British midwifery teachers were hired into grades established by the national education system. In July 1992 British midwifery teachers averaged 19,000 pounds per year ( $38, 000 American) and heads of midwifery faculties averaged 25,600 pounds ($51,200 American)

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232 Experienced A m e rican nurse-midwifer y instructors averaged $35,000 ( 1 7 ,500 pounds) per year. American heads of midwife r y faculties fared no better. Working in practice instead of teaching gave American nurse-midwives the ability to almost double their salaries. Continuing Education in Midwifery The Third Midwives Act of 1936 legally bound British midwives to periodically attend approved review courses. The Second World War prevented the formation of refresher courses until the late 1940s (Sweet 1990:427). Attending a continuing education course every five years was required by the Central Midwives Board after 1955 (Parnaby 1987:133). According to Royal College of Midwives informants, until the middle 1980s, 90% of British refresher courses were offered by the Royal Co llege of Midwives. By 1990, as providers of continuing education offered courses for profit, the percent of Royal College sponsored courses fell to 60%. The required refresher courses were a week long, residential programs. Midwives were sen t away from their homes and jobs so that they could concentrate on learning. Wales, in 1992, continued to require residential programs, but other United Kingdom states recognized day programs. Approximatel y 50% of the practicing midwives interviewed at the Royal College's annual general meeting said that their continuing education tuition was paid

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233 by their employer. The United Kingdom Central Council set the s tandards for continuing professional education. Individual refresher courses had to be approved by the National Boards. Midwifery Educational Models Summary Midwifery education in the United Kingdom followed British midwifery practice domains. British midwifery education was divided into community midwifery and hospital midwifery. American nurse-midwifery education was based on the domains of women s health treatment: gynecological care, family planning, preconceptional care, antepartum care, intrapartum care, postpartum care, and newborn care. Both countries stressed a nursing base for midwifery until 1992, when the United Kingdom changed its primary route of midwifery education to non-nursing, direct entry midwifery. Multiple routes of midwifery education existed in both the United Kingdom and the United States. Summary: Chapter 5 Chapter 5, Findings, presented data on the models of midwifery practice and education that currently exist in the United Kingdom and the United States. Historical antecedents and the politico-economic variables influencing these models were reviewed. Chapter 6, Analysis, discusses how politico-

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234 economic variables interacted with historical and sociocultural variables to form models of midwifery practice and education unique to the United Kingdom and the United States.

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THE MAKING OF A MIDWIFE: THE CULTURAL CONSTRUCTIONS OF BRITISH MIDWIFERY MD AMERICAN NURSE-MIDWIFERY by Cecilia Marie Jevitt A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Anthropology University of South Florida August 1994 Major Professor: Linda Whiteford, Ph. D.

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CHAPTER 6 ANALYSIS AND DISCUSSION 235 Chapter 6 a nalyzes the data by contrasting the models of midwifery practice and education in the United Kingdom and the United States. The analysis and discussion reveal how political and economic factors interact with historical and cultural variables to shape unique, national constructions of midwifery. Models of Midwifery Practice Even though the physical processe s of women's health, such as menarche and labor, remain constant across cultures, the methods used by midwives to support the processes differ. Models of midwifery practice differ in more ways than the techniques of support. Practice models have underlying philosophies, needs, and values that shape clinical practice. Midwifery Philosophy In the Royal College of Midwive's movie, A Privilege to be There, one midwife says, "Being a midwife is not just about the birth ... It' s not about the birth process; it' s about being

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236 a family." British midwives see their work as teaching women how to manage pregnancy, how to give birth, and how to bring the new baby into the family structure. Cronk and Flint ( 1989:80) write that, "The essence of postnatal care is to produce a woman who is confident in her ability to care for and nurture her child." Cronk and Flint then describe situations and language that help teach infant care in a positive manner. This focus on producing an environment, a safe matrix, where women become mothers and husband and wife become parents, pushes midwifery more toward being an art than a hard science. The brother of one English midwife described midwifery as "more pastoral than medical." This pastoralism is viewed by some midwives as a focus on the psychological aspects of women s health care. In the 1992 Winterton Report, the Royal College of Midwives testified that, ... pregnancy must be recognized as a life event and therefore there are other criteria (than maternal and perinatal mortality rates) which need to be looked at. We should base our indicators of value on the value which is important to that human life event, such as developing confidence in parenting, happiness at the outcome of having a baby ... Another important aspect is the sensitivity with which the mother has been treated ... (House of Commons l992:xxxviii). Helen Spiby, State Certified Midwife, speaking at the annual general meeting of the Royal College of Midwives, described

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237 the environment needed by women as one of safety, security, and privilege. At the same meeting, Mary McGinley, ADM, listed the needs of women as continuity in care, choice in care, and control. To Spivey and McGinley, the work of a midwife is to manipulate the environment to meet women's needs. Both British and American midwives use the normalcy philosophy as a rampart against the intrusion of technology into women's health. British midwives have the limited budget of the National Health Service to support their conviction against the use of unnecessary technology. With limited funding for fetal monitors, intravenous therapy, and surgical birth, birth is allowed to progress normally. American midwifery's concepts of normality and continuity in care are a British heritage that have withstood 70 years of pressure from American biomedicine that attempted to change nursemidwives into dependent physician assistants. Normal birth spared the budget, conserving British Maternity Service funds for high-cost illness such as preterm labor. Here, a distinction must be made between normal and natural. A normal birth is a birth where the physiological and psychological processes are supported by skilled health care providers. In a normal birth, intervention is used only as necessary for the processes to continue. Natural birth is a label that sprang from childbirth education movements, such as psychoprophylaxis. In popular use, natural birth has taken the connotation that the birth processes receive minimal support

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238 and no intervention is used. Many women confuse natural with normal birth. Thinking that midwifery care limits them to a natural birth (unmedicated) they fear and avoid midwifery care. Even natural birth as used in the popular press has interventions. Each culture has specific interventions for birth from moving the mother into a squatting position for birth to secluding her in an electronically equipped hospital room. British women have a better chance than American women of having a normal birth, but when therapies such as analgesics or intravenous fluids are needed, they are available. American nurse-midwives, having to re-establish the territory of midwifery practice, historically used the principle of normalcy to define their practice area. In the midwifery model of practice, complicated technologies, such as surgery and invitro fertilization, were the practice areas of physicians. American midwives and American physician s however, used different models of midwifery and obstetrical practice. In the midwifery model, midwifery care proceeded until a certain level of technological skill, u sually surgical skill, was required. Here, midwifery ended and obstetrics or gynecology began. In the medical model of practice, the normal process formed a knowledge base for technological and surgical skills. In medical reasoning, knowledge of the normal process placed it within the domain medical practice. Surgical skills outranked midwifery skills in the medical hierarchy,

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240 and newborn problems such as hypoglycemia (Pritchard and MacDonald 1980:949-951). Postdates pregnancies occur in 2.2 to 10.4% of all term pregnancies (Varney 1987:199). The variation in postdates rates is attributable to normal variations in women's menstrual cycles, incorrect calculation of the due date, and normal variations in the length of pregnancy. Postdates pregnancy is an area of high litigation in American obstetrics. To avoid the problems of prolonged pregnancy, many American physicians routinely began inductions of labor within the week to ten days following the expected date of birth. Labor inductions carry their own risks including higher rates of surgical birth. Midwifery management is expectant management: v erifying the expected date of b irth, arranging for fetal heart rate monitoring, examining the adequacy of amniotic fluid levels and offering support to the mother while she awaits the onset of labor (Varney 1 9 8 7:200). Expectant management is expensive, especially in a population where women start prenatal care late thereby reducing the accuracy of due date calculations. Some of the costs of postdates testing include: electronic fetal heart rate monitor (starting at $ 5,000) ultrasound machine (starting a t $50,000) the cost of the heart rate monitoring ($45.00) the cost of the ultrasound exam ($120.00) the cost of personnel to perform the extra testing the cost of the mother' s time to have the extra testing

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239 therefore, physicians must have been masters of midwifery skills. In midwifery reasoning, special skills and experiences were needed to master support of the normal process. Physicians were not educated to have the skills or experiences required to support the normal process. Because British midwifery had an unbroken history of a defined area of midwifery practice, British midwifery has not had to use normalcy to define its practice. The normalcy of the process was more assumed in the United Kingdom than in the United States. This assumption made all pregnancies and births the territory of British midwives, not only "normal" pregnancies and births. Because their terri tory has been birth, not only "natural" births, British midwives have used labour analgesics in their own rights since the 1930s. With midwives seen as birth attendants instead of specialists in natural birth by the public, fewer British women fear midwifery labour care. One occurrence during the research illustrated differences between the midwifery philosophy of care and the biomedical model. In 1992, physicians at one of the American study sites designed a research study intended to reduce the cost of postdates pregnancies (those pregnancies that continue more than two full weeks past the expected date of birth). Postdates pregnancies have a higher incidence of stillbirth, maternal tissue trauma during birth, postpartum hemorrhage, meconium passed into the amniotic fluid, fetal birth trauma,

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241 To prevent potential morbidity and mortality (and subsequent litigation) and to prevent the costs associated with postdates pregnancy, the physicians started a research study where women would go home with a week's supply of prostaglandin suppositories. Prostaglandin hormones ripen the uterine cervix in preparation for labor and play a role in the onset of labor. Women were to insert a suppository nightly from 38 weeks of gestation on with the goal to have women delivered by the expected date of birth. The best candidates for the study were heal thy women: the women who received prenatal care from the nurse-midwives employed by Tampa General Hospital. From biomedical morbidity and costeffectiveness criteria, the study rationale seemed valid. Viewed from midwifery philosophies of care, however, the study seemed unfounded. Ninety to 98% of healthy women would use a hormonal suppository to prevent 2-10% of pregnancies that went postdates and the smaller percents of complications that occurred subsequent to the prolonged pregnancy. The hospital cost of prostaglandin suppositories was about $80 each in 1992 ($130 retail). Some of the nurse-midwives felt that the study preyed on the tiredness of women near term. Women weren't really making an informed choice. Women near birth would try any technique to hasten delivery, especially if it were biomedically approved. In the long term, home use of hormonal suppositories to hasten labor increased biomedical control of pregnancy and birth. The unspoken message to women

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242 was, "Medicine knows better than your body when you should give birth." Although employed by the hospital, the nurse-midwives practiced under legal supervision by the physicians. The physicians expected the nurse-midwives to recruit subjects for their obstetrical studies. When the prostaglandin suppository study was announced, 5 of the 9 staff nurse-midwives decided it was against midwifery philosophy and refused to participate. Two of the nine nurse-midwives, whose practice borrowed heavily from biomedicine, fully supported the study. The remaining two midwives were undecided. They expressed feeling pressured to meet the demands of the physicians to enroll women in the study. The manager of the nurse-midwifery service directed the nurse-midwives to follow their consciences when deciding about study participation. This was not acceptable to the physicians. The physicians did not see the nurse-midwives as separately licensed health care providers, who could refuse any physician ordered treatment that they felt was harmful to the patient. All nurse-midwives were ordered to enroll subjects in the study. When the nurse-midwifery service manager attempted to explain the philosophical differences to the study's principal investigator, the discussion was terminated. As nurse-midwives continued their resistance to biomedical control, signs were posted in the antepartum clinic hallways by the physicians saying, "Tired of being pregnant?

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243 Ask your doctor or midwife about the postdates study." Only the unrelated closure of the nurse-midwifery service several months later ended the conflict of philosophies. Sullivan and Weitz (1988:69) proposed a model of midwifery care (Figure 10). In their model, ideal midwifery care had qualities directly opposed to the perceived qualities of biomedical care. Midwifery care was individualized. Midwifery care had a wellness orientation with passive management that allowed the physiological processes to proceed. Responsibility for management was shared with women. The prostaglandin study demonstrated biomedical tendencies at one extreme of Sullivan and Weitz's midwifery model. The physicians designing the prostaglandin study concentrated on the potential pathologies (disease orientation) All women received routinized care. It appeared as though economics were being allowed to determine policy. The physicians were searching for an active management routine. Coincidentally, that active management reinforced physician superiority in hierarchical care-giving.

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Figure 10. Sullivan and Weitz's Model of Midwifery Care. Blo:t-1EDICAL CARE f l outln l; nd cor o fh::>/...!JCP0r .1, 1 r f 110 -......_ t nt KHco z u l l o n 1\c t:-.. I Uororchlc o l ccrooMn(J Sh :1 1)\J r c .pcnJt;':ity ?:"<-.> ""' """"""' -'..:nll t iO:.:; ..._ CCIO h v .. ; . lduo:l r (' d C CJ ( l From: Sullivan and Weitz, 1988, page 69. 244 In addition to m<.lnaging care differently a s o u t l ined by Sullivan a n d Weitz, m idwives and physicians viewed populations a n d risk factors differently. Midwives, viewing pregnancy and birth as normal, physiologic processes, estima t e d that 80 to 90% of 100 pregnant w omen would h<1ve uncompli.c<1tc d pregnancies and births t h a t c ould be mannged solely by midwifery care. Midwives approache d all women witl1 the expectatJon that they would follow the normal process model. Physicians knc\v th<:1t 10 t o 20% of women Hould have some form of pregnancy or birth complication. Risk ptediction in

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245 pregnancy is neither sensitive nor specific. Women with many risk factors for pregnancy and birth complications can have uncomplicated pregnancies and births. Conversely, women with n o risk factor s can have pregnancy and birth complications. Physicians viewed all women as potentially complicated pregnancies or births. Figure 11 illustrates the foci of midwifery and biomedical population assessments. T here is an overlapping area between the foci of midwifery and biomedical assessments because pregnancy and birth complication rates vary between human populations. Figure 11. The Foci of Midwifery and Biomedical Population Assessment. Focus of Midwifery Normal Process Model Focus of Biomedical Illness Model <-------------> < --------------------------------------------------> 1 10 20 30 40 50 60 70 80 90 100 WOMEN IN LABOR (N 100)

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246 As midwifery grew in the United States, its philosophies became clarified and publicized. Differing philosophies of health care, such as biomedicine and chiropractic, have coexisted in the United States. Midwifery needs legal independence from biomedicine so that consumers can make a choice of caregivers that satisfies their philosophical and health needs. Midwifery Identity British midwives identified themselves as hospital or community midwives. Their identity was tied to the predominant site of their work. The identity of American nurse-midwives was tied to the fee for service system. When describing their positions, American nurse-midwives said, "I'm in private practice, 11 or "I work for a health department, or migrant health service, or hospital clinic (meaning that the patients are publicly funded)." As American nurse-midwifery was most accepted by physicians whe n midwives provided care to publicly funded patients, private practice positions were difficult to find. Private practice positions and their higher salaries conferred more esteem to the American nurse-midwife. With a national salary scale and with both types of British midwifery approximating a 40 hour week, community midwifery and hospital midwifery had equal economic prestige. Some British midwives, however, credited community midwives with greater and skill

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247 flexibilit y these being necessary to practice both i n poorly equipped homes and hospitals. Hospital Midwifery The British midwife was a generalist who could care for both the mother and newborn. This enhanced consistency in care and parenting education as the newborn and mother learned to live as separate bodies. In the United States, at least four separate providers did the work of the British midwife: the labor nurse, the anesthesiologist, the obstetrician, the postpartum nurse, and the nursery nurse. Not only did this fragment care, i ncreasing the potential for miscommunication between parents and health care providers, it was exp ensive for a health system to educate numerous specialists for general functions. The division of care seen in the American obstetrical model has been supported by the American fee for service system. Eac h provider documents a particular service and is reimbursed. In global, fixed-budget payment systems, s uch as the National Health Service, cost-effectiveness rests on eliminating u nnecessary or duplicated treatments. If one generalist can safely perform the work of three specialists, a global payment system mus t support the practice of the generalist to retain cost-effectiveness. The use of epidural analgesia illustrated the point o f general versus specific services. The use of epidural

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248 analgesia during birth had replaced the use of inhalable anesthetics in all of the American study sites. Fee for service health care in the United States paid the most for the most complicated care. Epidural insertion is a surgical technique and pays more to the anesthesiologist than use of intravenous or inhalable medications. Even though inhalable gasses are safe and cost effective, American physicians had learned to use the analgesia with the highest reimbursement, epidural analgesia, for patients with private funding. Women covered by public funds mos t often received injectable anesthetics. The decision to give analgesic medication was never the decision o f the American labor ward nurse. It was a specialist's decision. Many American hospitals required that the nurse -midwive's consulting physician give the order for epidural analgesia and be in the hospital during the labor when epidural analgesia was used. T his placed the management of two physicians the obstetrician and the anesthesiologist, in the labor originally managed by the midwife and continued the control of American birth by physicians. W ith epidural analgesia use, the anesthesiologist profited from birth. Requiring the obstetrician to be in the hospital when the anesthesia physician was present allowed a second medical specialty to profit from birth. The subject of anesthesia control has been debated in American nurse-midwifery for years. When asked, "Who makes the

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249 decision to order epidural analgesia, the midwife or the obstetrician?" a group of st. Alfred's College, England, preregistration midwifery (non-nurse, direct entry) students gave a surprising answer. In a group of 12, seven responded simultaneously out-loud, "The (laboring) woman. It's her decision." Their answer indicated that British midwifery students are enculturated to view labor management as patientdirected. The National Health Service, by making midwives, obstetricians, and anesthesiologists salaried employees, decreases the incentive for providers to make work that would ultimately increase their reimbursements. In the American system, those that had the least contact with the mother, the physicians, received the highest reimbursement for their work. With birth as a medicalized event, the physician earned his pay by claiming superior knowledge of how to deal with potential emergencies and by being available to apply that knowledge. True to the scientific production efficiency of Henry Ford, American hospitals became birth assembly lines during the 1950s and 1960s. Women were separated from their families and "prepared" to make birth cleaner and easier for the attendants. Preparation included enemas, shaving perineal hair, and analgesia strong enough to make women compliant. Women were moved from room to room as birth progressed, each room containing equipment suited to one stage of birth. Birth was sped with intravenous pitocin and infants were pulled out

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250 early with forceps. The assembly line heritage lives on in American labor wards in spite of movements beginning in the late 1970s to humanize birth. In addition to the assembly line atmosphere of American birth, American women were separated into two classes following the initiation of the Medicaid program in the 1960s: those who pay their own bills and those paid for by the government. Those funded by the government were seen by many as tax burdens. Women needing Medicaid coverage lived in poverty. The application of Medicaid according to income (instead of to the entire population) created a stigma for its recipients. The refinement and distribution of reliable birth control methods occurred along with the growth of Medicaid. As women were increasingly viewed as being in control of their fertility following the introduction of oral contraceptives in the 1960s, those who reproduced while accepting government funds were denounced for irresponsibility. The prejudice against women with Medicaid coverage for pregnancy and birth manifested itself as physicians who refuse to care for women without private insurance. The stigma of publicly funded health care created a niche for American nurse-midwives. The work of nurse-midwives was allowed to expand into family planning, gynecology, and primary care, as long as it didn't drain profits from physicians' practices. While not working in many of the areas staffed by American nurse-midwives, British midwives fill a role not

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251 staffed by American nurse-midwives, that of the neonatal intensive care nurse. In effect, the expansion of British midwifery into the intensive care nurseries kept other nurses, who were not midwives, out of the intensive care nurseries, thereby consolidating maternal-child health as the province of the midwife. An inclusion of neonatal nursery care in the role of the American nurse-midwife, a provider that cared for wellwomen and normal newborns, would have been contradictory. It is doubtful that American nurse-midwives would have accepted neonatal intensive care work. Premature infants are outside definitions of normalcy. Providers, such as neonatal intensive care nurses, who depend on technology to support their care are rarely comfortable in low technology situations. To sit with a laboring woman without using machines to record blood pressure, temperature, and fetal heart tones requires patience and self-confidence that would be eroded by the use of neonatal intensive care technology. Labor Admission. In the United States, women with public funding were not allowed hospital admission for healthy pregnancies until they have achieved 4 centimeters of cervical dilatation or until the amniotic membranes (bag of waters) had broken. The American technology was too expensive to use when public reimbursement for it is low. Some women with private insurance, however, had a labor admission with epidural analgesia beginning at one or two centimeters of dilatation.

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252 For liability reasons in the United States, any woman entering the hospital had to have nursing assessments at regular intervals. Those assessments had to be recorded in detail. A woman couldn't pick a room and go to sleep awaiting stronger labor as is done in the United Kingdom. In the United Kingdom, maternity units were continually staffed by midwives. Someone skilled in birth was present always. Continual midwifery staffing gave British maternity units the freedom to permit women to come and go as they needed during early labour. A woman could leave a British hospital in early labor at 9 P .M., progress rapidly, and return suddenly at 12 midnight, without worrying whether someone skilled at helping with birth would arrive at the hospital in time. In the United States, the power of diagnosis and labor management had been sequestered in the physician. Labor nurses might examine the woman and telephone the physician with a report, but the physician only had the legal power to admit to the hospital. Assessing Progress of Labor. Dilatation of the uterine cervix is the most reliable indicator of progressive labor. Dilatation is measured by performing a digital examination. The provider that performs the examination defines the reality of the labor. Biomedicine has researched lengths of labors and categorizes labors by normal, precipitous, protracted or arrested. In hospital birth, the provider who assessed

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253 progress in labor controlled the management of that labor. When midwifery care was available, physicians may have performed vaginal examinations under the ruse of "helping the midwife," while actually exerting ultimate control. Robinson (1989:167) cites examples where British physicians examined midwifery patients at regular intervals. Physicians who respected the skill and independence of midwifery did not exert their control of women and labor by performing unsolicited exams. The British system, where physicians are salaried, and where the work of midwives does not require the signature of a physician, removed any incentive for physicians do perform unnecessary treatments. Waterhouse (1989:396) describes the Royal Berkshire Hospital in England, where "Neither senior house officer nor registrar enter the room except at the request of the midwife." In the United States, with no "normal" model of pregnancy and birth as a guide, American physicians attempted to control the process by expecting labor progress to match the rates of cervical dilatation found 1n Friedman's average length of labor rates (Pritchard and MacDonald 1980:385). Those women who did not meet the average values had pitocin administered, the hormone that causes contractions. Applying the normal curve to Friedman's average rates would indicate that 50% of women will take longer than the average cervical dilatation rates. Thirty to 40% of these women could potentially have uncomplicated labors if the process were supported instead of

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254 artificially stimulated. American nurse-midwives exposed to the British midwifery model, where cervical exams occur every four instead of every two hours, give women 1 s labor longer to progress. With a healthy mother and fetus, instead of stimulating the labor the midwives were more philosophically inclined to provide relief for any pain and allow the woman to rest until her body was ready to resume the labor. American physicians accustomed to stimulating labors to fit the Friedman values imposed their control when women cared for by nurse-midwives had slower labors. Following the Joint Commission on Health Care Organization standards citing physicians as responsible for all hospital care and state laws that require physicians to supervise nurse-midwives, a physician could order treatment contrary to that of the nurse-midwife without consulting the nurse-midwive. Providers having this type of control were not likely to wait and see if a labor progresses physiologically. In a fee for service system, the more time spent with one labor, the lower the profit and the fewer total labors that could be attended each month. Labor stimulation increased profit potential. Nurse-midwives, who were largely salaried, had no financial incentive to stimulate labor. Fitting the progress of labor to expected values reinforced the view of labor as a time of disease. If fifty percent of women fell below average rates, then medical intervention must be needed for most labors. Therefore, labor must be an illness.

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255 The need to reinforce the disease model of labor may be the prime reason that American nurses ignored women's feelings and had them wait for a cervical exam when women had the urge to push. Delaying pushing gave the labor nurse time to call the physician to be present for the birth. Physicians who habitually missed births would have been hard pressed to collect the insurance payment and continue claims that birth is an illness that must be managed. American nurse-midwives resisted the evaluation and control of labor by the biomedical model. This was seen in interactions where nurse-midwives under-reported cervical dilatation to give women extra time to progress in labor or under-reported dilatation to avoid routine labor treatments such as bedrest and intravenous fluids that inhibit midwifery care. Where nurse-midwives under-reported dilatation in the first labor evaluation, women left the interaction with a perception of normalcy and were able to spend the largest part of their labor in control of their movements and positions. The British midwives studying with American nurse-midwives during the time of the study were not accustomed to having to manipulate the system to manage a labor using midwifery philosophies. They felt this dishonesty was a compromise of their professional integrity and experience. In the short term, this redefinition of cervical progress in labor enabled some women to have more comfortable labors. In the long term, the nurses and physicians had the opportunity to see that

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256 women could safely ambulate and drink in labor. The nurses and physicians were given the opportunity to see physiologic progress in labor. In some cases to have the midwifery model prevail, nurse-midwives manipulated the reality of women by defining progress in labor as less than it was. Nurse-midwives accused biomedical providers of manipulating the reality of labor so that women saw labor as an illness. However, nursemidwives also manipulated the reality of labor by redefining labor as normal, thereby prolonging their ability to work without biomedical interference. Electronic Fetal Monitoring. The British midwives used less electronic fetal heart rate and uterine contraction monitoring than did Americans nurse-midwives. The cost of technology may have slowed the spread of electronic monitoring in the United Kingdom. The routines of the Simpson Memorial Pavilion were an example of British midwifery labour evaluation. At the Simpson, midwives palpated the strength, duration, and frequency of uterine contractions for 10-20 minutes out of each hour. The fetal heart rate was auscultated every hour in early labour and every quarter hour in active labour. This hands-on care kept the midwife in the room with the labouring woman and increased her knowledge of the physical changes occurring labour. In the United States, physicians and nurses discredited palpation of contractions as subjective and, therefore, inherently inaccurate. However, palpation was

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257 taught in American nurse-midwifery educational programs. The American reimbursement system rewarded hospitals replacing nursing care with technology such as electronic fetal monitoring and automated blood pressure cuffs. As the Reagan federal government and insurance companies sought ways to contain hospital costs, caps were placed on the amounts reimbursed for diagnostic related groups (DRGs) beginning in 1983 (Feldstein 1988: 311). Hospitals largest expenses were wages and benefits. To contain costs, employees had to care for the maximum number of patients possible. Technology use decreased the amount of time spent in nursing care per patient. Medicare's DRG system did not control hospital expenditures on capital equipment (Equipment costing more than $500). Hospitals were reimbursed on a cost basis for their capital expenditures by Medicaid (Feldstein 1988:289). With electronic fetal monitoring, a nurse could care for two to three laboring women at the same time. The machine continuously recorded fetal heart tones and uterine activity so that the nurse could read what happened in her absence o r be alerted to potential problems by electronic alarms. The more biomedical machines a hospital purchased, the fewer nurses it had to employ. The Health Districts in the United Kingdom had fixed annual budgets based population. Working in a large scale capitation system, fixed budgets decreased the incentive to purchase unnecessary equipment or perform unnecessary

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258 treatments. with high British unemployment, the National Health Service had incentive to keep staff employed rather than economizing on staff by using technology to complete the work. The prohibitive cost of technology and the need for employment supports the use of low technology midwifery care. The American nursing time saved by technology came at the expense of the mother's comfort. Monitor parts were worn on two waist belts or inserted transvaginally. Both limited maternal mobility. Women under nurse-midwifery care could become caught in a tug of war between nursing and midwifery; the nurse strapped a woman onto the fetal monitor, wrapped a mechanized blood pressure cuff around one arm that constricted at regular intervals, and corralled the woman in bed by raising the safety rails. The midwife, bent on promoting labor normalcy and maternal mobility, unstrapped all the equipment and encouraged the mother to walk around the room or rock in a chair. The nurse, worried about safety and personal liability, returned to the room once the midwife left the room and rewrapped the laboring woman in biomedical monitors. The tug of war was not between nursing and midwifery, but between the biomedical illness model and the midwifery model of care. In the United States, the expense saved in nursing time was lost in the need to stimulate slowed labors with intravenous pitocin and in the increased time women spent recovering from Cesarean sections.

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259 cesarean Birth. The ten to twenty percent increase in Cesarean birth rates seen in the United States had multiple causes. The traditional explanation, that the physician wanted to go home at 5 P.M., was a small portion of the explanation. Liability worries push American physicians to take what they consider the most economical course, deliver the baby surgically. Physicians said, "No one is sued for unnecessary surgery when the baby is healthy. American physicians, who had almost limitless earning potential, had assets to protect. American nurse-midwives, who were most often salaried at less than half of an obstetrician's income, were poor targets for malpractice judgements. The salaried status of British physicians and midwives reduced their liability judgement potential. With no universal access to health care, American families were forced to sue for economic recovery when a baby suffered prenatal care or birth-related damage. British families did not have to sue to recover future health costs from physicians and midwives; it was guaranteed by the state in the universal care available through the National Health Service. A more sinister explanation for the high American Cesarean birth rates hinged on the billing structure of American health care. Like some factory workers, American physicians were paid by piece work. The more interventions they performed, including surgery, the more they were reimbursed. The time invested in a Cesarean section averages

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260 45 minutes. A labor could last three to 30 hours. A physician could choose to order a Cesarean birth permitting a speedy return to the office to see more patients. Until the mid-1980s, many third party payers reimbursed more for surgical births than vaginal births. This practice gave physicians the incentive to perform more surgical births. Until the initiation of diagnostic related categories, third party payers also paid by procedure rather than by category. A physician performing a pudendal block with an episiotomy and subsequent repair earned more than one attending an uncomplicated birth over an intact perineum. Use of the biomedical model paid more than use of the normal process model. Learning their profit loss due to increased surgical costs and post-surgical recovery costs, third party payers changed to equal reimbursements for vaginal and Cesarean births beginning in the middle 1980s. Shortly thereafter, as the cost-containment success of capitated managed care became evident, third party payers stopped paying for individual prenatal and labor procedures. Physicians were paid one allencompassing (global) fee for prenatal care and another for birth attendance. This turned the tables on reimbursement. Instead of making a profit from more work, the only way a physician could increase profits was to do fewer procedures. The least mentioned reason for the increased inclination of American physicians to perform surgical births may have

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261 been the most deep-rooted. Few American physicians ever saw a model of normal pregnancy and birth. The normal process was not included in their enculturation to obstetrics. After many years of convincing the American public that pregnancy and birth were inherently dangerous times, physicians convinced themselves of the dangers. They moved to surgery out of fear of the unknown. surgery was a controlled situation. Labor and birth were not. Both American nurse-midwives and British midwives were enculturated to the normal process model. Without surgical skills, they had no choice but to observe the process, support it when it was uncomplicated, and call for the surgeon when needed. British physicians, who saw the normal pregnancy and birth models and midwifery management throughout their biomedical enculturation were more accepting of those models. Episiotomy. British midwifery dates from a time when no provider made surgical episiotomy cuts into the vagina to speed birth or spare women tissue laceration. During the consolidation of British midwifery in the late 1800s, a surgical incision was a n opportunity for infection and lethal sepsis. British midwifery became a repository of knowledge to prevent vaginal tears during birth. British midwives preparing for American certification during the time of this research reported surprise at the casualness American nurse-midwives attached to episiotomy use o r vaginal lacerations. They

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262 described feeling ashamed if a woman's perineum was lacerated during birth. Skill at preserving perineal tissue differentiated midwifery from biomedicine. British midwifery did not incorporate suturing and episiotomy use fully until pushed to do so by the European Economic Community midwifery standards. During the study, British midwives reported that British physicians were reluctant to have midwives educated in suturing. Suturing education increased the independence of British midwives from biomedicine by decreasing their reliance on physicians to come to the labor room to repair lacerations. During my stay in Portsmouth, I was scheduled to attend a suturing class for 9 first year midwifery students. The Portsmouth faculty had assumed that American nurse-midwives wouldn't have suturing skills. They were surprised to hear that suturing is a core competency in American College of Nurse-Midwives' accredited programs. Then, the tutor teaching the class invited me to teach one-half of the students to suture an episiotomy using foam rubber models. I taught my group to repair the incision using buried, continuous subcuticular stitches. (When this repair is used with absorbable sutures, no sutures are visible and the wound heals without suture removal.) The students became confused. This method of suturing didn't seem familiar. When we called the tutor to help, she explained that many British hospitals, including St. Mary's, used interrupted sutures of silk on the perineum. Long tails were left on each knot. (Four to five

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263 interrupted stitches were used.) These silk interrupted sutures were believed to be less painful during healing. The community midwife removed the sutures during a horne visit approximately five days after birth. With no home visit system for suture removal, this type of suturing would have been impractical in the United States. The interrupted sutures were an example of waste in the British system that continued because the community midwives were making home visits for other reasons but were available to remove the sutures. For approximately the same cost and the same investment in suturing time, the British could have used absorbable sutures and saved the community midwife the time needed for suture removal. Winchester, Basingstoke, and the Simpson Royal Pavilion were changing to continuous, buried subcuticular stitches at the time of the research so that women would not be bothered by suture knots they could feel during healing. Episiotomy incisions have been routine practice by American physicians since the 1930s based on the theory that a surgical enlargement of the vagina instead of muscle stretching at birth preserved the strength of the perineal muscles. This practice was reinforced by third party payments that paid separately for procedures: local anesthesia to cut the episiotomy, cutting the incision, and repair of the incision. The more d d th proce ures one, e more money earned. Some nurse-midwifery programs with strong ties to medical

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264 schools taught routine episiotomy use. It was not unusual to observe nurse-midwives educated in the 1960s and 1970s perform delivery routines using the sterile technique and the maneuvers of biomedicine. Nurse-midwives educated at the Emory University Nurse-Midwifery Program in Atlanta, Georgia, juring the early 1980s were taught that all primiparous women needed pudendal anesthesia and an episiotomy for birth. Knowing episiotomy and suturing technique was a survival tactic for American nurse-midwifery. Without a culturally recognized profession and without independent practice, American nursemidwives had to prove that they could substitute for an obstetrician to find employment. To obtain hospital privileges, their work had to be approved by physicians. To win approval, nurse-midwifery had to use the biomedical model. American nurse-midwifery did not have a sufficient quantity of midwives skilled 1n low technology and a supportive professional nurse-midwifery literature until the mid 1980s. With critical mass and supportive literature, American nursemidwifery could assert its philosophy and resist unproven biomedical techniques such as the episiotomy.

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265 Infant Feeding. Breastfeeding received additional support in the United Kingdom due t o long postpartum lengths of stay. The average length of a postpartum stay was four days in 1988 (Dowie 1991:18). During the study, the Winchester and Basingstoke British midwives reported having women stay an average of three days postpartum. The women could return home anytime after the birth. Most were encouraged to stay and rest while the baby established a breastfeeding pattern. In Portsmouth, women from the surrounding countryside left St. Mary's hospital at 24-48 hours postpartum and were then able to spend up to an additional 4 days in a local "nursing home." The nursing homes were the equivalent of a rural, Level One American hospital. The nursing homes have their own midwifery staffs. Women could choose to give birth in the local nursing home. Having additional recovery time to support the initiation of lactation supported Britis h midwifery care. Breastfeeding speeds uterine involution decreasing maternal postpartum blood loss and postpartum anemia. Breastmilk contains ma ternal antibodies that protect the newborn against infection (Varney 4 79, 480). Midwifery support of lactation uses physiologic mechanisms to maintain the health of the mother and the newborn. When postpartum recovery for the mother and newborn can be managed nonpharmacologically, the model of labor and recovery as a normal process suitable for midwifery care is reinforced.

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266 Gynecological Care American Nurse-midwifery expansion from maternity into general women's health was more than the growth of a profession paralleling the growth of biomedical technology. As the Medicaid Program grew, administrators needed cost-effective providers for public health services. Nurse-midwifery grew to fill vacancies in public health services shunned by physicians. The use of nurse-midwives whose philosophy stressed disease prevention, health education, and the support of normal processes not only filled vacancies, but kept the cost of public health services low. The expansion of the nurse-midwifery construction to include gynecology services has been problematic for private practice nursemidwives. Cultural constructions of midwifery have been historically built around birth. Women did not associate midwifery with gynecology and family planning and did not seek midwifery care for those services. Advertising, marketing programs, and community reputations proven over time were needed to expand the public construction of midwifery to include gynecology and family planning. Since joining the European Economic Community, British midwives have to know pregnancy diagnosis and family planning management to match the standards of midwives from other European countries. This brought the scope of British midwifery closer to that of American nurse-midwifery. Most

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267 British family planning and routine gynecology work was provided by general practice physicians. With primary health care available to all Bri tains through the general practitioner system, there was no need to stretch the construction of midwifery to include gynecological care. In 1993, The British Department of Health issued recommendations to increase the acceptability and efficiency of the Maternity service. Recommendations included having midwives perform the initial prenatal examination (pregnancy diagnosis) and having the midwife as the "lead professional-undertaking the key role in the planning and provision of care (Department of Health 1993:11,5) ." British nurse-midwives entering practice in the United States needed gynecology course work and clinical practice before meeting American nurse-midwifery core competencies. Table 9 summarizes scope of practice differences between the British construction of midwifery and the American construction of nurse-midwifery. Both constructions included antenatal care, birth attendance, and postpartum support for mother and newborn as the work of midwives. American nursemidwifery practice has expanded to include family planning and gynecology care. American nurse-midwives rarely had the opportunity to provide community midwifery services. This could change as American hospital recovery time following birth decreases and providers attempt to substitute postpartum hospitalization with home visits. It is more likely, though,

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268 that 1n the current American fee for service system, no provider will do community visits. The time and effort burden will be shifted to the new parents. Insisting that the parent come into the providers' offices, allows the provider to maximize time efficiency and maintain profits.

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Table 9 scope of Practice Differences Between British Midwifery and American Nurse-Midwifery. 269 United Kingdom United States Antepartum Care + + Intrapartum Care + + Postpartum Care + + Newborn care + + Neonatal Intensive Care + Community Midwifery + Gynecological Care + Family Planning Prescription + Primary Health Scree n i n g + + present in scope of practice absent from scope of practice Alignmen t with t h e E urop ean Economic Community has increased the scope of British midwifery into family planning. Only further econom ization of the National Health Service would be expected to change the provision of gynecological care from its g e n eral practice base t o a midwifery or nurse practitioner base. Articles describing the use of nurse practitioners in the United Kingdom were found in the British nursing and medical literature. Compared to the United States,

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270 the use of nurse practitioners was r a r e in the United Kingdom. I n the case of midwives providing gynecological and primary care services, the construction of American nurse-midwifery could serve a s the model to e xpan d the construction of British midwifery and nursin g British and American constructions of midwifery differed even within a segment of practice such as antenatal care. Table 10 demonstrates variations in the birth process that British and American midwive s view differently. In the United Kingdom, midwives attended premature (preterm) births, births of babies born more than two weeks past their due dates (post term) births of twins, and the breech births. These births could b e attended without t h e presence o f a physician and were considered to be "normal As one British midwife said, A birth is a birth." Physicians were consulte d when the "normal" labor stopped or when there was a medical complication, such as diabe t e s that complicated the labor.

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2 7 1 Table 10. Midwifery Birth Management in the United Kingdom and the United States. UNITED UNITED KINGDOM STATES TERM BIRTH + + PRETERM BIRT H + POSTTERM BIRTH + MACROSOMIC FE TUS + TWIN GESTATI O N + BREECH PRESENTATION + + = with i n t h e scope of midwifery practice = outside of the scope of midwifery practice I n the United States, births occurring prior to 37 weeks (preterrn), postterrn births, births of infants greater than 9 pounds (macrosomic, greate r than 4 ,000 grams), twin birth s and breech pres e ntations are defined as abnormal in the biomedical model Because each variation carries some risk to the mother and infant, all women with these conditions received biomedical intervention. The biomedical definition of these conditions most often placed t h e m outside of the scope of American nurse-midwifery practice.

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272 Medical Records American nurse-midwives have long held that the medical record is the property of the patient. Many American midwifery services had women carry copies of their prenatal records in their purses for the duration of the pregnancy. During the 1980s, Kitty Ernst, CNM, taught nurse-midwives to have women measure their own weights and test their own urines, then do the documentation in their own medical records. The 1993 British Department of Health Changing Childbirth report ( 1993: 12) recognized that many British practices have patient carry the prenatal book, then recommended that all British women carry their own prenatal records. The traditional restricted access to medical records by physicians gave the care process its own mystique and placed the physician, instead of the woman, in control. The American fee for service system e xacerbated the issue of medical record control. Without universal coverage for care, many American women could not afford private insurance but did not qualify for Medicaid coverage. Physicians accepte d these women as patients with the provision that the entire prenatal fee be paid in cash by the start of the seventh month of pregnancy (28 weeks of gestation). This fee often amounted to several thousand dollars. Women who do not meet the payment schedule were dropped from the physician' s practice. Their medical records were not released until the bill was paid in full.

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273 some states had laws making the medical record the property of the patient to prevent such situations. Most people, however, did not know that the medical record was their property and were controlled by the physician's refusal to release records. American nurse-midwifery, growing largely in the public health sector, was not moved to restrict access to medical information to insure profits. The American liability climate heightened the conflict over ownership of medical records. A medical record could be the only memory of an event in court years later. Assessments and treatments had to be recorded carefully to be useful as future evidence in court. Physicians worried that if patients read their medical records, the patients would have evidence to begin a malpractice suit. Working with normal pregnancies gave midwives a lower liability risk than physicians. This lower perception of liability increased nurse-midwives' confidence in releasing health information directly to patients. Compared to the United States, British maternity cases rarely went to court, therefore, the British had less need of detailed chart documentation. Workshops and journal articles about legal issues for health care providers were common in the United States. Not one British midwifery journal reviewed during the study contained an article on legal documentation. British midwives were known in the States for their abbreviated documentation in medical records. They had been

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274 encul turated in a system where only the prominent facts required writing. To shift to a system that required detailed documentation necessitated more than increased writing, it required a redefinition of what was sufficiently significant in practice to document. Political variables Influencing the Practice of Midwifery In both the United Kingdom and the United States, midwifery models of practice were controlled by the state. The extent of state control of midwifery practice was shaped by political and economic variables, such as the strength of professional organizations and the system of health care. Certification. The British certification process, continuous assessment, was a sharp contrast to the national certification exam of the American College of Nurse-Midwives. In the United Kingdom, where nationalized business was common, the state educated, certified, and employed midwives. Certification of new midwives by existing midwifery faculties saved the state the expense of separate certifying organizations. In the United States, the state avoided the cost of certification by accepting certification done by the American College of NurseMidwives Certification Corporation. In America, the same corporation could not accredit education, certify, and discipline its members.

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275 The British educated nurse-midwives interviewed during the study had tremendous difficulty adjusting to the American certification examination that cost $385 plus travel and lodging but was a secret. Each class of precertification students asked for old national exams review books to purchase. They had to use for study or taken the American registered nursing certification examination, a multiple choice exam, and had used exam question review books to prepare for that examination. They expected a similar process for the nurse-midwifery certification exam. British-educated midwives have several disadvantages in taking the American national certification exam. Since 1980, exam responses to clinical situations were expected to utilize the nurse-midwifery process (Varney 1987:35-36). British midwifery education did not contain a nursing process model until the mid-1980's (Bryar 1987). British midwives educated before that time must learn American nurse-midwifery process to apply it to the exam situations. The British continuous assessment process was praised by all faculty members interviewed at Winchester, Portsmouth, Lothian, and NorthWest London. A British Senior Education Manager said that continuous assessment was no more work for the faculty. "They had always needed to test the safety of the students. Continuous assessment puts the responsibility for evaluating the students where it really was-with the schools, the people who know them (the students)." Since changing to

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276 continuous assessment, the examination pass rate is approximately 98% (Naisbitt 1990:431). Enculturation in a continuous assessment environment will place British midwives at increased disadvantage when taking the American College of Nurse-Midwives Certification Council essay exam. Independent Practice. The work of British midwives was not signed by physicians. British midwives did not have to file written agreements with physicians. However, the 1982, 1984, and 1985 Maternity Services Advisory Committees recommended that each maternity unit should have written operational policies to "ensure a consistent standard of care and avoid any confusion of practice (Robinson 1989:176)." Flint (1984: 18) commenting on the Committee's call for policies said, 11 guidelines are acceptable but policies written in minute detail are for unthinking automatons, not for practitioners who are trying to give individualized care to a unique woman experiencing a unique labour. 11 These policies were similar to the written agreements (also known as protocols) that Florida nurse-midwives filed with the state. American protocols were meant to limit and control midwifery practice. The British policies had another purpose. The British policies were used by the National Health Service to keep unnecessary treatments and technologies out of practice, thereby decreasing the cost of care. Starr (1982) gave additional insights into why British

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277 midwifery has been able to retain its legal independence. Starr (1982:6) claims that English physicians were more plebeian than American physicians. With the hereditary British class structure, British physicians were never able to attain the power that American physicians had. Instead of consolidating during the mid 1800s as American medicine did, the British medical hierarchy collapsed (Starr 1982:78). Even today, British surgeons are called "mister" rather than "doctor." Starr (1982:26) further wrote that British surgeons used their hands and were, therefore, considered craftsmen. Apothecaries were considered tradesmen. Physicians built a liberal arts background into their educational process and became considered educated gentlemen. With British physicians having less social power, midwifery retained its share of practice. Starr (1982:17) also wrote, "In a society were an established religion claims to have the final say on all aspects of human experience, the cultural authority of medicine will clearly be restricted." Starr then gave the example of the Church of England historically decreasing the power of British physicians. The use of an Anglican service to begin the 1992 annual general meeting of the Royal College of Midwives showed the continued power of the Church of England. The tempering of British biomedical social authority by religion increased the credibility of British midwifery. According to Starr (1982:18), the religious tolerance of

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278 the United States prevented one religion from having strong social power. A new American culture was formed built on "resistance to privileged monopolies and hierarchies (Starr 1982: 18)." American physicians were able to increase their social power by claiming the superiority of science and technology. Midwifery, predating scientific technological revolutions, was seen as less credible in the United States. American physicians claimed their oversight was necessary to maintain safe nurse-midwifery practice. Although American nurse-midwives had to pay physicians to be available for surgical consultation, American physicians did not pay other physicians to be available for consultation. For example, the State of Florida did not require pediatricians to file agreements signed by pediatric surgeons stating they would be available to help the non-surgical pediatricians. Pediatricians did not pay pediatric surgeons or pediatric cardiologists to be available to help their patients. In contrast, the money obtained from nurse-midwifery employment or consulting fees increases physician income. With legislation requiring physician involvement in nurse-midwifery practice, physicians maintain control of an economic territory. Control of midwifery through boards of medicine or nursing places nurse-midwives under physicians. Mandated supervision by physicians the opportunity to charge the supervision of physicians gives for permission to

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279 practice, thereby increasing the cost of health care. Safriet ( 1992: 451) says laws requiring physician supervision are "more than benignly redundant ... they are also harmful and costly" and they "mandate a life-long apprenticeship (Safreit 1992:452).11 In ceding control of midwifery to medicine, the state acts hypocritically (Safreit 1992:453). In granting licensure, the state proclaims that the nurse-midwife is a safe provider of midwifery care. The state then contradicts its licensure judgement by requiring a physician to be responsible for the nurse-midwive's practice. Midwifery Access to Hospi ta1s. According to Feldstein (1988:231-235) the medical staff within a hospital operate like a cartel to monopolize the provision of health care within an area and control the price of health care services. Technically, under Federal antitrust legislation, a medical staff cannot deny a nurse-midwife hospital staff membership based solely on education and skills. The nurse-midwife can be relegated to Allied Health Staff in a physician-dependent position, or the medical staff can make rules for midwifery practice. For instance, in 1993, a nurse-midwife seeking medical staff membership at Tampa, Florida's St. Joseph'sjWomen's Hospital was given a list of 12 rules for her practice. These rules included: 1. The physician employer of the nurse-midwife will be present for all births.

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280 2. The nurse-midwife will have 40 of her first 60 births observed by a physician who is not the physician employer. The physician employer must be in the hospital during these births. 3. The nurse-midwife will write all orders as verbal orders from her physician employer. The physician employer must co-sign all these orders before the patient is discharged from the hospital. These rules made midwifery practice physically and financially impossible To have the physician employer present for all births w a s a redundant use of s kills. The increased hours worked by the physician raised the cost of practice. Increased hours exhausted the physician, making the physician unable to carry-on his or her own practice. The 1989 Florida Nurse Practice Act stated that physicians do not have to be present for advanced nurse practice. It could take a year for a nurse-midwife to hav e 40 births observed In requiring the nurse-midwife to write all orders as verbal orders from the physician employer, the medical staff required the nurse-midwife to act illegally. It was illegal for a nurse to write an order as a verbal order when in fact, the physician did not give the order. Medical staffs that formulated rules suc h as those listed abov e assume that the nurse-midwife will not have the finances or time to hire an attorney to file a Federal Trade Commission restraint of trade suit against the medical staff.

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281 British midwives were not precluded from hospital practice. Restraint of trade is a principle that was difficult for British midwives to master. Unlike Americans, who had a history of trust-busting and pro-competitive legislation, the British were accustomed to national monopolies. Utilities and mines were nationalized in the past. The British Broadcasting company was a state controlled monopoly. The National Health Service was a health care monopoly. Restraint of trade issues had to be successfully mastered to pass hospital privilege questions in the American national certification exam. A midwife entering American practice had to know the legal steps to take when hospital privileges were denied in restraint of trade. An American nurse-midwife not fluent in restraint of trade and contract issues would be pushed from job to job when physicians no longer found midwifery services to their economic advantage. The Department of Health. Effective Care In Pregnancy and Childbirth (Chalmers, Enkin, and Keirse 1989) was one example of the effect the British Department of Health had on British midwifery practice Chalmer, e t al. 's recommendations served to standardize health care across the United Kingdom. Recommendations proven cost-effective through research and standardization decreased the use of unnecessary treatments, thereby preventing wastage in the National Health System. The Department of Health funded a longitudinal study of

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282 British midwifery careers and retention in midwifery to help plan staffing needs for the National Health Service. Through staffing research, the Department of Health had a direct effect on the numbers of British midwives in practice. The American analogue to the British Department of Health was the federal Department of Health and Human Services. American nurse-midwifery, however, did not have the representation at the federal level that British midwifery did within the Department of Health. The American College of Nurse-Midwifery communicated with the Department of Health and Human Services to discuss maternal-child health and midwifery issues whenever an issue would affect nurse-midwifery, however, Health and Human Services did not print guidelines for midwifery care nor research midwifery staffing. The British commonwealth and Midwifery. The Commonwealth influenced British midwifery in several ways. First, during the postwar years and the early 1960s, the United Kingdom received an influx of minority workers from Commonwealth Nations (Webb 1980:616). One British midwife from Trinidad described her entry into midwifery this way, When it looked like I wouldn't be married after school, my uncles decided that I would be sent to England to study psych nursing. So, I studied. I hated the locked psych wards and the strictness. All the keys we had to carry and guards to escort us! As soon as I could, I studied to be a midwife. A British midwife from Jamaica commented, "There's not much to export form Jamaica. They exported us." The

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283 commonwealth nations served as a reservoir of available nursing and midwifery labor. Doyle (1981:220) and Carpenter (1988:317) charged the United Kingdom with exploitation of immigrant labor. Phoenix (1990:274) wrote that racial discrimination and class privilege were institutionalized in Great Britain. Lindsey and stirk (1990:276) wrote that, "racism flows briskly through the veins of the NHS ... We need only to look at the large numbers of black midwives that make up the work force, in our large cities and towns, and compare this with the numbers who have achieved seniority in education or management." The role expected of the black nurse was to fill the most unpopular spaces in the labour force-the low paid, low opportunity and low status areas that were shunned by others. A survey of Oxford area in 1961 found that only 3% of students nurses in teaching hospitals were nonEuropean, compared to 21% in nonteaching hospitals. Nationally only 1-2% of students nurses in teaching hospitals were from overseas, leading to accusations in Parliament in 1965 that they might partly be the result of overt discrimination. The most accute problems were probably experienced by those overseas nurses who were lured to this country to undergo pupil nurse training by "the Roll" and the promise that they would receive valuable training. They often found that the training was inferior and that they were exploited as cheap labor ... After training, they found themselves with a qualification which gave them no opportunities of advancement within the NHS, and which was unlikely to be recognized in their home country (Carpenter 1988:317). Discriminatory work situations pushed British midwives to other countries. During times of American nursing shortages, overseas nurses received special immigration status ( INRA 1989). British nurses were favored for American recruitment because of their common language. Until the early 1980s only

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284 British midwives were eligible for American nursing work. other British general nurses did not have obstetrical education and were not eligible for American nursing licensure. Eleven (58%) of the British educated midwives attending the Frontier School of Midwifery Precertification Program at the Tampa General Hospital were born in Commonwealth Nations. Nine (82%) cited their perceptions of less overt racism and increased opportunity for them and their children as reasons for immigrating to the United States. The political cooperation in midwifery education between the United Kingdom and the Commonwealth nations has spread the British model of midwifery to many parts of the globe. Work with Commonwealth nations kept British midwifery focused on the normal processes of pregnancy and birth. Developing nations not able to afford sonogram machines and fetal monitors had to maintain low technology midwifery skills. British midwifery had to retain skills in low technology midwifery to be a continued educational resource to the Commonwealth nations. The United States did not have an international agreement analogous to the British Commonwealth. Ninety-four and onehalf percent of the 2,089 respondents to the 1987 American College of Nurse-Midwives survey reported Caucasian ethnic background (American College of Nurse-Midwives 1989:8). However, medical staffing corporations recruit British

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285 educated midwives for understaffed American nursing positions. This places British midwives in positions where their education is underutilized. Recruitment of midwives educated by the British state contributes to the international "brain drain" (Gish 1979: 5, 6) It has been a goal of the American College of Nurse-Midwives since 1992 to increase the ethnic diversity of its membership (American College of NurseMidwives 1992, 1993). European Economic Community support of Midwifery. The British midwifery model was shaped not only by the British political structure, but by the European Economic Community (EEC) Standards. Two staff members of the Royal College of Midwives said that the Royal College was relieved when the United Kingdom came under the EEC requirements for three year midwifery educational programs. Direct entry into midwifery reinforced a construction of midwifery separate from that nursing. Each of the midwifery educators interviewed during the study was enthusiastic about direct-entry, or preregistration midwifery. Educators said taking midwifery out of nursing allowed educators to teach student midwives about the healthy process of pregnancy and birth before exposing students to medical and nursing illness concepts.

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286 Table 11. Summary of the Political control of Midwifery in the United Kingdom and the United states. TYPE OF CONTROL CERTIFICATION UNITED KINGDOM National, by the national boards for nursing and midwifery through individual educational programs NATIONAL REGISTRATION By the United Kingdom Central Council STATE REGISTRATION None UNITED STATES National, by the American College of NurseMidwives Certification Council None Board of Nursing, Board of Midwifery, or Board of Medicine (board type varies by state) --------------------------------------------------------------LOCAL REGISTRATION Notification of District Supervisor of Midwives of intention to practice None --------------------------------------------------------------INSTITUTIONAL None By medical staff of hospital --------------------------------------------------------------

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287 Table 11 summarizes the political control of midwifery in the United Kingdom and the United States. Political control was stronger at the national level in the United Kingdom, with certification and registration centrally coordinated. Midwives in the United Kingdom did not have hospital credentialing, but did notify a district supervisor of midwifery of intent to practice locally. In the United States national credentialing was managed by a private organization, the American College of Nurse-Midwives. Legislative control of nurse-midwifery practice was at the state level instead of the national level. American nurse-midwives were additionally credentialed by hospital medical staffs, but did not report to local authorities. The Health care system. The British had a long legacy of health care as a right that was best exemplified by the British National Health Service. The British social contract had a goal of making health care available to all Britains. Myles (1975:vii) revealed British midwifery's importance to the future of Britain by writing, The wider implications of childbearing have also been considered, for although the birth of a baby is a very personal matter to the mother, at the same time the ultimate health and well-being of the nation depend on an efficient obstetric service. Varney's introduction to Nurse-Midwifery (1987:xiii,xiv) spoke of "underserved, high-risk populations .. the private patient sector ... and nurse-midwives being advocates for

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288 women regardless of economic background. The focus was on the individual woman not on the future of the state. American individualism, state sovereignty, and the small numbers of American nurse-midwives hold the view of American nursemidwifery in the immediate present instead of the future. When the National Health Service was formed in 1948, the United Kingdom had a war decimated population with the beginnings of a postwar baby boom. The National Health Service guaranteed access to health care for all British citizens. Its single-payor, capitation system with hospital ownership, state control of pricing, and state employment of health care workers has been acknowledged as being the most efficient method of providing universal access to care (Hanneman, Hage, and Hollingsworth 1990). British midwifery' s relationship with the National Health Service has been symbiotic: Without inclusion in the National Health Service as primary maternity care providers, midwifery in the United Kingdom would have perished. Without midwifery, the National Health Service could not provide cost-effective maternity services. With no unified federal system of health care, American nurse-midwifery has remained a profession united by philosophy of care and divided by differing state practice regulations. The American College of Nurse-Midwives directed considerable resources to documenting current nurse-midwifery laws in the fifty states and advising nurse-midwives how to change those laws to facilitate midwifery practice.

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289 Table 12. Health care System Variables in the united Kingdom and the United states. SYSTEM VARIABLE UNITED KINGDOM National health + policy single employer + Single payor + Salaried providers + Independent midwifery + Midwifery Organized within hospital structure + Midwifery supervision by midwives + Single laws for nursemidwives and direct entry midwives + Hierarchical midwifery administration + + = present in health care system = absent in health care system UNITED STATES

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290 Table 12 summarizes health care system variables in the United Kingdom and the United States. Equity in Health care Access. Biomedical care is not the primary determinant of women's health. Women's health depends on an unpolluted environment, adequate nutrition, sufficient rest, and physical safety. The World Health Organization's definition of health took this position by saying, "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (Turshen 1989:16,18)." Given the resources for physical, mental, and social well-being, the processes of women's lives: menarche, childbirth, lactation, and menopause proceed normally. Because health depends on more than genetic chance, a just society works to insure that all citizens have access to the determinants of health. Among industrialized nations, the United States stands alone in deciding whether the state has a duty to insure equity in access to health care. Turshen (1989:65) calls the rights that support access to health care: the right to a standard of living that ensures health, the right to social security, rights of motherhood and childhood, second generation rights. The United States was founded on first generation rights: the rights to life, liberty, and citizenship, freedom of religion and thought, and rights to a fair trial. The liberty and individualism inherent in these primary, founding rights form barriers to consensus about

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291 public provision of health care. Americans are expected to have the individual resources to provide for their own care. The fortunes of midwifery in the United Kingdom and in the united States are tied to state attempts to provide equity in access to health care. The British National Health Service has proven to be more a guarantee of access to medical care than a health service. Over its 50 year history, it has provided Britains with service to acute and chronic health problems, but has failed to equalize morbidity and mortality rates between the social classes (Turshen 1989, Susser 1993). In one area, however, health care that encompasses health education, improved nutrition, and improved rest is provided with equality of access. That area is maternity care. Maternity care must not be viewed as a small portion of women's lives. Pregnancy is the most common condition that pushes women to seek health care between the ages of 15 and 45. The National Health Service would hav e had difficulty equitably providing maternity services without the British construction of midwifery. British midwifery, using the model of pregnancy and birth as normal processes, provides a costeffective maternity service. Cost-effectiveness has two components in maternity care: 1) the use of costly technology is low, and 2) health is supported so that medical intervention is needed infrequently. British midwives support health by serving as reservoirs of normal pregnancy and childbirth knowledge. They counsel on adequate nutrition and

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292 rest. Midwives serve as gatekeepers to enhanced social services for mothers by signing the maternity leave forms of working mothers and referring them to other social service agencies. Midwives teach parentcraft (childbirth education) classes that become a self-fulfilling prophecy. British women are taught to expect uncomplicated births. In more often than 80% of births, British women follow the pattern they are taught. The necessity of equal access to care is enculturated in British midwifery students. Midwifery textbook lists from St. Alfred's College, The Selent School of Health Studies in Portsmouth, and the Lothian College, for example, included these readings: Feminist Practice in Women's Health Care, c. Webb 1986 The Captured Womb, A. Oakley 1984 Women Confined, A. Oakley 1980 Racial Equality and Good Practice in Maternity Care, M. Pearson 1985 Power and Politics and Pregnancy Health Rights, B. Pratten 1990 A Savage Enquiry, Who Controls Childbirth?, W. Savage 1986 Health Policy and the NHS, J. Allsop 1984 The Politics of the NHS, R. Klein 1983 Midwives and Medical Men, J. Dennison 1988 Promoting Health, L. Ewles and I. Simnett 1985 Health and Ethnic Minorities, A. McNaught 1987

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293 The Politics of Health Education, S. Rodmells and A. Watt 1986 Personal and Community Health, A. Barnes 1987 Community Health, Preventive Medicine and Social Services, J. Meredity Davies 1983 The Politics of Maternity Care, J. Garcia 1990 Power and the Profession of Obstetrics, W. Arney 1982 Black Reports: Inequalities in Health, HMSA 1980 Multiracial Initiative in Maternity Care, Maternity Alliance 1985 Medicine Under Capitalism, V. Navarro 1976 These readings assisted in the construction of British midwifery. The readings stressed health promotion for all. Gaining that access was a political process. Oakley, Donnison, Garcia, and Navarro approached health care from a political economy background. British midwifery education connected inequalities in British health care with political and economic causes, then, worked to produce midwives who would resist political and economic forces that decreased women's access to health care. The text lists of American nurse-midwifery programs were more focused on clinical care than social policy. This was consistent with the construction of the American nurse-midwife as a physician substitute instead of the pastoral-like construction of the British midwife. The University of Florida Nurse-Midwifery Program listed these texts addressing health promotion and access to care:

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294 social Transformation of American Medicine Understanding Public Policy Ordered to Care: The Dilemma of American Nursing Cost, Quality and Access in Health Care The Painful Prescription: Rationing Hospital Care The Community Based Nurse-Midwifery Educational Program and the Precertification Program of the Frontier School of Midwifery and Family Nursing listed these textbooks related to midwifery and social policy: Witches, midwives and nurses: A history of women healers, Ehrenreich and English 1973. Maternity Care in the World, International Federation of Gynecology and Obstetrics 1976. In Labor: Women and power in the birthplace, Rothman 1982. Lying-in: A history of childbirth in America, Wertz and Wertz 1979. American nurse-midwifery programs may have focused less on the political control of health because health control was divided between state and federal control and private enterprise. In addition, many nurse-midwifery students travelled out of state to study. To teach the health politics of one state would have little meaning to students from another. American nurse-midwifery programs may have restrained text selections in order to be less confrontative to nursing and medicine, professions to which it was intimately tied. The inequity in the availability of American health care

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295 created American nurse-midwifery and sustains it. Since the time of the Frontier Nursing Service, the base of American nurse-midwifery prospered in programs for women without private health insurance. The attempt of the United states government to provide health care to the poor, the Medicaid Program of 1965, gave a financial base to American nursemidwifery practice. In improving access to care by creating a separate system of health care for poor women, the Medicaid program created inequitable access to practice for nursemidwives. When the Health Care Finance Administration formed rules for nurse-midwifery payment under Medicaid, nurse-midwifery reimbursement was set at a minimum of 65% of the physician's fee. Some states paid up to 80% of physician's fees. Less than five states paid nurse-midwives 100% of physician's fees. The Medicaid reimbursement rates were critical to nurse-midwifery practice because private insurance carriers followed Medicare/Medicaid reimbursement patterns. American nurse-midwives had to follow the same standards of practice that obstetricians and gynecologists followed. When nurse-midwives were sued for malpractice, they were expected to have provided the same work that a physician would have produced. Nurse-midwives were expected to produce the same work, but were paid less for that same work. While nursemidwives did have less human capital invested in practice and their liability insurance costs were lower, the cost of

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296 practice overhead was identical to that of a physician for normal maternity care. The lower reimbursement served as a disincentive for physicians, hospitals, and health services to employ nurse-midwives. A health care group could employ a physician and be reimbursed the full fee (100%) instead of the 65% paid to the nurse-midwife. Some physicians worked around differential reimbursement rates by stretching the issue of physician supervision. Under this logic, in states where the physician was legally responsible for nurse-midwifery care, the group of physicians employing the nurse-midwife billed as a group. Medicaid or the private insurance carrier reimbursed at the full physician rate. At one Florida hospital from the late 1980s through 1993, physicians signed a statement that was rubber-stamped onto progress notes saying that they had personally supervised major portions of the labor and birth. The physicians then billed for the 100% Medicaid physician reimbursement instead of the 80% reimbursed to Florida nurse-midwives. Some obstetricians, nervous about federal fraud cases involving physician billing for nurse practitioner work, ordered that the nurse-midwives page them into a room when birth was imminent. At best, the physician observed the birth, signed the supervision statement and left. Many physicians entered the room of a woman they had not seen before and began to give the nurse-midwife instructions on proper positioning for birth, perineal support, and delivery of a placenta. At

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297 worst, the physician entered with one or more medical students and residents, then formed a spectator's row at the back of the room, never interacting with the laboring woman. The invasion of a woman's privacy and the disturbance of the birth environment were more important issues to the nursemidwives than the reimbursement rates. Physician intrusion into the labor room put the physician in control of the birth regardless of who had managed the care to that point and who was doing the work. Nurse-midwives found ways to resist this physician intrusion on birth. First, physicians did not want to be paged on night shift. They slept, when possible, in call rooms and signed the supervisory paperwork at the end of night shift or later in medical records. Several nurse-midwives preferred night shift work for this reason. Second, a nursemidwives were relieved when the physicians were in surgery and could not come to observe the birth. The physician then signed the supervisory statement following surgery. In a third method of resistance the nurse-midwife waited until the fetal head was being born, then instructed the nurse to page the physician. By the time the physician entered the room, the newborn was with its mother. The nurse-midwife could then pretend to be an idiot who was surprised by the speed of the birth leaving insufficient time for the physician to arrive. In working to improve access to health care for poor women, American nurse-midwifery actually decreased services available to women Backed by the concept of normality, nurse-

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298 midwifery practices from the 1960s to the 1980s proved their cost-effectiveness by keeping women sufficiently healthy to be admitted and discharged from hospitals or birth centers within 24 hours of birth. During the 1960s, hospital postpartum lengths of stay were as long as five days. During the late 1980s, when postpartum stays for normal birth had decreased to 48 hours for mother and baby, cutting the postpartum stay in half still provided savings to third party payers and hospitals. Nurse-midwifery care proved so cost-effective that many insurance companies reimbursed full fees to nursemidwives during the 1980s. Health maintenance organizations in many states sought nurse-midwives to provide care in their capitated systems. The American early discharge programs of the 1980s accustomed third party payers to short postpartum stays. By 1993, third party payers expected women to be discharged by 24 hours postpartum regardless of her level of pain, her knowledge of breastfeeding, or her social support at home. By the end of 1993, insurance companies kept statistics on prenatal services and obstetricians. Those with the longest lengths of stay were pushed out of competitive bidding for preferred provider status. The push from insurance companies became so strong that by the end of 1993 in one Florida study site, 15 year old primigravidas were being sent home with newborns at 36 hours post-Cesarean section. While the British "domino" system, where women were

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299 discharged home 6-10 hours following birth, was similar to American early discharge programs, it had one vital difference: the British had the community midwifery system to provide home support for the mother and newborn. The Domino system was often denounced by British midwives who had been practicing more than fifteen years. Said one, "It's immoral to send a mother packing the same day she's given birth." During 1992, American nurse-midwives joined the effort to form national health coverage. Knowing the niche created for British midwifery by the National Health Service's maternity services, American nurse-midwives worked to be included in the American health plan as independent providers. Independent provider status for nurse-midwives was a part of the Clinton administration's original Health Securities Act description. This language was dropped when the Health Securities Act was filed. The model of independent British midwifery working within the National Health Service could be an important example during the formation of American state and federal health plans. Economic Variables Influencing Midwifery Privatization of British Health care. Thatcher Government, British hospitals authority to assume trust status. Trust In 1990 under the were given the status partially privatized the hospitals. Trust status was meant to cut costs

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300 by giving control of income and expenses to local areas. Hospitals could set their own fees and salary ranges. This would give hospitals an income independent of the District Health Authority budget. To make a profit, hospitals would have to cut input expenses. The trust status issue was debated at the 1992 annual general meeting of the Royal College of Midwives. Managers with business background were being placed in charge of maternity services. In 1992, British Maternity Service units operated under the direction of a triumvirate: the Business Manager, the Director of Midwifery, and the Obstetrical Consultant. Clinical services were to be managed by the midwives and "hotel services" by the general manager (Willis 1992:24). The Royal College of Midwives branch delegates argued that, in reality, most power was deferred to the Consultant and women were suffering under the efforts to cut costs. Efforts to reduce costs included decreasing midwifery staff, decreasing length of hospital stay after birth, and closing smaller community general practice units often used by midwives. A show of hands revealed that approximately 75% of the branch delegates worked in hospitals that had taken trust status. One impassioned delegate said to the floor, "The market system pits provider unit against provider unit to compete for the favors of the consumer ... if we let it!" Closing smaller hospitals and decreasing the length of hospital stay displaced midwives and decreased their links to

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301 their communities. Moving women from their communities into larger district hospitals increased the perception of birth as an illness, weakening the potential for midwifery practice and increasing the desirability of biomedical management. Unrestrained trust status freedom could push the British construction of midwifery closer to American nurse-midwifery, where providers competed for patients instead of working together to care for those patients. Professional Midwifery organization The Royal College of Midwives and the American College of Nurse-Midwives. The Royal College of Midwives supported British midwifery by: bringing together local representatives of midwifery so that midwifery can respond to cultural and legal changes in an organized, proactive manner serving as a reservoir of midwifery experts for policy formation and government consultation providing continuing education for midwives raising money to support midwifery related projects -maintaining the world's largest library on midwifery and archival material on British midwifery serving as a trade union for midwives only Table 6, page 189, showed the goals of the British and American midwifery professional organizations. While five of

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302 the six goals were similar in intent, the goals of the American College of Nurse-Midwives were more focused on recognition of midwifery and professional survival, reflecting the tenuous position of nurse-midwifery in a competitive health care system. The American College of Nurse-Midwives worked to insure the right to practice and financial stability for each nurse-midwife. The right to practice and financial survival were assumed in British midwifery. The larger membership of the Royal College of Midwives needed a more representative form of government than did the membership of the American College of Nurse-Midwives. Merelman (1991:11) described the British culture of political participation as "a generally static, hierarchical model of group solidarity, revolving around social class." He contrasted this with the culture of political participation in the United States which was "fluid, egalitarian, and individualistic." Merelman' s national styles of political participation were reflected in the governing of the midwifery professional organizations. The Royal College of Midwives had a hierarchically structured, representative professional organization, while in the United States, the general membership of the American College of Nurse-Midwives voted directly on issues. The general membership of the College of Nurse-Midwives was purposefully placed at the top of the organizational diagram (Figure 8, page 191). In a nation where sovereign states had individual midwifery regulations, the

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303 national professional organization had to rely heavily on participation by individuals to extend its work to local levels. American precertification teachers interviewed stated, "Foreign midwives drop-out of practice once they're certified. They're never active in the ACNM (American College of NurseMidwives)." A midwife enculturated in the hierarchical British system would not be expected to summon the individualism needed for organizational work in the American midwifery construction. Association of Radical Midwives. Members of the Association of Radical Midwives viewed midwifery as a profession distinct from nursing that should be free of any physician influence. They wanted midwives to be able to use their intuitive and nontechnological skills without being pressured by physicians or hospital administrations to use the technology available. If Association of Radical Midwives members viewed the Royal College of Midwives leadership as old stodges, then, for them, the Association of Radical Midwives was Great Britain's midwifery culture of resistance. Independent Midwives Association. Although a small organization, its founding signalled dissatisfaction with the current status of midwives as employees of the National Health Service, which had increasingly adopted the medical view of

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304 birth as an illness that must be managed within a hospital. Cronk and Flint 1 s 1989 Community Midwifery contained a chapter on independent midwifery detailing legislation related to independent practice, suggested business practices, and sample documentation forms. This inclusion of independent midwifery in a midwifery textbook further demonstrated the desire of British midwifery to have increased self-control. There was no American association for privately employed midwives. This could have stemmed from the diversity of midwifery employers and state regulations affecting American nurse-midwifery. No one employer symbolized the medicalization of birth or had dominant influence over American nursemidwifery in the manner of the British National Health Service. Therefore, there was no unified perceived need to resist that influence. American nurse-midwives were resisting the medical model of birth as personified in powerful physician organizations such as the American College of Obstetricians and Gynecologists rather than single employers. Midwives Alliance of North America. The Midwives' Alliance of North America was America's closest analogue to the Association of Radical Midwives. Some certified nursemidwives were members of both the American College of NurseMidwives and the Midwives' Alliance of North American. Unlike the Association of Radical Midwives, whose work complements that of the Royal College of Midwives, the Midwives' Alliance

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305 and the American College of Nurse-Midwives were more competitive than cooperative. Since the early 1980s, the leadership of the American College of Nurse-Midwives has debated changing the College's structure to incorporate nonnurse, Midwives' Alliance members. The frequent polarization between the two groups centered on the construction of midwifery: Is midwifery a separate art or is it a branch of biomedical nursing? The polarization also had economic roots: If a midwife can be prepared with two to three years of education, how would the four to six year nurse-midwifery model compete? What place would a master's prepared midwife have in a system that used direct entry midwives? Unionization. Unionization was a foreign concept to most American nurse-midwives. American health professions organized by professional organization rather than unionization. Two American hospitals that employed nurse-midwives included antiunion, pro-employerjemployee relationship discussions during new employee orientation. The United Kingdom had a long history of unionization, however, the 1980's Thatcher Government promoted strong anti-union sentiment. The Employment Act of 1980 restricted the right to picket (Sethi and Stuart 1982:87). The 1980 Employment Act also prevented those in management positions from participating in union activities without risking disciplinary action (Sethi and Stuart 1982:87). These provisions of the Employment Act of

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306 1980 pushed the unionization of British midwives closer to the nonunionized model of the American nurse-midwifery. one of the criticisms leveled at British educated midwives who become American certified nurse-midwives was that they do not participate in the political process or the work of the American College of Nurse-Midwives. Based on the differences between the British and American models of midwifery, this may have been a justified comment. British midwives were used to working as members of the National Health Service, a large organization with explicit structure and regulations. They were represented by a professional organization, The Royal College of Midwives, that had union status and bargained directly with the central government. The Royal College had a full complement of more than 30 paid staff members to manage midwifery union activities, political actions, education, and special projects. A career as a British midwife did not require much independent action to continue employment or benefits. The Royal College could resist challenges from biomedicine without perceived resistance at the individual member level. In contrast, American nurse-midwives were represented mainly by their own efforts. The American College of NurseMidwives did speak for nurse-midwives at the federal level, but with only 4,000 members, making legislative changes was difficult. The College of Nurse-Midwives could not represent nurse-midwives at the state level because each state regulated

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307 nurse-midwifery in a different manner. A British educated midwife entering practice in the United States, who was expected to represent herself to her hospital, to the state, and to the federal government, would have little experience to give her direction. The Relationship of Nursing to Midwifery. Early attempts by American nurse-midwives to organize were frustrated by their inability to form a nurse-midwifery council within either the American Nurses Association or the National League for Nursing. Certified Nurse-Midwives (CNMs) were accused of practicing medicine, not nursing, by both physicians and nurses. CNMs organized under the National Organization for Public Health Nurses until its incorporation into the American Nurses' Association in the early 1950s (Ernst 1979:D-1; Varney 1980:7). The American College of Nurse-Midwives (ACNM) was formed in 1955 and has remained structurally independent of nursing and medicine since. CNMs see themselves as members of two separate professions: nursing and midwifery. "Midwifery does not require nursing either as a prerequisite or as a recognized component of the profession" (Burst 1980:4). Although nurse-midwifery could not be incorporated into the American Nurses' Association, the ACNM historically stressed the use of "nurse-midwife" to create an identity separate from that of traditional granny or lay midwives, who lacked formal education. This identification with nursing has been a two-

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308 edged sword. Some CNMs entered American nursing only as a mechanism for becoming a legal midwife. They viewed nursing as being less independent and less clinically skilled than midwifery. The increased independence of the clinician's role has been problematic for nurse practitioners (Lukacs 1982:4 7) Rosoff (1978:338,339) attributed this to the socialized dependency of women and nurses. Nurse-midwifery educational programs may be affiliated with colleges of nursing, colleges of medicine, or colleges of public health. The placement of many nurse-midwifery educational programs are located in colleges of nursing, pushes the College of Nurse-Midwifery to make its definitions, standards, and requirements as compatible with organized nursing as possible. This increases American nurse-midwifery's affiliation with biomedicine and decreases its self-control. The University of Florida faculty, requiring an applicant to be a registered nurse with a bachelor's degree (nursing bachelor not required), maintained that the nursing base was essential to give students the nursing skills needed for midwifery care, such as enema administration. When questioned how British faculty members taught non-nursing students the nursing background required for midwifery practice, one program head did not understand the question. After being given examples of techniques such as injection that Americans perceive as nursing knowledge the Program Head replied, "Those aren't nursing, those are midwifery." Further

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309 questioning of other midwifery tutors revealed that British midwifery did not have the same knowledge domains as did American nurse-midwifery. Figure 12 illustrates the cognitive domains of midwifery, nursing, and medical obstetrics in the United Kingdom and the United States. In the United Kingdom, with no labor and delivery nurses, midwives performed tasks, such as bed baths, that would be considered nursing work in the United States. In the United States, health was specialized and stratified. While the nurse-midwife could technically and legally perform tasks such as injection and phlebotomy, those tasks were most often relegated to nursing staff, while the nurse-midwife occupied the niche of the obstetrician. British midwifery predated the professionalization of British nursing and medicine. As new healing techniques were developed, such as anesthetic gases, they were incorporated into British midwifery without being seen as nursing or medical techniques. The growth of American nurse-midwifery occurred largely after 1970, when the constructions of American nursing and medicine were well defined. Any use of techniques also used by nursing and medicine were not perceived as midwifery practice but as encroachment on nursing or medical terri tory. The American fee for service system fosters provider territoriality. A defense for nurse-midwives

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310 Figure 12. Cognitive Domains of Midwifery, Nursing, and Medicine in the United Kingdom and the United States. COUNTRY: PROFESSION: PARTIAL LIST OF TASKS: Bed m aking, b e d baths Injections, enemas Medication administration Analgesia prescription Anesthetic gas united /MIDWI FERY Kingdom \ administration Phlebotomy Non-stress testing Episiotomy, suturing Ultrasonography /IV placement Prescr1pt1on Episiotomy, suturing Instrumental delivery United States MEDICAL OBSTETRICS NUR SING MIDWIFERY MEDICAL OBSTETRI CS surgery Bed making, bed baths Injections, enemas Medication administration IV catheter placement Phlebotomy Prescription _//Non-stress testing suturing Prescription /Non-stress testing Episiotomy, suturing Instrumental birth "" Surgery Ultrasonography ANESTHESIOLOGY -Anesthetic gas administration

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311 accused of unlawful practice of medicine was to retreat into the more accepted profession of nursing. Another way American nurse-midwifery retreated into biomedicine through nursing was by adopting Varney's nurse-midwifery process. The nurse-midwifery process is an adaptation of the nursing process, an adaptation of the scientific process. To receive insurance reimbursement, midwives had to be able to form a diagnosis. Diagnosis, however, was the practice of medicine. To be seen as a credible scientific profession, nurse-midwifery had to articulate its own process. Varney accomplished this for midwifery by producing this process: 1. Obtain data 2. Identify problems or diagnoses 3. Anticipate potential problems 4. Evaluate the need for nurse-midwifery intervention, consultation, collaboration with a physician, or referral to a physician 5. Develop a comprehensive plan of care 6. Direct or implement the plan of care 7. Evaluate the effectiveness of care (Varney 1980:43) The nurse-midwifery process was meant to be used so that nurse-midwifery assessment yielded an accurate medical diagnosis. American nurse-midwives, who were seen as practicing second rate obstetrics using a hand-me-down profession, were expected by biomedical providers to make mistakes. Nurse-midwifery had to be a faultless science not an intuitive art. British midwifery process has a different purpose than American nurse-midwifery process. British midwives, who focus

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312 on the normal process of pregnancy and birth and have an established profession, are expected to correctly assess a problem. British midwives use midwifery process to individualize the care given women (Murphy-Black 1993, Bryar 1990). British midwives entering American practice have a difficult time substituting Varney's model for what they have learned previously. Because they have been accustomed to using midwifery process to individualize care, British midwives do not see nurse-midwifery process as an essential method to form a diagnosis. The American College of Nurse-Midwives Certification Council national exam is based on use of the nurse-midwifery process. Its questions use the language of Varney's nurse-midwifery process. Eighteen of the 20 British m idwife studying for American certification at the Tampa General Hospital Precertification site had to repeat tests because of nurse-midwifery process errors. The two students who grasped nurse-midwifery process easily were Americaneducated nurses who studied midwifery in England. Use of nurse-midwifery process was easily added to their fluent use of American nursing process. Competition With Physicians. Capitation for British general practitioners led to a system called "shared-care." In shared care, the general practitioner diagnosed the pregnancy and did the first physical exam. The prenatal booking (first prenatal v isit history) was completed b y the community midwife, often

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313 in the woman's home. From that point, the midwife and the general practitioner alternated prenatal visits (Waterhouse 1989:396). Most often, the midwife attended the birth. The midwife was the most senior attendant at 75% of British births (Association of Radical Midwives 1990:2). The image of the British midwife as a skilled health care provider was enhanced by midwifery's position as the system's primary provider of maternity care. General practitioners insisted that shared care was necessary for them to maintain their relationship with the woman and her family during pregnancy (Robinson 1989:35) Delegates at the 1992 annual general meeting of the Royal College of Midwives argued that the only reason for general practitioners to be involved in maternity care was for them to continue t o receive the capitation fee. Delegates said: "How long will this government pay for doctors to be midwives?" "Gps love antenatal clinics because women are young and cheery. If they don't do antenatal, they will be given dreary surgical geriatric clinics." "Don't you tire of GPs who collect for your services but won't come out for births or hom e confinements?" Clearly, the midwives feared tha t the National Health Service might view the midwives as being more redundant than the maternity services provided by general practitioners. Some authors proposed that a system where midwives reported directly to the obstetrical consultant (obstetrician) instead of through the general practitioner should be implemented

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314 (Smith and Jewell 1991:1443, House of Commons Health committee 1992:xli,lix). This would eliminate redundancies and increase the functional independence of the midwife. The British midwife was also responsible for the care of newborns through day 28 of age. Examination of the newborn was done by midwives before hospital discharge and continued during postnatal home visits by the community midwife. When illness was identified in the newborn, the midwife contacted the general practitioner, who contacted a pediatrician as needed. The House of Commons Report (1992:li) recommended that instead of contacting the general practitioner first, midwives contact pediatricians directly as needed, to decrease the time and cost involved pediatric diagnosis.

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315 Figure 13. The Place of Midwifery Within the Health care Delivery system in the United Kingdom and the United states. CONTINUUM O F CARE: WOMEN'S PRIMARY HEALTH CARE l UNCOMPLICATED PRENATAL AND BIRTH CARE 1 COMPLICATED PRENATAL AND BIRTH CARE PRIMARY CARE P R OVIDER : UNITED KINGDOM General Practice Physician* l Midwife* J/ G eneral Practice Physician l Obstetrician; Gynecologist P erinatologist UNITED STATES Obstetrician/ Gynecologist* General Practice P hysician (Nurse-Midwife) Obstetrician/ Gynecologist* P erina t ologist = most numerous provider Figure 13 illustrates the p osition of midwifery in the United Kingdom and the United Sta t e s In the Unite d Kingdom, the midwife has a recognized position as a provider of prenatal and birth care. There is a single system of referral. In the United Sta tes, the position of the nurse-midwife is incidental to tha t of the obstetrician. In the Unite d States, surgically educate d obstetricians provide primary care. In the United Kingdom, primary care is provided by the non-surgical

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316 general practice physician. Fitting the years of medical education to the care requirements of the provider's work saves funding in the United Kingdom. Critics of the general practitioner system argue that the midwife with 18 months of specialized midwifery education has more knowledge of normal pregnancy and birth than does the general practitioner with three months of obstetrical residency and three months of gynecological residency. By 1988, only 6% of births were booked with general practitioners, calling into question the ability of general practitioners to maintain their skills in the provision of maternity care (British Medical Journal 1991:1487-1488). Figure 13, page 3 16, demonstrates that when a British midwife e ncountered a pregnancy complication, she referred to the general practice physician. The general practice physician had less education in normal pregnancy than does the midwife. If needed, the general practice physician referred to the obstetrician. In the United States, the nurse-midwife referred problems directly to the obstetrician, but legally, the work of the nurse-midwife was the work of the physician. GP's are added to the obstetric list and paid at a higher rate to give maternity care for the rest of their professional lives, because at some time in the past-however distant-they had obstetric experience or an obstetric qualification. But to remain in practice a midwife takes a compulsory refresher course every five years (Beech and Robinson 1992:27). The Association of Radical Midwives argued that general practitioner education is rooted in the medical (illness)

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317 model and that midwives should be "the point of entry into the care for all pregnant women (Klein and Zander 1989:188) ." Green, Kitzinger, and Coupland (1986) compared three British hospitals with the traditional three-tiered structure to three hospitals with a newer, two-tiered structure that did not have registrar grades. They determined that midwives in the two-tiered system performed an increased range of tasks and were more empowered to make decisions. They concluded that the two-tiered system decreased competition between house officers and midwives. In some British localities, consultants asked to screen each woman during the pregnancy, once early in the second trimester and once late in the third trimester. This practice eroded the clinical responsibility of British midwives to screen normal pregnancies and refer women for additional treatment when necessary. In one American midwifery practices, the obstetricians insisted on seeing each woman once during pregnancy. The physicians encourage this as a method for a woman to be acquainted with the obstetrician in case she were to need medical or surgical help. In reality, this practice kept the midwife in a second class position, her diagnosis of normalcy tentative until approved by the obstetrician, leaving the obstetrician in ultimate control. In the United states, the role of the general practitioner during birth has been nearly eradicated by the emergence of the obstetrician. The specialization of American

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318 physicians decreased consumer confidence in primary care providers such as the midwife and the general practitioner. In 1970, 77% of American physicians were specialists compared to 34% of British physicians (Hollingsworth, Hage, & Hanneman 1990:41). scope of Practice. The scope of American nurse-midwifery practice has increased since the importation of the British construction of midwifery into Kentucky in 1925. Figure 14 diagrams historical changes in the scope of American nursemidwifery practice.

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319 Figure 14. Historical Changes in the scope of Practice in British and American Midwifery 1930, 1970, 1990. POSSIBLE RANGE IN SCOPE OF MIDWIFERY PRACTICE <---------------><------------------------><-----------------> gynecology pregnancy gynecology family planning childbirth family planning preconceptional lactation hormonal care replacement 1930 SCOPE OF PRACTICE United Kingdom United States < -----------------------> < -----------------------> 1970 SCOPE OF PRACTICE United Kingdom United States < -----------------------> < ---------------><-----------------------> 1990 SCOPE OF PRACTICE United Ki ngdom United States < -----------------------> < ---------------><------------------------><--------------->

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320 In 1930, both British midwifery and American nursemidwifery had the same scope of practice. Midwifery work was focused on pregnancy, childbirth, and lactation support. By 1970, as American programs funding women's health grew, American nurse-midwifery diverged into the provision of family planning and gynecology services. As the women cared for by nurse-midwives educated in the 1970s and 1980s aged into menopause, the again, this scope of American nurse-midwifery changed time expanding into primary health and gynecological care for menopausal women. In the early 1990s, American nurse-midwives provided a full range of primary health care services for women during the early 1990s. For women health care, American nurse-midwives occupied the niche of the general practice physician in the United Kingdom. Employment Opportunities. With a recognized role in the National Health Service, British midwives should have had abundant employment opportunities. Despite Department of Health and regional provider needs research, decreases in the numbers of student midwives educated in the United Kingdom since 1989 have not been sufficient to prevent the unemployment of new midwives. A number of factors may have accounted for the surplus of British midwives, including: -the recession of the early 1990s forcing many midwives who would previously have changed careers or left midwifery to raise children to continue midwifery

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321 employment, -decreasing hospital postpartum stays decreasing the numbers of hospital midwives needed, and -a birthrate decline as the population swell of postwar babies aged-out of their reproductive years decreasing the need for midwives. The same demographic factors creating a surplus of British midwives exacerbated the maldistribution of American obstetricians in urban areas during the early 1990s. The numbers of practice opportunities for American nurse-midwives increased during the early 1990s, but the majority of these positions were as employees in practices serving low income or rural women. The worldwide recession decreased the need for British midwives but created work for American nurse-midwives where physicians did not want to practice. Salary Levels and Hours. grade and pay levels of Placing British midwives in the nurses with less responsibility reduces their status as independent practitioners and erodes the separate identity of midwifery. During the 1992 annual general me eting of the Royal College of Midwives, a motion was made for the College to develop a pay and grading system for midwives separate from nursing. Said one Chichester delegate, "We 1 re not necessarily asking for more, we 1 re asking for separate and fair." Another delegate said, "District health authorities are using nonrnidwifery criteria to evaluate

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322 Table 13. Economic control of Midwifery: The cost of Being a Midwife. PROCESS BRITISH COST Midwifery education none Certification exam none National registration $90 initial nursing registration plus $25 extra for midwifery qualication State registration Professional organization membership Malpractice liability insurance Physician retainer fees $45 every 3 years following none Royal College of Midwives $180 per year none (included in RCM annual dues) none AMERICAN COST $15,000 -$25,000 $360 none $45 to $160 every 2 years -varies with state American College of Nurse-Midwives $210 per year $3,000 -$5,000 per year $0 -$800 per birth depending on legal structure of CNM/MD relationship --------------------------------------------------------------

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323 midwives. In my district the criteria for a water health worker is used." The motion passed unanimously. Table 13 illustrates the differing costs of midwifery practice in the United Kingdom and the United States. While American salaries were higher than British midwifery salaries, American costs of practice were higher. The primary difference between the costs of practice in the two midwiferies was in the locus of economic control. In the United Kingdom, the only required fee for midwifery practice was the national registration fee. Membership in the Royal College of Midwives and malpractice liability insurance were not required. In the United States, some state governments required nurse-midwives to purchase malpractice liability insurance before a license to practice was issued. In addition, some hospitals would not allow nurse-midwives to practice unless the nurse-midwives demonstrated proof of liability coverage. The nurse-midwife could pay education, certification, registration, and liability fees but still not be able to practice unless a physician was willing to sign an agreement to be available for consultation and referral. Physicians, unless employed by the state, generally charged for this availability. Charges ranged from $100 to $800 per birth. (Medicaid reimbursed a nurse-midwife $800 to $1,500 per birth depending on the state of residence.) Physicians did not charge other physicians for consultative availability. The economic control of American nurse-midwifery was held by

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324 physicians. The economic control of British midwifery rested with the state. Models of Midwifery Education Midwifery Education The differences between British and American nursemidwifery education are some of the most visible differences between the two midwifery constructions. Although British and American philosophies behind midwifery practice are essentially the same, the structure and process used to teach these philosophies and the clinical skills to implement them are different. Cultural Value of Education Rose (1985:280) wrote how the growth of industrial urban society in the United Kingdom from the 1840s required increasing numbers of "gentlemanly professionals" such as physicians and engineers. Starr (1982:26) described how British physicians added a liberal arts education to their professional requirements making themselves gentlemen, thereby increasing their social standing. Sutherland ( 1985: 3 34) wrote of the educational disparity between the British classes.

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In 1962 it was estimated that 45 percent of the children of higher professional families were likely to enter some form of higher education, while only 4 percent of the children of skilled manual workers were likely to do so (Sutherland 1985:334). 325 The United Kingdom expanded higher education during the 1960s and 1970s, raising university or polytechnic attendance from the 1961 4.6% to about 15% in 1970 {Sutherland 1985:334). Although the United Kingdom expanded a system of polytechnic institutes, educational opportunities remained limited for nonprofessionals. Sutherland ( 1985: 336) attributed this to early specialization by students in the secondary (high) schools. Webb {1980:557,558) describes the compartment-alization of British education and the use of technical education in place of university education. British students can enter nursing or midwifery education immediately following the completion of secondary school. Attaining legal independence before the proliferation of universities and polytechnics, British midwifery did not have to add a liberal arts component into educational curricula to prove professional competence. Reducing midwifery education to the skills necessary for the provision of safe care has helped restrain the cost of women's health care in the United Kingdom. Without constraints such as the rigid British class and educational structure, American nurse-midwives have used post-secondary education in a manner similar to that of Victorian era physicians to increase social status. American nurse-

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326 midwifery education, following the British model, was originally at the certificate of midwifery level. As nursemidwifery education grew, programs were started at the master's level within colleges of nursing. American nursemidwifery educators claim that the intention of college affiliation was to give nurse-midwives experience in critical thinking and research. College affiliation must be acknowledged to increase the scientific credibility and the social status of midwives thereby, better equipping then to compete with physicians. Working within a culture that defines birth as normal and having legal independent practice, British midwives have never had to use education as a tool of upward mobility. Structure of Educational System Prior to the 1980s, British midwifery education was under the local control of the health districts. The major benefit of this system was that the demand for midwifery services could be met by recruiting from within the district and keeping graduates within the district (Dowie 1991:4.32). The Advanced Diploma of Midwifery was a one year course of study with a research focus. It was the minimum educational level required to teach midwifery. The programs visited during the study each required a registered general midwife to have two years of clinical experience before entering advanced study.

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327 This requirement was another illustration of the importance of work experience (apprenticeship) to the British educational system. The development of bachelor's and master's level midwifery education in the United Kingdom showed the efforts of midwifery to remain within a system where biomedical knowledge and educational requirements were continually increasing. To be competitive on a global scale, British midwifery will have to have research and writing skills at the master's level. Increased education of British midwives improves the international marketability of midwifery skills. American nurse-midwifery programs could be based in colleges of nursing, medicine, or public health. The diversity of potential program affiliations demonstrated the poorly defined borders in the American nurse-midwifery construction: Were the midwives nurses, midwives doing the work of medical physicians, or were they part of a separate profession most closely aligned with public health philosophies? American nurse-midwifery programs could be 18 month certificate programs or master's level programs. The State of Utah required that midwives be master's prepared in 1992. Several other states had proposed similar legislation. This type of restrictive legislation would prevent more than 50% of the American nurse-midwives from moving freely between states to practice. It would many prevent foreign educated nursemidwives from entering American practice because most midwives educated outside of the United States are educated at the

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328 certificate or bachelor's level. Members of the Florida Board of Nursing who favored master's preparation claimed that master's preparation assured practice competency for the many groups of advanced practice nurses that did not have national certification exams. The British continuous assessment model for certification of midwifery students demonstrates that quality can be evaluated and centrally standardized in certificate level education. American master's preparation enhanced nursing clinical credibility and allowed nursing a greater claim to biomedicine's control of diagnosis and treatment. NurseMidwifery has resisted the imposition of master's degree requirements by upholding the definition of midwifery as a separate profession and maintaining that the American College of Nurse-Midwives national certification exam was the best proof of safe entry level practice. Content of Educational Programs American midwives referred to midwifery as an art and a science. This dual claim attempted to incorporate the intuitive skills passed from midwife to midwife during apprenticeship and the scientific credibility and useful technology of biomedicine. To remain economically viable, American midwives stretched the construction of midwifery trying to include whichever concepts American physicians and

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329 American consumers would accept. When posed with the question, "Is midwifery an art or a science?", 8 of 9 British midwifery educators responded by saying, "It's a bit of both." Three of the nine educators, members of the Association of Radical Midwives, cautioned that the art of midwifery was being lost in academic settings and that the intuitive and social skills of midwifery were the most important to preserve. One Scottish midwifery educator held that midwifery was an art, but recognized that it had been pulled into health sciences. In her evaluation, if a faculty saw midwifery as an art, the curriculum would contain social science courses. If a faculty saw midwifery as a science, the curriculum would be heavy with math and chemistry courses. In the course comparisons between British and American midwifery educational programs, Tables 7 and 8,pages 214 and 215, the British midwifery programs contained more social science courses, where the American nurse-midwifery programs had more biological science courses. American nursemidwifery leaned more to science than art. British educational integration ran deeper than organizing course work along themes. Areas of clinical practice, such as antepartum care and newborn care are integrated into British themes instead of being divided into separate clinical midwifery students newborn care as rotations. At the University of Miami, studied intrapartum, postpartum, and a unit (perinatal health care). This

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330 amalgamation decreased the traditional nurse-midwifery divisions used in biomedical education that reduced the care of women and their newborns into artificial segments. British faculties integrated social and science concepts into midwifery curricula to foster a holistic view of women's health care. The side by side comparison of the Lothian and Miami curricula (Table 7, page 214) revealed the strong identification of American nurse-midwifery with nursing. Seven of the 13 (54%) University of Miami midwifery courses contained nursing in their names. The incorporation of midwifery into nursing at the University of Miami perpetuated the enculturation of midwifery students into nursing instead of midwifery as a separate profession. British midwifery courses were labeled midwifery making a stronger case for midwifery as a separate profession. In the United Kingdom, nurses earned degrees in midwifery. In the United States, those desiring to practice midwifery earned degrees in nursing. The University of Miami curricula demonstrated how education in a market health care system must change to meet market demands. The courses now called Primary Health Care of Women by the University of Miami were most often divided into two courses, antepartum care and gynecology/family planning, by other midwifery programs during the early 1980s. When the concept of managed primary care seemed to be the most likely

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331 base for Florida universal health care and national health care, schools such as the University of Miami changed the focus of midwifery education to primary care. This prevented graduates from being excluded by managed care systems that would include only general primary providers or physician specialists. With legal access to independent practice for graduates, British midwifery programs were free build a curriculum around the philosophy of care instead of the current philosophy dictated by the market. status of Midwifery students Observation of midwifery students in the United Kingdom revealed a difference in the status of student midwives related to the finance of the health care system. In the United Kingdom, the role of a student was valued. Students shadowed a midwifery tutor learning by example and demonstration. Students' clinical experiences looked like apprenticeships. students were introduced as students. Tutors asked students questions in front of patients. Patients were asked to explain their experiences to students in a manner that drew students into a learning relationship with the midwife and the patient. student midwives wore a uniform and colored belt that identified them as students. Student uniforms and belts were of different colors than certified midwives' and nurses' uniforms and belts. All National Health

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332 Service hospitals and practices were student learning sites. only 8 midwifery services in the United Kingdom were not midwifery student clinical sites in 1992. British patients expected to be teaching students. The expectation that the patient had something to teach the student was the opposite of American expectations. Americans with health insurance expected that they were paying for a "real" doctor or a "real" nurse. Students were seen as second class care providers. Health care students received a large portion of their clinical education in publicly funded institutions where medically indigent patients were seen as captive models. This relegation of students to publicly funded institutions further eroded the image of students. Anything American that was publicly funded was expected to be second class. To compensate for this, American health care educators attempted to prepare the student to look like a real doctor or a real midwife. Students were lectured about a procedure, shown pictures or movies, and given a plastic manikins on which to practice. After being assessed for the technical correctness of their practice in a laboratory setting, students were sent in to care for patients while instructors waited close-by. students adopted symbols and manners of speech that convinced patients they were credible. For example, medical students wore white lab coats and stethoscopes. Instead of saying, "I don't know," in reply to

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333 a patient's question, the medical students learned to say, "We are still awaiting the results of your last laboratory test. Then we can tell you about ... This gave the medical student time to slip out, find the answer, and return, saying, "Your test indicates ... Haas and Shaffir (1987) labelled this the cloak of competence. The cloak of competence involves making oneself appear in control of any situation, masking real emotions, and concealing any weakness. American nurse-midwifery students adopted the cloak of competence. Perhaps this process was learned through years of educational experiences alongside medical students and residents in inner-city hospitals. Perhaps the nurse-midwifery students of the 1960s and 1970s were hurried through their clinical rotations because there were so few nurse-midwifery clinical sites. Adopting the cloak of comp etence was necessary for them to learn in an abbreviated time. The cloak of competence was reinforced by a health care system that separately funds indigent care, creating classes of patients. Most damaging to midwifery was the way the cloak of competence eroded the apprenticeship of new nurse-midwives. Without a long period as a student following an experienced midwife, the midwifery student could not learn the intuitive art of midwifery. Lessons about which women labored easily and how to coax a baby down a birth canal could not be reduced to textbook words. The cloak of competence was symbolized by American nurse-

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334 midwifery's adoption of the long white lab coat used by American physicians. Street clothes were worn under the lab coat to separate nurse-midwives from staff nurses who wore the uniform required by their employers. Many nurse-midwives, working for an identity separate from physicians, wore street clothes with no coat. This was intended to symbolize a more equitable relationship between the midwife and the woman. Pre-registration Education The 1970s brought a change in thinking about midwifery preparation in the United Kingdom. The 1960s second wave of feminism stressed greater control by women of their own health. The issue of control manifested itself in reproductive health as a reaction against the "redefinition of pregnancy and birth as a medical problem" (Thompson 1990:CS-20-04). The answer to resisting biomedical intrusion into normal processes was the midwife educated in midwifery, not nursing or the biomedical model. British midwifery had long resisted the increasing state control of midwifery through nursing. By the late 1970s, the government funded and evaluated midwifery education and practice through nursing. During the early 1980s, a period of nursing and midwifery staff shortages, the British government became concerned with retention in midwifery. The government was spending to educate many nurses who used midwifery

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335 education only for promotion, not to practice midwifery. Containing health care costs required trim staff projections. Compared to post-registration midwives, pre-registration midwives stayed in practice longer (Towler and Bramley 1986:235). The nursing entry route into midwifery cost the National Health Service 3 years of nursing education plus 18 months of midwifery education with the nurse being paid her usual salary for the 18 months. Direct entry midwifery produced a midwife in 3 years. The direct entry midwife was increasingly seen as being a stronger practitioner of pure midwifery who was more likely to continue midwifery practice. In 1988, the English National Board called for more 3 year, direct entry midwifery programs (St. Alfred's College 1992:3). British alignment with the European Economic Community beginning in 1972 gave British midwifery an opportunity to wrest itself from biomedical control. In 1980, the United Kingdom was the only European country having nursing background as the dominant entry route for midwifery. Other countries had professional midwives who were educated in 3 year or bachelor degree programs. To match Economic Community midwifery standards, the United Kingdom had to offer direct entry midwifery and include the use of suturing and family planning care in its midwifery construction. British midwifery moved quickly to redefine midwifery. The Royal College of Midwives and the Association of Radical Midwives supported pre-registration midwifery. In 1989, sixteen sites provided

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336 direct entry midwifery (Kent 1992: 15) All the midwifery educators interviewed during the study enthusiastically supported direct entry midwifery, indicating that it was a purer model of midwifery. The educators agreed that they were a select, biased group saying further that resistance to preregistration midwifery was strong, particularly outside of academic centers. According to many Scottish midwifery educators, resistance to pre-registration midwifery from nursing and medicine was particularly strong in Scotland because Scotland had not had pre-registration midwifery education for several decades. With the start of the fall 1992 academic year, preregistration midwifery became the method of midwifery preparation in England, Scotland, and Wales. The speed with which the British changed midwifery entry routes dramatically demonstrates the power of economic and government needs on a cultura l construction of midwifery. During the research period, the State of Florida reopened laws permitting the education and 1 icensure of non-nurse midwives. Resistance by physicians and nurse-midwives to another provider, the direct entry midwife, who would further decrease their earnings was strong. Questions about educational preparation and practice safety were used as a cover to hide the economic threats posed by another provider. In the struggle over what constituted the American construction of midwifery, nurse-midwives were pulled into the

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337 hierarchical structure of biomedicine and assumed that any provider with fewer years of education was unsafe. Denouncing a new construction of midwifery treated direct entry midwifery in the same manner as nurse-midwifery was treated by physicians while nurse-midwives constructed the nursemidwifery profession within biomedicine. Aiding the polarization of the two constructions of Florida midwifery was the licensure process. Florida, for example, licensed nurse-midwifery through the State Board of Nursing, Department of Professional Regulation, as advanced practice nursing. Licensed midwifery, not viewed as a profession, was regulated by a small department of the Department of Health and Rehabilitative Services until 1992. In 1992, the Florida licensed midwifery law was rewritten allowing for new schools of direct entry midwifery to be opened in Florida and moving the regulation of licensed midwifery to the Department of Professional Regulation under a separate Board of Midwifery. Regulation of both nursemidwifery and direct entry midwifery under single standards and a single Board of Midwifery, as was done in the United Kingdom, could clarify the construction of midwifery and strengthen midwifery independence from biomedicine. Figure 15 summarizes routes of entry into midwifery in the United States and the United Kingdom.

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338 Figure 15. Routes of Entry into Midwifery in the United Kingdom and the United states. UNITED KINGDOM PRE-REGISTRATION 3 year direct entry (primary route 1992) POST-REGISTRATION 18 month Diploma of Higher Education, Midwifery UNITED STATES 2 year Bachelor's Degree, Midwifery NURSE-MIDWIFERY / ------------------/ 18 month 18 month DIRECT ENTRY -----------state licensed certificate of midwifery Master's Degree with certificate of midwifery lay midwife with certificate or Associate's Degree in Midwifery

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339 Midwifery Educators Apparently valuing practice more than teaching, experienced American nurse-midwifery instructors averaged $35,000 (17,500 pounds) per year. American heads of midwifery faculties fared no better. Working in practice instead of teaching gave American nurse-midwives the ability to almost double their salaries. Pay differentials served as a disincentive for experienced nurse-midwives to teach leaving many vacancies in American midwifery faculties. If pay grade were an indication of value, then the Britis h value midwifery teachers more than Americans do. While there is no central job description for midwifery educators (making for variations within grading from college to college), the salaries for midwifery teachers started at approximately 22,000 pounds per year (almost $44,000) during the time of the study. Continuing Education in Midwifery Compared to British midwifery, continuing education requirements came late to American nurse-midwifery. The United States federal government had no recommendations for professional continuing education. Approximately 50% of the s tates that licensed nurse-midwives through a board of nursing required the accumulation of continuing education hours for relicensure. In 1987, the American College of Nurse-Midwives

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340 started a program of continuing competency assessment. Formalized continuing competency assessment served two purposes. First, malpractice liability carriers increasingly required continuing education specific to practice before issuing liability insurance. Second, continuing competency assessment could be held like a shield to counter biomedical claims that midwives could not provide state of the art care. Although strongly recommended, continuing competency assessment through the American College of Nurse-Midwives was not required for certification maintenance. Approximately 50% of American employers paid continuing education costs as a benefit to nurse-midwives. Governmental desire to let the market manage health care weakened American continuing education requirements. Continuing education requirements were controlled by the British government where the government had a strong interest in assuring that its own programs were safe for its citizens. Summary: Chapter 6 Chapter 6 showed that the profession of midwifery, while falling under one international definition (Varney 1987:4) had different models of practice and education in the United Kingdom and the United States. Differing political and economic variables shaped and maintained those models. Chapter 7 discusses how changing political and economic variables

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341 effected the constructions of midwifery in the United Kingdom the United States.

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CHAPTER 7 CONCLUSIONS AND RECOMMENDATIONS 342 Since the birth of American nurse-midwifery in 1925, comparisons of midwifery in the United Kingdom and the United States have occurred in conversation but have rarely progressed to formal study. Data for a comprehensive analysis of the formal culture of British midwifery have not been available in the United States. Any comparisons of the two constructions of midwifery concentrated on the similarities and differences in midwifery education and regulation revealed in parts of the formal culture. These conversational comparisons did not take into account the historical, sociocultural, and politico-economic matrices that shaped midwifery practice and education. This descriptive study provided an overview of the formal culture of midwifery in the United Kingdom and the United States. Numerous similarities and differences were found in the constructions of British and American midwifery. The usefulness of the data were reduced if only the formal midwifery cultures are compared. The socio-cultural and politico-economic variables that have shaped and continue to change the constructions of midwifery must be acknowledged as

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343 forces vital to the cultural manifestations of midwifery. When a new language is learned as an adult, the speaker, although using technically correct words, persists in the patterns and accent of the native language. Midwifery as a culture can be compared to a language. A midwife from one country can learn the words of another country's midwifery: the standards of practice and the method of state regulation, but, that midwife will practice midwifery with an accent. The accent is provided by the socio-cultural and politico-economic variables underpinning her native cultural construction of midwifery. Socio-cultural and politico-economic variables related to a construction of midwifery make a midwifery construction unique to a nation. For example, the national construction of British midwifery is so unique, that the making of a midwife in Great Britain is more correctly called the making of a British midwife. Because critical theory challenges the objectivity of biomedicine and biomedical redefinition of social problems as diseases as does midwifery theory, a framework incorporating critical theory broadened the interpretation of data. The study conclusions demonstrate the major differences between the British construction of midwifery and the American construction of nurse-midwifery. The following summarizes the historical, socio-cultural, and politico-economic contributors to those differences. Using a structural framework for analysis would have ignored the sociocultural and politico-

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344 economic factors supporting or changing the formal structure of midwifery education and practice. The reflective capacity of critical theory would have been lost if a political economy framework had been used for analysis. A political economy framework would have limited analysis of the data. The political economy literature favors Marxist ideologies. A comparative analysis of British and American health systems relying exclusively on a political economy framework would favor the socialist tradition of health care in the United Kingdom. Political economy theory incorporates analysis of political and economic causation. Clinging to Marxist analysis will limit the applicability of an analysis. Few 1993 governments are capitalist or socialist in pure Marxist terms. World government is changing rapidly into models that have not yet been studied and labeled. Recognizing the political and economic components of a cultural construction without narrowly labeling governmental and production styles produces an analysis with broader future generalizability. Critical medical anthropology exemplified by Bibeau uses the most appropriate analytic perspective combining several frameworks and disciplines. critical medical anthropology was used to look at midwifery incorporating many angles: history, structure, cultural matrix, political and economic background. Use of Bibeau's tridimensional model permitted gathering baseline data about mid-and macrolevel midwifery phenomena.

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345 Bibeau's model has been used as a tool to compare and contrast unique cultural constructions of midwifery. The study data yielded insight into how socio-cultural and politico-economic factors unique to the United States changed the British construction of midwifery imported into the United States in 1925 into the current construction of American nursemidwifery. British midwifery responded to its own changing socio-cultural and politico-economic matrix and now has a separate cultural construction. Additional studies of British and American midwifery could produce additions to the tridimensional models of midwifery. Conclusions Historical Matrices of Midwifery Table 14 compares the historical matrix of British midwifery with the historical matrix of American nursemidwifery since the time of the Great Depression. The austerity of the 1930s during the worldwide depression pushed the United Kingdom to expand the domiciliary midwifery system. Increased numbers of midwives were educated so that women could be attended in their homes. Building hospital beds would have been cost-prohibitive. Increasing the number of midwives employed more women. The opposite occurred in the United

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346 Table 14. Historical Matrices of British Midwifery and American Nurse-Midwifery. variable World Depression World War II Post-War austerity, then economic growth Individual Rights Movements United Decade Kingdom 1930 -1940 Domiciliary midwifery strengthened 1940 -1950 National Health Service 1950 -1960 National Health Service growth 1960 -1970 Birth hospitalized World Recession 1970 -1980 Health care standardized to European Community united States Birth hospitalized Private health insurance Medicalization of health Out of hospital birth movement Medicaid/ Medicare 1965 Health care diversified ----------------------------------------------------------Market Economics 1980 -1990 Competition re-introduced into National Health Service Competition managed ------------------------------------------------------------

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347 States. Most American births, especially those in urban areas, were attended by physicians at the time of the Depression. It would have been cost prohibitive to have educated increased numbers of physicians. Americans moved births into the hospitals to increase the efficiency of the physicians. Women received routine care. Physicians could live near the hospital decreasing time spent in traveling to women's homes. Physicians could attend several women within one hospital structure. Continued austerity in the United Kingdom during the Second World War and the decade immediately following the War supported the formation of the National Health Service. The United States government placed wage controls into effect during World War II. Employers could, however, increase benefits packages to entice employees. The third party payor health insurance industry grew during this era. During the two decades from 1940 to 1960, universal health care coverage grew in the United Kingdom first demanded by postwar austerity, then supported by economic growth. During the same two decades, health care coverage of the individual spread in the United States as individual insurance policies proliferated and health care became more medicalized as Americans had increased ability to pay for care. The decade between 1960 and 1970 was individual rights movements around the world, colonial independence movements to American a decade of from British civil rights

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348 movements. The Second Wave of Feminism swept both the United Kingdom and the United states. As individual rights were strengthened in the United Kingdom women's rights to hospital birth were promoted and the United Kingdom build sufficient hospital beds for every laboring woman. In the United States, the Second Wave of Feminism urged women to retake control of their bodies. The feminist movement supported the growth of prepared childbirth, midwifery, and the home birth movement. In 1965, Medicaid and Medicare established federal payment for indigent health care. During the worldwide recession of the 1970-1980 decade, the United Kingdom sought economic remedies by joining the European Economic Community. British health care and profession, such as midwifery, were standardized to meet Economic Community guidelines. In the United States, health care technology continued to grow creating diversification intead of standardization. New professions, such as respiratory therapy, were born in response to growing technological needs. The decade from 1980 to 1990 saw a re-introduction of market economics in United Kingdom. Prime Minister Thatcher pushed for competition in the National Health Service by giving hospitals trust status, therby enabling them to compete with each other. Competition included the ability to set wages and prices. The United States tried to temper competition between 1980 and 1990 with the growing concepts of managed

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349 care and managed competition. Health maintenance organizations (HMOs) were established that paid providers capitation fees to provide care for identified groups. Insurance companies began to limit providers to those that could produce care costeffectively. Table 14, page 34 7, demonstrates that while responding to the same global events, the United Kingdom and the United States often took opposite measures. Sociocultural Matrices of Midwifery Table 15 illustrates the sociocultural variables affecting the British and American cultural constructions of midwifery. These variables interact to form a sociocultural matrix surrounding the development of midwifery. The British have an ancient culture with an uninterrupted history of midwifery. Midwifery as an ancient profession does not seem outdated in a country where history is thousands of years old. The United States is a young nation that embraced rapid scientific development. Compared to modern technology, midwifery seems antiquated. British national traditions include cultural recognition of midwifery. In the United

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Table 15. The Sociocultural Matrices of British Midwifery and American Nurse-Midwifery. variable Ancient Culture Nationalization (state ownership of resources) State religion National traditions Cultural recognition of midwifery United Kingdom + + + + + United States 350 --------------------------------------------------------State supported maternity leave + -------------------------------------------------------------Abundant natural resources + -------------------------------------------------------------Abundant home technology + -----------------------------------------------------------Fast pace of life + ----------------------------------------------------------

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351 states, as immigrant cultures integrate to form a new national culture, cultural recognition of midwifery is replaced with belief in biomedicine. The strength of the Church of England during the 1800s prevented British biomedical physicians from taking social control of health. The lowered social status of British physicians relative to American physicians helped to preserve British midwifery. British consumerism movements have provided feedback to the National Health Service allowing British women greater choice is the provision of maternity services. This choice allows women to request and support midwifery services. Within the fragmented American health care system, physicians can limit the health care choices available to women. The European Economic Community maternity leave provides rest for women that decreases health complications during pregnancy and the postpartum period. This state support of maternity decreases physical complications thereby supporting the normal process of pregnancy and birth that is the cornerstone of midwifery practice. A lack of abundant natural resources in the United Kingdom supports midwifery. With limited resources, the British government must ration public services. Using low technology midwifery instead of medical obstetrics conserves health care funding. Limited natural resources and energy sources decreases the amount of home technology, such as clothes dryers, used by Britains. This, in turn, slows the

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352 pace of life. A low technology milieu and a slow pace of life prepare women for the normal processes pregnancy and labor as supported by midwifery care. Midwifery Practice British midwifery practice is based in the model of pregnancy and birth as a normal process. British midwives have the legal independence to resist the imposition of biomedical models upon their practice. American nurse-midwifery has its roots in the 1925 British construction of midwifery. Existing within a biomedically-based health care system has pushed the American construction of nurse-midwifery care toward acceptance of biomedical practices. Legal dependence forces nurse-midwives to either accept biomedical practices when they conflict with midwifery practices or subversively resist biomedicine. American nurse-midwifery forms a culture of resistance to American biomedicine. The resistance of American nurse-midwifery is what Aptheker (1989:173) labelled "women's resistance." There is a women's resistance that is not "feminist," "socialist 11 "radical or "liberal" because it does , not come out of an understanding of one or another social theory ... Women's resistance ... is shaped by the dailiness of women's lives ... Women's resistance is not necessarily or intrinsically oppositional ... it does, however, have a profound impact on the fabric of social life because of its steady, cumulative effects (Aptheker 1989:173).

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353 Figure 16. The Formation of Core Cognitive Domains in Midwifery. VARIABLES CULTURE HISTORY ---> POLITICS / ---> ECONOMICS CORE DOMAINS LOCATION ---> BRITISH MIDWIFERY PRACTICE FUNDING ---> AMERICAN NURSE-MIDWIFERY PRACTICE British midwifery and American nurse-midwifery have different core cognitive domains. Socio-cultural, historical, political, and economic variables have interacted to produce those differing core cognitive domains (Figure 16). The British conceptualize midwifery practice by location. The two general cognitive domains of British midwifery are community midwifery and hospita l midwifery b ecause midwifery employment and third party payment are constant in the Unite d Kingdom (Figure 17, page 355). Americans conceptualize nurse-midwifery practice by funding sources. The t w o genera l cognitive domains of American midwifery are public practice and priva t e practice because third party payment varies and employment opportunities vary with third party payment (Figure 16, page 3 60)

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354 Figure 17. Core Cognitive Domains in British Midwifery and American Nurse-Midwifery. Country Core Domain Practice Domains United Kingdom --Location United States Funding
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but glorified nurse, 11 independence. ignore the Midwifery Education strength of 355 legal British midwifery education has been tailored to meet the needs of practice. Entry level education has remained at the certificate level from the 1800s through 1992. American nursemidwifery originally remained faithful to the British certificate level preparation for practice. Several factors pushed the education of American nurse-midwives away from the certificate model toward master's level preparation, including: a) American use of post-secondary education for upward mobility, b) the use of master's leve l nurse-midwifery preparation to prove scientific, professional midwifery education that was competitive with medical education, and c) affiliation of American nurse-midwifery programs with colleges of nursing, requiring nurse-midwifery programs to conform with the master's degree preparation of nursing clinicians. British midwifery education is paid for by the state. This reduces the opportunity cost of entering midwifery, increasing the attractiveness of midwifery as a career. With

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356 time as the major personal investment in education, British midwives are attracted to salaried state positions. American nurse-midwifery students finance large parts of their own education. The large opportunity costs of midwifery education push American midwives to seek more remunerative private sector employment. This push toward the private sector maintains the understaffing of the public health sector and reinforces the second class status of the public health sector. The content of British midwifery educational programs contains more social science course work than does American nurse-midwifery content. American nurse-midwifery educational programs have more science and nursing content that do British programs. With a construction of midwifery separate from biomedicine and nursing, British midwifery has focused on the impact of environmental and social problems on the health of women. American nurse-midwifery, educationally bound with nursing or biomedicine and legally bound to biomedicine, has integrated biomedical techniques into its practice. Use of biomedical curative techniques can pull midwifery practice away from its wholistic incorporation of social and environmental causes of disease. The economic interests of the state have pushed Great Britain to cost-effectively produce a safe midwife and meet the standards of other European Economic Community states. In little more than a decade's time, Great Britain switched from

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357 post-registration (nursing background) midwifery to preregistration midwifery as entry level practice. Without central control, this process could not have occurred so quickly. With no state control of midwifery education, American midwifery is developing along two separate routes, nurse-midwifery and direct entry midwifery. The development of separate regulating bodies and educational programs for midwives of different entry levels duplicates services and is costly to the state. With the unified certification British post-and pre-registration and registration midwives and of the consolidation of American biomedicine during the late 1800s as examples, it can be concluded that American nurse-midwifery and American direct entry midwifery will make incremental changes in their constructions until American midwifery is unified as a profession. Politico-Economic Matrices of Midwifery Table 16 summarizes the political control of midwifery in the United Kingdom and the United States. Control of midwifery is centralized in the United Kingdom with certification, registration, and unionization located at the national level. Certification of British midwives since 1992 is done by midwifery educational programs with state oversight. state control of British h ealth car e provides mechanisms, such as

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358 the Department of Health, for midwifery care to be research based and nationally standardized providing greater costeffectiveness. --------------------------------------------------------------Table 16. Political Control of British Midwifery and American Nurse-Midwifery. UNITED UNITED CONTROL VARIABLE KINGDOM STATES NATIONAL CERTIFICATION + + NATIONAL REGISTRATION + NATIONAL UNIONIZATION + STATE REGISTRATION + LOCAL REGISTRATION + INSTITUTIONAL CERTIFICATION + ------------------------------------------------------------While certification of nurse-midwives is done nationally in the United States, it is done in the private sector by the American College of Nurse-Midwives Certification Corporation. Licensure is decentralized to the state level. Institutional certification (hospital-medical staff credentialing) in the United States exemplifies private sector control of nurse-

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359 midwifery. Nurse-midwives cannot practice without hospital credentialing. Hospital credentialing is controlled by the physician staff. Private sector control of American health care limits the ability of nurse-midwives to practice independently and decreases the standardization of care, thereby increasing the cost of American health care. Legal control of American nurse-midwifery practice by physicians who insist that midwives use biomedical routines inhibits the cost-effectiveness of nurse-midwifery care. Midwifery educational slots and employment positions are state controlled in the United Kingdom. To assure a sufficient quantity of midwives, the United Kingdom subsidizes midwifery education. With state subsidized midwifery education, those who are drawn to midwifery as a career are able to obtain the necessary education. Control of American nurse-midwifery educational positions and employment positions is left to market control. Americans desiring a nurse-midwifery career face severe opportunity costs and may not be able to afford midwifery education. Table 17 contrasts the economic costs of midwifery in the United Kingdom and the United States.

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360 Table 17. Economic Control of Midwifery in the united and the United States: The cost of Being a M1dw1fe. COST UNITED UNITED TO MIDWIFE KINGDOM STATES MIDWIFERY EDUCATION + CERTIFICATION EXAM + NATIONAL REGISTRATION + n;a STATE REGI S TRATION nja + PROFESSIONAL ORGANIZATION MEMBERSHIP + + MALPRACTICE LIABILITY + INSURANCE PHYSICIAN RETAINER FEES + + Cost paid by the midwife No cost to the midwife Economic control of midwifery in the United Kingdom rests with the largest employer, the National Health Service-the state. Physicians, the legal gatekeepers to American nurse-midwifery practice, have more economic control of nurse-midwifery than do states or the federal government. The single payor, capitated British health system decreases physician incentives to control midwifery practice. The British system

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361 removes incentives to use technology unnecessarily while trying to prove the superiority of the biomedical model. The uncontrolled, fee for service American system places physicians in direct competition with nurse-midwives for employment and income. Until the advent of managed care, the American system supported unrestrained biomedical use of technology, thereby marketing unproven biomedical technology, such as electronic fetal monitoring, to consumers. This decreased the credibility of low technology providers such as nurse-midwives. British unionization empowers the Royal College of Midwives to represent British midwifery. The lack of unionization in American professional health care and the sovereignty of states, limits the ability of the American College of Nurse-Midwives to represent nurse-midwifery. Because of the educational similarities between British midwifery, American nurse-midwifery, and American maternity nursing, American employers bring British midwives to the United States to fill maternity nursing and nurse-midwifery vacancies. The British midwives complete the work safely. Their long term satisfaction and professional growth, however, may be inhibited by socio-cultural and politico-economic factors underpinning their native construction of midwifery. Their native midwifery construction gives them expectations that may never be fulfilled by the American construction of midwifery.

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362 Since the middle 1800s, more than 50 nations have been exposed to British health care systems, including the British construction of midwifery. The assumption that midwives from former British colonies will practice midwifery like British midwives and American nurse-midwives was not supported by this research. For example, Australian midwifery cannot be assumed to be similar to British midwifery because Australia was for a former British colony. This research has shown that sociocultural and politico-economic variables can change a national construction of midwifery in less than 50 years time. This study added to anthropological knowledge of midwifery by changing the focus of study from midwifery in preindustrial or underdeveloped countries to midwifery in two industrialized nations. The involvement of the principal investigator in midwifery practice and education strengthened the ernie perspective of the study. Data generated from this study have been used as tools in applied anthropology work concerning the development of American nurse-midwifery. The research recommendations indicate the practical applications of the data. Recommendations American nurse-midwives should be given legal autonomy. The British midwifery construction demonstrates 91 years of safe, cost-effective prenatal and birth care by autonomous

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363 midwives. The American construction of nurse-midwifery demonstrates that midwives can expand their scope of practice without increasing existing educational program lengths. A variety of women's health care services outside of the maternity cycle could be provided by midwives in the united Kingdom. American states should integrate the certification and registration of midwifery for midwives of all educational backgrounds. Midwifery should be regulated as a profession separate from biomedicine or nursing. The American College of Nurse-Midwives and the Midwives' Alliance of North American should work together until a single set of core competencies and standards for the practice of midwifery are formed. Once again, the British construction of midwifery could serve as a model for the integration of American midwifery. The American College of Nurse-Midwives should revise the precertification process for foreign educated nurse-midwives to include a module that contrasts American nurse-midwifery with other national midwifery constructions. This would make explicit the historical, socio-cultural, and politico-economic variables that contribute to the American construction of nurse-midwifery thereby facilitating entry into American practice. The module detailing cultural constructions of midwifery should be used in the education of American midwifery students to clarify midwifery's continual reconstruction in response to

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364 changing socio-cultural and politico-economic variables. Exposure to the mid-and macrolevel organization of other national midwifery constructions would give students options for the improvement of midwifery. State licensing boards and hospital medical staffs should not require master's preparation of British educated nursemidwives who have been certified by the American College of Nurse-Midwives Certification Corporation. Master 1 s preparation does not increase midwifery skills and adds to the cost of health care. State planning for adequate numbers of midwifery providers in the United States must use British staffing models with caution. In the United States, labor and delivery nurses do much of the work that is done by British midwives in the United Kingdom. Generalizing the quantity of British midwives in practice to any area of the United States will produce an oversupply of midwives. Cultural constructions of midwifery should not be generalized between nations. Further research should be done to explicate the cultural constructions of midwifery in postindustrial nations. Those national constructions of midwifery should then be analyzed and compared cross-culturally. Crosscultural comparison of midwifery constructions could yield data on how a women's health profession can best respond to socio-cultural and politico-economic contingencies. The United States has entered an era of health care

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365 reform as expenditures are brought into line with available resources. As has been done since the time of Mary Breckinridge, the British construction of midwifery can be used as an example of safe, cost-effective health care for women. Use of politico-economic variables supporting British midwifery can further democratize and economize American health care. Incorporation the British midwifery principles of pregnancy and birth as normal processes and provider education to match the level of skill needed would support an American shift toward primary care on a national level. Wilbanks and Romans ( 1993: 122) in writing about the future of women 1 s health care called for a "professional 'horne base 1 in a newly created women 1 s health specialty." They seemed to arguing for a restructuring of biomedical divisions to create a specialty that focuses on health instead of illness. There is no need to manufacture a new women's health specialty. That specialty, one that supports physiological processes and promotes health, has been constructed and reconstructed for centuries in many nations. It is midwifery.

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384 Royal College of Midwives 1987 Report. of the Royal College of Midwives on The Role and Educat1on of the Future Midwife in the United Kingdom. London: RCM. 1991 110 Anniversary year: everyday a birthday. London, England: RCM 1992 A Philosophy for Midwifery. London, England: RCM. 1992 Diary 1992. London, England: RCM. 1992 Membership. London, England: RCM. Safriet, Barbara J. 1992 Health Care Dollars and Regulatory Sense: The Role of the Advanced Practice Nursing. Yale Journal on Regulation 9(2): 417-487. Sarana, Gopala 1975 The Methodology of Anthropological Comparisons. Tucson, AR: The University of Arizona Press. Scheper-Hughes, Nancy 1984 Infant Mortality and Infant Care: Cultural and Economic Constraints on Nurturing in Northeast Brazil. Social Science and Medicine 19(5) :535-546. 1990 Three Propositions for a Critically Applied Medical Anthropology. Social Science and Medicine 30(2) :189-197. Scheper-Hughes, Nancy and Margaret M. Lock 1986 Speaking ''Truth" to illness: Metaphors, Reification, and a Pedagogy for Patients. Medical Anthropology Quarterly 17(5):136-137. Scupholme, Anne, Jeanne DeJoseph, Donna M. Strobino, and Lisa Paine 1992 Nurse-Midwifery care to Vulnerable Populations-Phase I: Demographic Characteristics of the National CNM Sample. Washington, D.C.: American College of Nurse Midwives. Sethi, Amarjit s and stuart J. Drirnrnock 1982 Industrial Relations and Health Services. London, England: Croom Helm. Sibley, L. . 1994 Helping Hands: The influence of care-g1v1ng on maternal-neonatal health outcomes of parturition. In American Journal of Physical Anthropology, Supplement 18.

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389 Wolf, Eric R. 1982 Europe and the People Without History. Berkely,CA: University of California Press. Yates, Susan A. 1983 A Refresher Program for Nurse-Midwives: The Booth Experience. The Journal of Nurse-Midwifery 28(3) :11-17.

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390 APPENDICES

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391 APPENDIX I. CONTACT SUMMARY SHEET SITECODE _______ NAMEOFSITE LOCATION ----------------------------------DATE ___________ HOURS ______________________ 1. SUMMARY OF MAIN EVENTS 2. PEOPLE CONTACTED MAIN THEMES DURING INTERVIEW 3. DATA TO BE APPLIED TO RESEARCH QUESTIONS 4. DATA REQUIRING FURTHER INVESTIGATION 5. NEW CODES

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392 APPENDIX 2. PREFIELD CODE LIST midwifery history promotion of midwifery regulation of midwifery professional organization of midwifery professional relationshios between midwifery and other health professions employment opportunities for midwives midwifery certification educational content of midwifery programs continuing education required of midwives midwifery clinical education midwifery management process community practice hospital practice domiciliary practice midwifery management careers midwifery philosophy health system feminist movements competition from obstetrics health movements professionalization of nursing

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APPENDIX 3. POSTFIELD CODE LIST certification midwifery clinical education community midwifery competition from obstetrics content of midwifery educational programs continuing education required for midwives culture general British EEC/Commonwealth employment opportunities for midwives feminist influences in midwifery history of midwifery hospital practice immigrant midwives independent midwives language liability movements health 393 regulation of midwifery relationships -between midwifery and other professions structure of midwifery educational programs system of British health care techniques clinical technology unionization nursing influence on midwifery organization professional, of midwifery philosophy of midwifery preregistration process midwifery management

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APPENDIX 4. POSTFIELD CODES SORTED BY STUDY VARIABLES 1. HISTORY history of midwifery culture -general British language movements -health feminist influences on midwifery 2. DEMOGRAPHICS 3. POLITICAL EEC/Commonwealth immigrant midwives certification of midwifery regulation of midwifery unionization 4. ECONOMIC system of British health care organization -professional, of midwifery nursing -influence on midwifery competition from obstetrics relationships between other health professionals employment opportunities for midwives liability 5. MIDWIFERY EDUCATION philosophy of British midwifery structure of midwifery educational programs content of midwifery educational programs clinical education process -midwifery management preregistration midwifery continuing education required of midwives 6. PRACTICE hospital practice community practice independent midwives techniques -clinical technology 394

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395 APPENDIX 5. EUROPEAN ECONOMIC COMMUNITY MIDWIVES DIRECTIVES 80/155/EEC ARTICLE 4 "Member states shall ensure that midwives are at least entitled to take up and pursue the following activities:-i) to provide sound family planning information and advice; ii) to diagnose pregnancies and monitor normal pregnancies; to carry out examination necessary for the monitoring of the development of normal pregnancies; iii) iv) v) vi) vii) viii) ix) to prescribe or advise on the examinations necessary for the earliest possible diagnosis of pregnancies at risk; to provide a programme of parenthood preparation and a complete preparation for childbirth including advice on hygiene and nutrition; to care for and assist the mother during labour and to monitor the condition of the fetus in utero by the appropriate clinical and technical means; to conduct spontaneous deliveries including where required an episiotomy and in urgent cases a breech delivery; to recognize the warning signs of abnormality in the mother or infant which necessitates referral to a doctor and to assist the latter where appropriate; to take the necessary emergency measures in the doctor's absence, in particular the manual removal of the placenta, possibly followed by manual examination of the uterus; to examine and care for the new-born infant; to take all initiatives which are necessary in case of need and to carry out where necessary immediate resusci-tation; to care for and monitor the progress of the mother in the postnatal period and to give all necessary advice to the mother on infant care to enable her to ensure the optimum progress of the new-born infant; x) to carry out the treatment prescribed by a doctor; xi) to maintain all necessary records"

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396 APPENDIX 6. THE PHILOSOPHY OF THE AMERICAN COLLEGE OF NURSEMIDWIVES Nurse-midwives believe that every individual has the right to safe, satisfying health care with respect for human dignity cultural variations. We further support each person's r1ght to self-determination, to complete information and to active participation in all aspects of care. We believe the normal processes of pregnancy and birth can be enhanced through education, health care and supportive intervention. Nurse-midwifery care is focused on the needs of the individual and family for physical care, emotional and social support and active involvement of significant others according to cultural values and personal preferences. The practice of nurse-midwifery encourages continuity of care; emphasizes safe, competent clinical management; advocates nonintervention in normal processes; and promotes health education for women throughout the childbearing cycle. This practice may extend to include gynecological care of well women throughout the life cycle. Such comprehensive health care is most effectively and efficiently provided by nursemidwives in collaboration with other members of an interdependent health care team. The American College of Nurse-Midwives (ACNM) assumes a leadership role in the development and promotion of high quality health care for women and infants both nationally and internationally. The profession of nurse-midwifery is committed to ensuring certified nurse-midwives are provided with sound educational preparation, to expanding knowledge through research and to evaluating and revising care through quality assurance. The profession further ensures that its members adhere to the Standards of Practice for NurseMidwifery in accordance with the ACNM philosophy. Revised and approved October, 1989

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397 APPENDIX 7. A PHILOSOPHY FOR MIDWIFERY Aims Th7 aim midwifery profession is to provide a service wh1ch fac1l1tates the safe and satisfying transition of women to motherh?od. This is achieved principally b y the processes of.supportlng, caring, guiding, monitoring and educating. The un1que and personal needs of women in their childbearing years are central to this service. Implicit within this aim is the intention to:--Empower women during their childbearing experience -Provide holistic care -Maintain professional credibility -Be proactive and sensitive to social change and changing patterns of health relevant to the profession Functions The function of the profession is to participate in providing a framework for midwifery practice which is underpinned by state; the EC Midwifery Directives (EEC 80/154, 155) the 1979 Nurses, Midwives and Health Visitors Act and the Midwives Rules (UKCC 1991). This framework enables:--Midwives to fulfil their role as autonomous, accountable practitioners from the point of registration -The setting, maintenance, development, evaluation and regulation of standards -The development of a research-based body of knowledge to underpin practice -The provision of an ethical framework for practice and client advocacy where appropriate -The provision of education to equip the midwife to work in a variety of situations and settings -Professional representation in public debate to promote and support a high quality maternity service Needs The primary need of the midwifery profession is: -To maintain professional identity, accountability and autonomy in order to delivery quality care Secondary needs emerging from this are:--To build upon its own body of knowledge through research-based and reflective practice . -For midwifery clinicians, managers and to be unified, assertive and mutually support1ve

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Appendix 7, page 2. -To have a strong sense of self-worth -To respect and recognition from women, other profess1onals and society -To and deliver its own initial and advanced educat1on Values The values that underpin the profession are:-Respect for individuals and for life -Altruism which focuses upon the childbearing women -Integrity -which is reflected in honesty and moral principles -Justice and equity -Democratic principles and processes -Self development derived from life experiences and educational processes 398 -Midwifery education firmly rooted in midwifery practice Beliefs The midwifery profession holds the following beliefs:--Each mother is an individual with her own rights, needs, hopes and expectations -The midwifery profession has the power to influence both the nature and delivery of services to the childbearing woman and her family -The future health of a nation depends on the quality of care given to potential parents, mothers and babies -Mothers' and babies' needs matter and are to be valued above market forces Assumptions The assumptions of the midwifery profession are that:-Having a baby is a major life event during which women both need and want the services of midwives Midwifery is the profession whose prime function is to ensure the wellbeing of the childbearing woman and her baby Midwives are autonomous practitioners working in a collaborative partnership with other members of the health care team From: The Royal College of Midwives, 1992, London, England.