Delivering the `new' Canadian midwifery: the ... - Wiley Online Library

16 downloads 33823 Views 175KB Size Report
Delivering the `new' Canadian midwifery: the impact on midwifery of integration into the Ontario health care system. Ivy Lynn Bourgeault. Department of ...
Sociology of Health & Illness Vol. 22 No. 2 2000 ISSN 0141±9889, pp. 172±196

Delivering the `new' Canadian midwifery: the impact on midwifery of integration into the Ontario health care system Ivy Lynn Bourgeault Department of Sociology and Faculty of Health Sciences, University of Western Ontario

Abstract

This paper addresses the impact on midwifery of its recent integration into the provincial health care system in Ontario, Canada. Data are derived from participant-observation, primary and secondary source documents, and key informant interviews. Based on these data, I argue that midwifery has changed throughout the integration process but it has also successfully resisted change. Specifically, the organisation of the midwifery community evolved from an amorphous social movement to a more bureaucratically organised profession. The regulation of midwifery also shifted from direct-regulation by clients to professional self-regulation. The educational model of midwifery also changed from an eclectic apprentice-based approach to a more standardised baccalaureate degree programme. The midwifery model of practice, however, was sustained. Although these changes occurred at the hands of key members of the midwifery community, they were made in response to the structural context of the health care system into which they were attempting to become integrated.

Keywords: Midwifery integration, midwifery, professionalisation, organisation, regulation, practice and education, profession-state relations Introduction Before the early 1980s, there were few midwives in Canada and their practice was neither legal nor officially recognised. In fact, Canada had the dubious distinction of being the only Western industrialised nation not to have any formal provisions for midwives to provide care to pregnant women. Maternity care was almost exclusively provided by medical and nursing attendants in the hospital setting. Yet by the end of 1993, midwifery in the # Blackwell Publishers Ltd/Editorial Board 2000. Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street, Malden MA 02148, USA.

Delivering the `new' Canadian midwifery 173

province of Ontario had become fully integrated into the governmentfunded health care system. It took a little over 10 years for midwives to go from obscurity to official recognition. This is a remarkably short period of time for such an achievement, particularly if viewed from a comparative perspective (see Bourgeault and Fynes 1997). But what has been the impact of this relatively expedient integration process on midwifery philosophy and practice? The fall and rise of midwifery Before the turn of the 20th century, women acting as midwives were the predominant attendants at childbirth in Canada. These `midwives' tended to be neighbour women known to the pregnant woman and who had experience in childbirth. They often served not only as birth attendants, but as nurses, housekeepers and childminders during the postpartum period. Their training was often acquired informally through observation and participation; some also had training through a more formal apprenticeship. However, midwifery at this time was far from an organised profession. It existed largely as a local system of women helping other women in time of need, and payment was usually in kind (Mason 1987). This local system of lay midwifery was eclipsed in the late 1800s and early 1900s due to a variety of factors. These included opposition by some members of the medical profession; concomitant restrictive state regulations; difficulties midwives faced in attempting to organise as a profession; and overall changes in cultural perspectives on childbirth favouring medical attendance in hospital (Biggs 1983, Buckley 1979, Connor 1994, Mason 1987, 1988, Rushing 1991, see also Donegan 1978, Ehrenreich and English 1973, Kobrin 1966, Leavitt 1986, Litoff 1978, Wertz and Wertz 1977). Attempts were made in the early to mid 1900s to establish a system of nursemidwifery similar to Britain and the United States, but such attempts never came to fruition other than in the remote Northern regions of the country. Although midwifery persisted at the margins of Canadian society, it had for the most part been eradicated. The `rebirth' of midwifery in Canada in the mid to late 1970s, as in many areas in North America, stemmed from a consumer backlash to medicalised childbirth, promoted most emphatically by the counterculture Home Birth Movement. Proponents of this movement argued that birth was a normal life process that should take place naturally within the supportive, familiar environment of one's home; it was not a medicalised and mechanised event that should be under the direction of a physician in a hospital (Davis-Floyd 1992, Hosford 1976, Reid 1989). It was within this environment that some women who had had a home birth, or who had attended a home birth, became birth assistants and educators. These assistants were similar to traditional lay midwives in that they were usually friends of the birthing woman who had had experience with birth and had begun to help out at births (Mason 1988, McCool and # Blackwell Publishers Ltd/Editorial Board 2000

174 Ivy Lynn Bourgeault

McCool 1989); their training was derived from experience and participation in the home birth culture. They did not originally regard themselves as experts nor did they envisage what they were doing as a career or profession (Sullivan and Weitz 1988, Ventre 1978). Midwifery arose specifically as an alternative to mainstream maternity care practices. The philosophy of the `new' midwifery In line with the philosophy of the Home Birth Movement from which it arose, the essence of this new midwifery practice was not to create another childbirth authority, but to put control over the birthing process back in the hands of the woman giving birth (Rothman 1982, Sullivan and Weitz 1988). The woman and her family were the central focus (Barrington 1985, Kay et al. 1988, Rushing 1993). They would make the decisions not only about where but how their baby was to be born. Midwives provided supportive assistance, monitoring, information and advice to parents in an egalitarian `therapeutic alliance' (O'Connor 1993). They helped foster a reallocation of knowledge, responsibility and power among childbirth participants (Peterson 1983, Teasley 1983). This egalitarian relationship between the midwife and the woman she cares for is in keeping with the Old English derivation of the word `midwife' to mean `with woman'. It is this philosophical basis of greater personal control and responsibility that prompted support for this new midwifery from some activists in the Women's Health Movement. Although the women's health movement originally engaged in `freeing women from the shackles of childbirth and mothering' (Barrington 1985:151) by lobbying for access to contraception and abortion, some activists later began to focus on the oppression of women through maternity care practices (Arms 1975, Corea 1977, O'Brien 1981, Rothman 1982, Ruzek 1978). The new midwifery soon came to be seen as a symbol of women controlling the reproductive process, as it enabled women to be active and in control of childbirth (Rothman 1989). It came to be regarded as `subtle feminism' (Rushing 1993) and `feminist praxis' (Rothman 1989). Some argued that the fate of midwives typified the struggle of the women's movement (Ehrenreich and English 1973). For example, Canadian feminist activist, Mary O'Brien, asserted that: Midwifery is integral to the women's movement. Its revival is a triumphant affirmation of women's right to choose (as cited in Barrington 1984:7). Thus, an integral part of the new midwifery philosophy espoused by its promoters is the egalitarian relationship between the midwife and the woman for whom she provides care. Seeking integration The ability to openly practise this kind of midwifery in many areas in North America, including Ontario, was (and in some places still is) severely limited # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 175

by lack of official recognition. There have been several cases of midwives being charged with practising medicine without a licence, criminal negligence, and even homicide in the unfortunate event of a baby's death (Barrington 1985, Burtch 1994, Evenson 1982, Sullivan and Weitz 1988). Such charges have been laid almost exclusively by members of the medical profession. Although some argue that the prosecution of midwives in the courts created a platform through which midwives could openly promote the legitimacy of their work, such trials made clear the vulnerable legal position of practising midwives (Arms 1975, Barrington 1985, Burtch 1994, Evenson 1982, Gaskin 1991, Ruzek 1978, Sullivan and Weitz 1988). This vulnerability provoked midwives and their supporters into more sophisticated patterns of political action (Barrington 1985). They began to organise around the issue of integration into the health care system and to lobby for favourable legislation and regulatory policies. In seeking integration, many midwives hope that they will be able to practise more openly, improve their rapport with other health professionals, and secure protection from legal harassment (DeVries 1982, 1996, Sullivan and Weitz 1988). Midwives in Ontario also hoped that with integration into the government-funded health care system, their services would not only be considered more legitimate but also that the cost of providing these services would be covered, together making midwifery care more accessible to a wider group of clientele (Van Wagner 1988). Without integration, midwifery would continue to be regarded as a `fringe' practice and midwives would continue to have to charge women directly for their care. Some midwives and midwifery advocates, however, express concern that integration will limit midwives' practice, deny consumer self-responsibility, and set up midwives as a new class of childbirth authority thereby corrupting midwives' philosophy of care (Barrington 1985, DeVries 1982, 1996, Mason 1990, Sullivan and Weitz 1988). These changes would increasingly undermine the focus of midwifery practice that made it an alternative to mainstream maternity care. With integration, some argue, midwifery practice would quickly come to resemble the orthodox practice it initially arose to criticise. These contradictory themes of legitimacy and co-optation are not unique to the midwifery movement. They recur extensively in the literature on professionalisation and in the literature on the relations between women's groups and the state. Professionalisation via medical vs. state sponsorship Scholars working within the broad theoretical domain of the sociology of the professions conceptualise the process by which occupations attempt to become professions as professionalisation (Saks 1983). Studies of the professionalisation efforts of aspiring health professions, like chiropractic, optometry, and physiotherapy, reveal that the process of seeking integration often begins with some sort of organised effort. This usually involves the # Blackwell Publishers Ltd/Editorial Board 2000

176 Ivy Lynn Bourgeault

development of a professional association which comes to be controlled by an elite group of members that leads not only the integration process, but also rallies consumer support for their endeavour (Biggs 1989, Coburn and Biggs 1986, Donnison 1977, Gort and Coburn 1988, Larkin 1983, Wardwell 1981, Willis 1989, Witz 1992). Such organised efforts are often needed to help overcome the usual opposition to integration expressed by the dominant medical profession (c.f. Freidson 1970a, 1970b). Sometimes the elite group of the aspiring profession attempts to overcome opposition by seeking a strategic alliance with, or sponsorship from, influential members of the medical profession (Larkin 1983). In exchange for this sponsorship, the aspiring profession must accommodate to its sponsors' demands (c.f. Coburn and Biggs 1986, Larkin 1983). This usually results in a limitation of the aspiring professions' scope of practice, subordination of its practitioners, and medicalisation of its ideology (Biggs 1989, Coburn and Biggs 1986, Gort and Coburn 1988, Larkin 1983, Wardwell 1981, Willis 1989). Research specifically on the integration of midwifery into the British (Donnison 1977, Witz 1990, 1992), Australian (Willis 1989), and American (DeVries 1982, 1996, Reid 1989, Sullivan and Weitz 1988) health care systems reveals similar outcomes. Indeed, where midwives have been successful in securing protective legislation, the practice of midwifery has been limited and has become more medicalised in focus (DeVries 1982, 1996, Donnison 1977, Sullivan and Weitz 1988, Willis 1989, Witz 1990, 1992). Medical sponsorship, however, is not the only method by which an aspiring health profession can achieve integration. In many cases, sponsorship is sought directly from state elites, often bolstered through consumer support (Biggs 1989, Willis 1989). As the state comes to have increasing power within the health care division of labour, particularly in countries with national health insurance or national health service (c.f. Coburn 1993), seeking direct state support has proved to be a successful strategy (Coburn and Biggs 1986). This is particularly the case for aspiring health professions which are numerically dominated by women (Witz 1990, 1992). Witz (1992), for example, describes how `legalistic' tactics via the state were more successful for female professional projects in Britain than were `credentialist' tactics aimed at institutions in civil society (i.e. universities and hospitals). Similar state-directed tactics also tend to be more successful for other efforts to advance women's health and social justice issues, such as pay equity, access to abortion, anti-pornography efforts, and violence against women (Fox Piven 1990, Fudge 1996, Gotell 1996, Levan 1996, McDermott 1996, Smart 1989). In seeking state sponsorship, aspiring health professions attempt to avoid some of the more negative consequences of medical sponsorship. Despite the relative success of feminist initiatives via state sponsorship, feminist activists have nevertheless begun to re-examine their state-directed strategies. With respect to the issue of violence against women, for example, Macleod (1987) argues that although there have been some positive gains # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 177

made, such as the growth in the number of crisis shelters and greater stability in funding, most shelters have moved away from a collective model to a hierarchical staff structure and many staff no longer see political work as an integral part of their activities. Similar changes have also occurred to alternative feminist abortion collectives (Bart 1981). Many feminist activists have become critical of the way in which state policies and the general process of bureaucratisation compromise the ideals of their movements (Levan 1996). Thus, whether sponsorship is sought from the dominant medical profession or by the increasingly dominant state, aspiring health professions must accommodate to their sponsors' demands. In what follows, the dynamics of this sponsorship process between midwives, the medical profession and the state in Ontario will be examined, highlighting the impact of this process on midwifery. I will argue that through the process of integration, the conditions by which midwives in Ontario are able to practise according to their espoused egalitarian philosophy have shifted in some subtle and some not so subtle ways. Methods A social historical research design was employed to examine how and why midwifery changed throughout its integration process. Data were collected using three interconnected methodologies. The first involved over four years of participant-observation within the midwifery community in Ontario. For the purposes of my research, the midwifery community was broadly defined as those practising, receiving or having received midwifery care or those otherwise involved in the midwifery integration process. My participation in this community began initially as a recipient of midwifery care and later as a politically active member of a committee lobbying for the creation of a freestanding birth centre to be staffed by midwives. As the focus of my thesis research evolved to the question of the impact of integration on midwifery, so too did my relationship to this community evolve from participant to observer1. Field notes were taken only on an ad hoc basis as the main aim of this participant observer phase was not entirely directed toward research, but it did prove to help inform and aid in the other more direct methods of collecting data. Data were also collected from primary and secondary source documents relating to the integration of midwifery in Ontario from the early 1970s to mid 1990s. The search for documentary material began in the libraries/ collections of midwifery, nursing and medical organisations. This included entire newsletters, articles in newsletters and journals, and policy documents. From there, key committees influencing midwifery policy were identified and later contacted for publicly available correspondence, minutes from meetings and official reports. # Blackwell Publishers Ltd/Editorial Board 2000

178 Ivy Lynn Bourgeault

Finally, to obtain information not available in the documents, I conducted in-person and telephone interviews with key informants who were identified through my participant-observation and in the documents collected as knowledgeable and influential in the Ontario midwifery integration process. Care was taken to include a cross-section of key consumers, midwives, nurses, physicians, hospital administrators, midwifery policy makers and state officials. Of 43 informants contacted, interviews were secured with 39. The four who did not participate included two midwives and one consumer who did not return my phone calls or correspondence and one member of a midwifery policy committee who was out of the country during this phase of data collection. Interviews lasted from 20 minutes to over two hours and were taped and transcribed for analysis. Data collection and analysis occurred simultaneously and involved a constant iterative process between documents, interviews and the information garnered from my participant observation. I initially began to create a historical timeline of activities and committees involved in the midwifery integration process. This quickly became unwieldy so I subsequently decided to divide these timelines into clusters of related activities. These included: (1) the initial organisation and reorganisation of midwives and the women they cared for around the pursuance of integration; (2) key events and committees related to the regulation of midwifery; (3) the evolution and formal conceptualisation of the model of midwifery practice; and (4) entry to practise midwifery and midwifery education. The categorisation of the data into midwifery organisation, regulation, practice and education was also informed by the theoretical literature on professionalisation. Data were subsequently sorted, coded, and categorised according to these four domains. For each, I then began to create a description of how midwifery existed before integration was pursued, in part from the documents but in large part from the recollections of the midwives and consumers interviewed. This would help establish a sort of `baseline' against which changes could be compared. The process and outcome of integration within each of these domains was then drawn out, highlighting significant events in the change process and factors and forces influencing change. The key findings will be illustrated in the following discussion of the changes to the organisation, regulation, practice and education of midwives in Ontario. The evolution of the organisation of the midwifery community Enhancing integration through increasing bureaucratisation As midwifery emerged in Ontario in the late 1970s, midwives and the women they provided care for initially existed as an amorphous group with few divisions and little hierarchical separation of caregiver and client. In fact the terms `caregiver' and `client' may not be appropriate in describing the roles of each, as a far more egalitarian, friendship-oriented relationship existed # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 179

than these terms connote. Often a woman would help a friend out at birth and that friend would in turn help her out. Midwives and the women they cared for shared similar interests in striving for more choice and control over the childbirth process than was afforded by mainstream medical attendance. They also shared a similar socioeconomic background (i.e. predominantly older, white, middle class, well-educated and family-oriented). Midwives and women were not seen as having different interests from each other. One of the earliest instances of organisation among this amorphous group was the Midwives' Support and Study Group in Toronto and similar groups in other Ontario cities. Women interested in midwifery and childbirth alternatives, regardless of their status as caregiver or client, met together in each others' homes to share information and resources. These early organisations later evolved into a province-wide association, the Ontario Association of Midwives (OAM), which became officially established in 1981. One midwife described the informality of this newly established organisation: It wasn't really an official organisation. It was just a support group to help each other [out]. . . . We opened the membership to anyone who supported midwifery . . . people who had had midwives, and others who were interested in learning about them (practising midwife interview, 1994). Similar to the study groups that came before, membership of the OAM was open and included both midwives, consumers and other supporters. Unlike before, however, membership in the group was more formally differentiated according to these categories. This marked the initial demarcation of midwives from the women they cared for and a critical first step in their professionalisation project. The establishment of the OAM was timely because soon thereafter in 1983 a government-appointed committee was established to review legislation governing all health professions in Ontario. The Health Professions Legislation Review (HPLR), contacted the OAM to ask if midwifery should be included in their new legislative package. The HPLR had also contacted an older but relatively inactive group of non-practising nurse-midwives who made up the Ontario Nurse-Midwives Association (ONMA). Representatives from the OAM and ONMA subsequently met to discuss the responses they were preparing to the HPLR, and the possibility of making a single submission. Agreeing on the philosophical compatibility of the two groups, which focused on more choice and control for women in childbirth, and the need for midwifery to help achieve this, the leaders of the two organisations decided to make single submission to the HPLR as the `Midwifery Coalition'. Both groups felt that unification would create a larger and more forceful midwifery lobby. # Blackwell Publishers Ltd/Editorial Board 2000

180 Ivy Lynn Bourgeault

The Coalition also included a newly created consumer advocacy and support group, the Midwifery Task Force of Ontario (MTFO), made up of midwifery consumers and supporters who were previously members of the OAM. The establishment of the MTFO was proposed as a strategy to help best present the midwives' case for integration. Through a separate consumer group, public support for midwifery could be made more evident. In the words of one midwife: It's better to have a consumer group rather than blowing your own trumpet to say the things that need to be said about the need for midwifery (practising midwife interview, 1995). In turn, having a separate association representing their `professional' interests, midwives at the time felt they could more effectively exhibit their appearance as professionals worthy of inclusion in the system of health professions. Although there was significant cross membership on OAM and MTFO committees and arguably a shared interest in pursuing integration, the development of a separate consumer group nevertheless marked a conceptual differentiation between midwives' interests and those of women seeking their care. This organisational division persisted with the later merger of the OAM and the ONMA into the Association of Ontario Midwives (AOM), the present professional association of midwives. Reflected in this organisational separation of the interests of consumers and midwives is a shift from the originally undifferentiated, nonhierarchical organisation of `midwives' and `clients' marking the initial step in the creation of midwifery as a profession. That is, amorphous groups which originally represented the shared interests of a social movement, including both women and their midwives in an undifferentiated way, evolved into separate, more bureaucratically organised structures representing the `different' interests of midwives and clients. Although these organisational developments helped propel the efforts to integrate midwifery into the provincial health care system, they nevertheless marked a general shift in midwifery away from an egalitarian social movement striving for alternatives in childbirth, to the beginnings of the midwifery professionalisation movement and the development of hierarchical midwife-client relations. Similar professionalising trends were also indicative of the evolution of the regulation of midwifery. The push for professional self-regulation Mediating women's involvement in the regulation of midwifery Although early contemporary midwifery has been described as an `unregulated' profession, this is not completely accurate. Midwives, as one early observer described, were directly `regulated' by the women they served: # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 181

Midwifery . . . is an earned position in the birthing community, accredited by parents rather than by a piece of paper (Barrington 1985:41). This form of `regulation' originally operated largely through word-of-mouth referrals within the alternative childbirth community, and was later formalised into an informed choice agreement. In such an agreement a midwife would outline her education, background, experience, as well as the services she would provide for the pregnant woman. It described the roles and responsibilities of both the midwife and the woman for whom she was to provide care. Given the midwife's qualifications and preparation, the woman would then decide if she felt comfortable having that midwife as her birth attendant, and whether she was comfortable with her responsibilities under the agreement. Once signed, the informed choice agreement became a contract between the midwife and client. In addition to this form of consumer regulation, midwives were also regulated through the civil and criminal justice systems (see Burtch 1994). In the case of unfortunate consequences to the mother or baby, the criminal justice system could be used to lay charges against midwives, such as criminal negligence causing bodily harm. The Coroner's Office would also be involved in the regulation of midwifery in the case of death of a baby at a home birth. Although there were no civil or criminal trials against midwives in Ontario, there were two well-publicised inquests into baby deaths at home births attended by midwives in 1982 and 1985 and trials in other Canadian provinces. Given midwives' generally bad experience with inquests, added to the general concern in the midwifery community resulting from the trials in other areas, this form of `regulation' came to be regarded not only as inadequate but potentially threatening to the continuance of midwifery. As one midwife describes: We knew that in California midwives were being charged with criminal charges. . .and [the possibility of it] happening in Ontario made people feel very vulnerable (interview, 1995). But although midwives wanted protective legislation, they did not want to be regulated by another profession, such as medicine or nursing. In their submission to the HPLR, the Midwifery Coalition made a strong case for midwifery to be a self-regulating profession. Their argument was based on the efficacy of this form of regulation internationally as well as the commitment midwives in the province had begun to exhibit in setting standards and regulating midwifery in an otherwise unregulated environment. The lengthy process the HPLR undertook afforded participants, which included nursing and medical organisations, the opportunity to comment on each other's submissions. Both of these professions argued that it would be # Blackwell Publishers Ltd/Editorial Board 2000

182 Ivy Lynn Bourgeault

more appropriate for midwifery to be regulated either by the College of Physicians and Surgeons of Ontario or by the College of Nurses of Ontario. The HPLR Committee, however, was generally more impressed with the quality and clarity of the submission by the midwives than their professional competitors. The Committee was particularly persuaded by the international research that the midwives cited to support their position. For example, the midwives argued that `the ability of the midwifery profession to set standards of ethical and professional practice and conduct is demonstrated internationally' (Midwifery Coalition Submission to the HPLR 1983:9). By way of contrast, the responses of the nursing and medical profession to the Coalition's submission were not considered to be of the highest quality by those reviewing them; they cited little or no research to substantiate their assertions, but relied instead on statements of opinion. In its final report presented to the Provincial Minister of Health in 1989, the HPLR ultimately recommended that midwifery would be included in the legislation of all health professions in Ontario. Given the HPLR had decided that self-regulation would be the model form of regulation for its recommended legislative package, midwifery's inclusion in this package necessitated this form of regulation for midwifery. Hence, a College of Midwives was created, which is, as it currently stands, made up of a total of nine members: five midwives and four public members, who need not necessarily be midwifery consumers. Thus, with self-regulation and protective legislation, midwives are less vulnerable to the legal harassment of inquests and criminal trials. In this way, they have secured protection through integration. At the same time, however, midwives are no longer directly regulated by their clients as they once were. The regulation of midwives is no longer solely in the hands of clients but is now mediated through a professional self-regulatory body, the College of Midwives. The establishment of a bureaucratic organisation to regulate midwifery in place of midwifery consumers, albeit in their interest, may serve to distance midwives from their clients. That is, midwives are now not only accountable to their clients, they are accountable to the selfregulatory body that licenses and sets standards for them. The separation of the self-regulatory body for midwifery from its professional association, also makes more apparent the distinction between midwives' interests and those of their clients, exacerbating the organisational separation described above. Having said this, midwives' success in achieving self-regulation is not an insignificant feat, especially when considered in a comparative perspective. Self-regulation has been very difficult, if not impossible, for midwives to achieve, as exemplified by the early cases of midwifery legislation in Britain (Donnison 1977), Australia (Willis 1989) and most recently the United States (DeVries 1996, Sullivan and Weitz 1988). Lack of self-regulation has resulted in serious negative consequences for the midwifery profession, such as significant medical control, limited scope of practice and limited client pool (c.f. DeVries 1982, 1996, Sullivan and Weitz 1988). In achieving self# Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 183

regulation, Ontario midwives anticipate being able to avoid some of these negative consequences of integration, something which they have achieved at least insofar as their model of practice is concerned. Enhancing yet preserving the midwifery model of practice Increasing midwives' accountability Many Ontario midwives originally began practising in the late 1970s and early 1980s as assistants to physicians who attended home births. The midwife would come to the woman's home once her labour became established or earlier if the labouring woman needed her support. She would be in attendance at the home birth to coach the woman through the labour, offering advice and reassurance, and comforting measures such as massage and relaxed breathing. Midwifery care focused on serving not only the physical but also the emotional needs of the woman, providing her with care options and following her lead in how she wanted to give birth. Providing information to the woman, which she would then use to make choices regarding her care, was a core component of midwifery care. Thus, informed choice and woman-centred care became the cornerstones of this new midwifery practice. Although midwifery practice was originally limited to childbirth attendance, midwives later began to do prenatal care and education, holding their own clinics independently of the physicians they assisted (Barrington 1985)2. Appointments were scheduled throughout a woman's pregnancy and were informal, lasting approximately an hour or so. This allowed sufficient time for the woman and her midwife to explore important social and emotional issues arising from the pregnancy. Spending this time helped the midwife and woman to get to know each other and to establish a relationship of trust. In addition to providing prenatal and antenatal care, midwives also began to provide postnatal care for the women they assisted and their babies, usually up to six weeks after the birth. Continuity of care thus became another integral component of the care midwives provided. Midwives' assistance at childbirth was not restricted to home births. Some women who were not yet comfortable with a home birth but who nevertheless wanted the care midwives provided sought their assistance at their hospital birth. Midwives' services in hospital largely imitated their assistance at home births ± labour would be monitored at home and once active labour was well established, the midwife would accompany the woman to the hospital. Once in the hospital, however, the midwife's role was severely limited by her lack of official status. At home, midwives sometimes `caught' the baby even if the physician was present. This was not allowed in the hospital setting. Midwives' practice of catching the baby at home increased rapidly when physicians discontinued attending home births in response to a formal directive from their College in 1983. Midwives quickly became primary # Blackwell Publishers Ltd/Editorial Board 2000

184 Ivy Lynn Bourgeault

caregivers at home births subsequent to this. Their status in hospitals, however, remained as labour coaches and patient advocates. This limited midwives' ability to provide continuity of care for a woman transferring or choosing to birth in hospital. Thus, the model of midwifery practice which evolved throughout the late 1970s and early 1980s centred on the woman-centred principles of continuity of care, informed choice, and choice of birth place. Although members of the midwifery community sought changes to the regulation and legitimacy of midwifery care through the integration process, they wanted to preserve this model of practice, including access to home birth. At the same time, however, they also wanted to expand their scope of practice within hospitals to enhance continuity of care for those women choosing a hospital birth. Midwives also sought to increase the accessibility of their services to a wider clientele through public funding. These proposals would face several challenges throughout the integration process, particularly around the negotiations for ensuring access to home and hospital birth. Although the first opportunity for Ontario midwives formally to articulate their model of practice was in their submission to the HPLR, decisions regarding how midwifery was to be integrated were delegated half-way through the HPLR process to a government-appointed Task Force on the Implementation of Midwifery in Ontario. Members appointed to the Task Force included two lawyers, a family physician and a nurse-educator who had prior training as a nurse-midwife; all were arguably supportive of the midwifery initiative. Part of their mandate was to make recommendations regarding midwives' scope of practice and in doing so they undertook a lengthy consultative process. This involved inviting written submissions and oral presentations from local stakeholder groups, including midwives, consumers, nurses, physicians, and hospital representatives; setting up public hearings and meetings among these groups; as well as undertaking an investigation of midwifery internationally (Report of the Task Force on the Implementation of Midwifery in Ontario 1987). In their submission to the Task Force, midwives argued that their scope of practice be based on the International Definition of Midwifery, in particular their independent practice in a variety of community and institutional settings. They argued that any model of midwifery care must be planned in order to achieve maximum continuity of care for clients. It was also argued that a model of midwifery care should ensure that clients were seen as active participants in their own care (i.e. informed choice), and that their choices of birthplace be respected and supported through enabling midwives to practise in both hospital and community settings. Having hospital admitting privileges which enabled both hospital and community practice was considered to be the best model to sustain the midwifery model of practice ensuring both continuity of care and women's choice of birthplace. Mirroring the dynamics in several other authorities, midwives and consumer supporters made a strong argument for preserving the option of home birth # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 185

(AOM Submission to the Task Force on the Implementation of Midwifery in Ontario 1986). In the submissions made by medical organisations, almost all maintained that if midwifery were to be integrated in Ontario it should be restricted to hospital-based practice. Home births were not considered acceptable. They also expressed opposition toward a hospital admitting privileges where midwives would be operating as independent practitioners, arguing instead for a nursing-staff model. Submissions from the nursing profession strongly supported many elements of a midwife's scope of practice included in the International Definition of a Midwife, but nevertheless argued that midwifery be practised as a specialty of nursing. Similar to the medical organisations, not much support was expressed by nursing organisations for the option of home birth. Many Ontario hospitals also wished to limit midwives' practice to the hospital setting, though some saw a place for home birth and were willing to provide backup support (Report of the Task Force on the Implementation of Midwifery in Ontario 1987). When the Task Force made its recommendations to the Minister of Health almost two years later, they essentially paralleled the proposals made by the midwives and their advocates. They recommended that Ontario enact a Midwifery Act in which the midwife's scope of practice was consistent with the international definition of a midwife. In line with this, the Task Force further recommended that midwives be allowed to perform the activities delineated under their scope of practice in a variety of settings, including hospitals and at home. As one Task Force member stated: A community-based model was more . . . responsive to what we were hearing was the void that needed filling. The medical and nursing models were less responsive to this void in our view (interview, 1995). With respect to the home birth issue, the Task Force felt, in the words of one of its members, that `after looking at all the issues, we felt that home birth should still be allowed'. (interview, 1995). Given that a small, yet persistent segment of the population would always choose to give birth at home, and that planned home births could never be eliminated, the members asked not if home births should be allowed, but how they should be made as safe as possible. Framing the question in this way meant that medical and nursing organisations, who were united in their opposition to planned home births, were hard pressed to disagree with the Task Force's intention to make home births as safe as possible: That put it in a different context than having to fight for home birth per se. It was a fight for good care (practising midwife interview, 1995). The Task Force recommended that safety could be accomplished by (1) ensuring that a trained attendant (i.e. a midwife) assist in home births; # Blackwell Publishers Ltd/Editorial Board 2000

186 Ivy Lynn Bourgeault

(2) having the governing body for midwifery prepare a home birth protocol covering assessment of risk and contra-indications to home births; and (3) having the midwifery governing body develop a standard of practice with regard to the care of women who choose to give birth at home despite contra-indications. These recommendations have been implemented by the College of Midwives. Regarding hospital birth, the Task Force recommended that midwives should have access to this setting: If midwives cannot attend hospital births, their clients will be forced to choose between giving birth at home and giving birth in hospital with a caregiver (a physician) not of their choosing. Far from advancing the policy of encouraging women to give birth in hospital, excluding midwives from hospitals will encourage women to stay at home (1987:100). The Task Force agreed with midwives' assertions that to ensure that women have continuity of care and choice of birthplace, midwives should be allowed to have hospital admitting privileges. But for midwives to be allowed hospital admitting privileges, the Provincial act governing privileges, the Public Hospitals Act (PHA), would need to be amended. Government representatives, however, felt that opening the Act for statutory changes to allow midwives access would `open the ``flood gates'' ' (government representative interview, 1995) for other professions also to lobby for privileges. It was decided instead that only regulatory changes would be made allowing hospitals to grant privileges to midwives similar to the way they granted privileges to physicians. But because only regulatory amendments were made, this meant that individual hospitals are free to choose whether or not to grant privileges to midwives. This leaves a midwife seeking hospital privileges little recourse when denied privileges (and this has indeed happened). Moreover, because legislation for admitting privileges under the PHA was created for physicians, it stipulates supervision and control by physicians. Hence, because midwives are treated like physicians when seeking privileges, the practice of midwifery in hospitals also falls under a pre-existing structure of medical supervision and accountability. Thus, midwives are under varying degrees of medical supervision and control in the hospital setting. The day-to-day challenges of working in the hospital setting, however, are not limited to medical supervision, but also include being accountable to the hospital and its policies (which arguably are more reflective of a medical than a midwifery model of care). Midwives now have to deal with what are sometimes competing lines of accountability to their clients and to the hospital that has granted them privileges: My whole role in the hospital is totally different now that I am a primary caregiver. My thinking is different than when I would go in there as a # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 187

labour support person, . . . I could challenge. . . . I had no allegiance to the hospital. I had allegiance to my client and that was it. Now I have a responsibility to the hospital (practising midwife interview, 1995). Thus, although women are theoretically still the focus of the midwifery model of practice, this focus is increasingly constrained and diffused to other concerns. Midwives now must practise not only according to what their clients need and want, they must also adhere to professional standards and hospital policies. In the hospital setting, there may be continuing challenges to the autonomy of midwives as well as to the alternative form of care they wish to provide, paralleling what others have found, for example in the United States (Annandale 1989). These, however, may be less restrictive than if midwives were hospital employees. Moreover, despite the shortcomings of hospitalbased midwifery practice, the model of midwifery care and the core principles of informed choice, choice of birthplace and continuity of care have not only been preserved but have been enhanced through the integration process. Women now have the freedom to choose to have a midwife as their primary caregiver either at home or in hospital. Midwives also no longer have to transfer care to a physician as they cross the hospital threshold. This is a remarkably unique outcome of integration, particularly when compared to midwifery practice in other countries. As mentioned before, an aspiring profession almost always experiences a limitation of its scope of practice and subordination of its practitioners. But although Ontario midwives have managed to preserve their model of practice, dramatic changes were made to their model of education. This would prove to be the most politically contentious issue within the midwifery movement arising from the pursuit of integration. From community to university-based education Seeking legitimacy through changes to midwifery entry to practice As midwifery emerged in the late 1970s, the kind of educational training midwives undertook was varied and eclectic. Often, midwives learned midwifery directly from their clients; that is, they learned by doing. This experiential learning was supplemented with self-directed reading of the reproductive health care literature. Mason, for example, noted how `to find out what she needed to know, [the midwife] read books, talked to other women doing the same thing, and watched the labouring women' (1990:1). A few midwives also undertook midwifery training in the United States and abroad. As the number of midwives increased and had `developed a comprehensive base of experience' (Barrington 1985:44), apprenticeships were sought with more experienced midwives. These apprenticeships usually involved two or more years of obtaining clinical experience through # Blackwell Publishers Ltd/Editorial Board 2000

188 Ivy Lynn Bourgeault

observing and attending births, supplemented with reading and informal courses. Thus, before integration, much of a midwife's learning came from her direct experience with clients and from the experiences of other midwives. This was augmented by ad hoc courses, lectures, and reading. It was selfdirected, eclectic and largely community-based. When contacted by the HPLR in 1983, a heated debate ensued within the midwifery movement over whether midwifery education should be standardised or whether it should remain more experiential and apprenticeship-based. Proponents of apprenticeship argued that this model was more supportive of midwifery philosophy: It is a self-directed and self-motivated learning process requiring the student to be able to perceive and choose the best way to acquire and retain core competencies. . . . It is by nature a personalised learning process which helps one to teach in a personalised way and respect each person for their unique way of approaching their pregnancy and birth (practising midwife interview, 1995). Although the leaders of the Midwifery Coalition agreed with these arguments, they came to realise that in order for midwives to be adequately recognised within the established health care system, particularly as a primary care provider, they would need to have a formalised, standardised educational programme. The uneasy compromise reached was to propose a formal model of education that incorporated the apprenticeship model, including immediate hands-on experience and mentorship: The best way midwifery can be taught is by a formal recognised programme of education with . . . a period of internship . . . incorporated into the programme (Midwifery Coalition's First Submission to HPLR 1983:10). In keeping with the spirit of the coalition with nurse-midwives, the Coalition also argued for multiple routes of entry to practice ± direct-entry as well as following nursing training or practice. In subsequent submissions to the HPLR, midwives recommended a four-year degree programme with ongoing clinical experience under supervision (Association of Ontario Midwives, Third Submission to the HPLR 1985). Along similar lines to their recommendations regarding midwifery regulation and practice, both medical and nursing organisations argued that prior nursing training should be a prerequisite for a formal midwifery education programme. However, subsequent government-appointed committees which examined the issue of midwifery education upheld the proposals made by the midwives. For example, the Task Force recommended a baccalaureate degree programme with multiple-routes of entry, housed at a university, # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 189

preferably one with a health sciences centre. As the midwives had argued, a university setting was regarded as necessary to increase the legitimacy of midwifery in the Province. One of the Task Force members emphasised: If we really expected that midwives would have a place in this spectrum of health professions, it was pretty difficult to see how you could confer professional autonomy, hospital privileges . . . to people without a university degree (interview, 1995). Following the Task Force Report, a committee was established to design the curriculum for a new midwifery education programme which ultimately began in September, 1993. It is a four-year, direct-entry, baccalaureate programme run by a consortium of three universities across the Province with a strong focus on gaining hands-on clinical experience. Students get together intermittently throughout the term for formal courses in basic sciences, social science, health sciences and women's studies, but much of their training is in the community with clinical activities beginning in their first term. Although international reviewers of the programme argue that it effectively combines apprenticeship with academic study, others maintain that `midwives have repudiated much of their own non-medical birth culture and have constructed a curriculum that is at times indistinguishable from any other progressive medical curriculum' (Mason 1990:4). With the establishment of a baccalaureate educational programme, some argue that educational texts for the professional `expert' and standardised professional knowledge have been given priority over the individualised experiential, client-based knowledge that was the core of the midwifery apprenticeship model. The new midwife's learning is now structured to come equally from educational texts for the professional expert as well as from clinical birth experience. Thus, there has been a change in both content and form. Although these changes to the model of midwifery education were proposed by midwifery activists, they were made in response to external pressures. Changes were regarded as necessary to increase the integration potential of midwifery. That is, the new midwifery education programme was used as a vehicle for achieving legitimacy within the mainstream health care system. As midwives stated in their submission to the HPLR: In Ontario public trust in midwifery care would be fostered by a consistent standard of university education leading to the BScM (Third Submission to the HPLR 1985:37). This is not a strategy unique to midwifery in Ontario; it is a typical professionalisation strategy (see Coburn and Biggs 1986 for example). This points to the embeddedness of what is regarded as an acceptable form of professional education. # Blackwell Publishers Ltd/Editorial Board 2000

190 Ivy Lynn Bourgeault

It is important to point out, however, that the model of midwifery education in Ontario could have changed more than it did if certain stakeholders' (i.e. nursing and medicine) proposals had been implemented. Nevertheless, the potential for these changes to continue to affect midwifery, including the midwifery model of practice, is significant. The reorientation of midwives' knowledge base may serve as yet another way to distance midwives from the woman they provide care for. Perhaps as midwifery consumer and advocate Mason predicts, `the midwife will now be the teacher and not the taught, and the woman her pupil rather than a partner in the birthing process' (1990:4). Discussion It is difficult to truly know from this research whether egalitarianism in midwifery actually existed prior to the pursuit of integration; the retrospective methodology used does not allow for a completely accurate assessment of this. Nevertheless, it can be shown that the conditions by which this egalitarianism could or could not be fostered have indeed changed throughout the integration process. In each domain of the new midwifery examined here, there has been a shift away from this espoused egalitarian philosophy. The changes in the organisation of midwifery in the early stages of the integration process set the trend for the increased hierarchy and distance between women and their midwives. The position of women seeking midwifery care moved from significant involvement in the regulation and training of midwives to a more marginalised role. The further along the integration process, the more structurally mediated the relations between midwives and their clients became ± by their separate associations, the self-regulatory body, by the hospital, and by the state. Midwives now have to practise within the system and not outside it. The pressures to conform to mainstream practices are tremendous. Why have these conditions changed? First, a recurring theme of many integration processes is the need for an aspiring profession to make compromises so that it can fit into the existing `system' of professions (Abbott 1988, Coburn and Biggs 1986, Larkin 1983, Willis 1989). That is, the system, or structure, creates the boundaries within which aspiring health professions must fit. This is, in part, what has happened to midwifery in Ontario. Despite recent trends strongly suggesting the diminishment of medical dominance in light of the increasing power of the state (Coburn 1993, Coburn et al. 1997), the system of health professions in Ontario is one that is still dominated by the medical profession. In fact, one could argue that this dominance is `structurally embedded' (Alford 1975) into the health care system. In each of the domains examined, midwives came up against this embeddedness of medical dominance in the system. In terms of the changes to the organisation and regulation of midwifery, having a separate # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 191

association and regulatory body is modelled after the organisation of the medical profession. Locating the educational programme within a university is also a response to the need for the recognition of midwifery largely in the eyes of the medical profession, which would not recognise any other form of education for a primary care provider. But the embeddedness of medical dominance is most clearly evident in midwives' efforts to obtain hospital admitting privileges. Medical control and power is embedded in the statutes of the Public Hospital's Act, so for midwives to gain official access to hospitals, they had to agree to work within pre-existing parameters of medical supervision and control. There have been changes to midwifery, most in response to seeking a legitimate place in a medically dominated health care system; and many of these changes are indicative of professionalisation as conceptualised in the contemporary literature on the health professions. But, not all the changes that have occurred are detrimental to midwifery philosophy and the midwife-client relationship. Moreover, there have been significant ways in which midwives have resisted change, particularly with respect to their model of practice. A key factor in this resistance is the agency of key actors in the process; a factor infrequently mentioned in the profession's literature. One cannot accurately describe the midwifery integration process in Ontario without highlighting the tenacity, insight and political astuteness of the midwives and their supporters. These women accurately realised and proposed those elements of integration that were necessary to maintain the aspects of midwifery that they did not want to change: autonomy vis a vis nursing and medicine with respect to organisation, regulation, practice and education. They became very good at manoeuvring within the system so as to ensure the maintenance of their model of care. They had great insight in contextualising their local efforts in the international midwifery community. Reference to the international recognition of midwifery highlighted Canada's embarrassing situation of not having any provisions for midwifery. It also bolstered the midwives' proposals for an independent form of midwifery. It must also be acknowledged that these efforts on the part of midwives and their supporters were met with a particularly receptive audience within the state. Many key bureaucrats and state officials were female, feminist, and supportive of midwifery, not the least of which were the four successive Ministers of Health prior to official integration. These actors within the state helped to promote the integration efforts of the midwives in part because midwifery was viewed as a cheaper alternative, but also because of the feminist symbolism midwifery embodied (Bourgeault and Fynes 1996/7). State support was evident at several levels, including the establishment and funding of midwifery policy committees, such as the Task Force, and the purposive appointment of people supportive of midwifery to these committees. Moreover, the Ministers acted on the recommendations of these committees. The government agreed to the funding of the midwives' self-regulatory # Blackwell Publishers Ltd/Editorial Board 2000

192 Ivy Lynn Bourgeault

body, midwifery educational programme, and midwifery services all at a time when government funding in health care was being increasingly cut back. It is in large part because of the combination of the agency of these predominantly female actors, both external and internal to the state, that midwifery in Ontario has been able to resist some of the more negative features of the integration process documented in the literature, and in fact garner some more positive changes. Thus, although midwifery has changed, it could have changed more drastically than it has. Instead of being a vulnerable underground movement, midwifery is now a legitimate health profession. Moreover, midwifery is at least in principle more accessible to more women regardless of their ability to pay. The kind of care a midwife provides, despite changes since its origins in the late 1970s, is still quite different from that which is available in the traditional medical system, particularly in the present climate of health care cutbacks. Thus, state sponsorship for this aspiring health profession has been an effective strategy in helping minimise the negative consequences integration usually entails. This may be largely caused by the fact that there were responsive actors within the state. This insight may prove to be of increasing importance in the professionalising efforts of other female professions in light of the increasing feminisation of the state (Benoit 1998). Perhaps we are coming to a point where the state is not only the weaker link in the chain of patriarchal occupational closure, as Witz (1992) argues, but that it may be the stronger link in the promotion of the integration and professionalisation efforts of largely female-based professions. Address for correspondence: Ivy Lynn Bourgeault, Department of Sociology, The University of Western Ontario, Canada, N6A 5C2 e-mail: [email protected]. Acknowledgements This paper is based on the author's thesis from the Department of Community Health at the University of Toronto entitled, `Delivering midwifery: an examination of the process and outcome of the incorporation of midwifery in Ontario', 1996. The research was jointly supported by a Social Sciences and Humanities Research Council of Canada Doctoral Fellowship and a Doctoral Fellowship from the National Health Research and Development Program of Health and Welfare Canada. The author would like to thank D. Coburn and the two anonymous reviewers for their helpful comments on this paper.

Notes 1

Please refer to MacDonald and Bourgeault (1999) for a detailed description of the dilemmas involved in participant observation research of the small, and somewhat politically vulnerable midwifery community in Ontario.

# Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 193 2

Midwifery clients also had to receive prenatal care from a physician as midwives did not have any official status to order diagnostic tests prior to the proclamation of the Midwifery Act at the end of 1993.

References Abbott, A. (1988) The System of Professions. Chicago: University of Chicago Press. Alford, R. (1975) Health Care Politics. Chicago: University of Chicago Press. Annandale, E.C. (1989) Proletarianisation or restratification of the medical profession? The case of obstetrics, International Journal of Health Services, 19, 4, 611±34. Arms, S. (1975) Immaculate Deception: a New Look at Women and Childbirth in America. San Francisco: San Francisco Book Company. Barrington, E. (1985) Midwifery is Catching. Toronto: NC Press Limited. Barrington, E. (1984) The Legalization of Midwifery in Canada: A brief. Toronto: The National Action Committee on the Status of Women. Bart, P. (1981) Seizing the means of reproduction: an illegal feminist abortion collective ± how and why it worked. In Roberts, H. (ed) Women, Health and Reproduction. London: Routledge. Benoit, C. (1998) Equity, employment rights, and client choice: the politics of midwives' caring for other women. Paper presented at ISA bi-annual conference on the sociology of the professions, Professional Identities in Transition. 1±2 May, Gothenburg, Sweden. Biggs, C.L. (1989) No Bones about Chiropractic? The Quest For Legitimacy by the Ontario Chiropractic Profession, 1895±1985. Unpublished Ph.D. Dissertation, University of Toronto. Biggs, C.L. (1983) The case of the missing midwives: a history of midwifery in Ontario from 1795±1900, Ontario History, 65, 21±35. Bourgeault, I.L. and Fynes, M.T. (1996/7) Delivering midwifery in Ontario: how and why midwifery was integrated into the provincial health care system, Health and Canadian Society, 4, 2, 227±62. Bourgeault, I.L. and Fynes, M.T. (1997) The integration of nurses and lay midwives in the U.S. and Canada, Social Science and Medicine, 44, 7, 1051±63. Buckley, S. (1979) Ladies or midwives? Efforts to reduce infant and maternal mortality. In Kealey, L. (ed) A Not Unreasonable Claim: Women and Reform in Canada 1880s±1920s. Toronto: The Women's Press. Burtch, B.E. (1994) Trials of Labour: the Re-emergence of Midwifery. Montreal and Kingston: McGill/Queens Press. Coburn, D. (1993) State authority, medical dominance, and trends in the regulation of the health professions: the Ontario case, Social Science and Medicine, 37, 129±38. Coburn, D. and Biggs, C.L. (1986) Limits to medical dominance: the case of chiropractic, Social Science and Medicine, 22, 1035±46. Coburn, D., Rappolt, S. and Bourgeault, I.L. (1997) Decline versus retention of power through restratification: the case of medicine in Ontario, Sociology of Health and Illness, 19, 1, 1±22. # Blackwell Publishers Ltd/Editorial Board 2000

194 Ivy Lynn Bourgeault Connor, J.T.H. (1994) `Larger fish to catch here than midwives': midwifery and the medical profession in nineteenth-century Ontario. In Dodd, D. and Gorham, D. (eds) Caring and Curing: Historical Perspectives on Women and Healing in Canada. Ottawa: University of Ottawa Press. Corea, G. (1977) Hidden Malpractice: how American Medicine Mistreats Women (Updated Edition), New York: Harper Colophon Books. Davis-Floyd, R.E. (1992) Birth as an American Rite of Passage. Berkeley: University of California Press. DeVries, R.G. (1982) Midwifery and the problem of licensure, Research in the Sociology of Health Care, 2, 77±120. DeVries, R.G. (1996) Making Midwives Legal (2nd Edition). Columbus, Ohio: Ohio State University Press. Donegan, J.B. (1978) Women and Men Midwives: Medicine, Morality and Misogyny in Early America. Westport CT: Greenwood Press. Donnison, J. (1977) Midwives and Medical Men. London: Heinemann. Ehrenreich, B. and English, D. (1973) Witches, Midwives, and Nurses: a History of Women Healers. New York: The Feminist Press, Old Westbury. Evenson, D. (1982) Midwives: survival of an ancient profession, Women's Rights Law Reporter, 7, 4, 313±30. Fox Piven, F. (1990) Ideology and the state: women, power, and the welfare state. In Gordon, L. (ed) Women, the State and Welfare. Madison: University of Wisconsin Press. Freidson, E. (1970a) Profession of Medicine: a Study of the Sociology of Applied Knowledge (2nd Edition) Chicago: University of Chicago Press. Freidson, E. (1970b) Professional Dominance: the Social Structure of Medical Care. New York: Atherton. Fudge, J. (1996) Fragmentation and feminization: the challenge of equity for labourrelations policy. In Brodie, J. (ed) Women and Canadian Public Policy. Toronto: Harcourt Brace. Gaskin, I.M. (1991) Midwifery reinvented. In Kitzinger, S. (ed) The Midwife Challenge (New edition). London: Pandora Press. Gort, E. and Coburn, D. (1988) Naturopathy in Canada: changing relationship to medicine, chiropractic and the state, Social Science and Medicine, 26, 1061±72. Gotell, L. (1996) Policing desire: obscenity law, pornography politics, and feminism in Canada. In Brodie, J. (ed) Women and Canadian Public Policy. Toronto: Harcourt Brace. Hosford, E. (1976) The home birth movement, Journal of Nurse-Midwifery, 21, 3, 27±30. Kay, B.J., Butter, I.H., Chang, D. and Houlihan, K. (1988) Women's health and social change: the case of the lay midwives, International Journal of Health Services, 18, 2, 223±36. Kobrin, F.E. (1966) The American midwife controversy: a crisis of professionalism, Bulletin of the History of Medicine, 40, 350±63. Larkin, G. (1983) Occupational Monopoly and Modern Medicine. London: Tavistock. Leavitt, J.W. (1986) Brought to Bed: Childbearing in America 1750±1950. New York: Oxford University Press. Levan, A. (1996) Violence against women. In Brodie, J. (ed) Women and Canadian Public Policy. Toronto: Harcourt Brace. Litoff, J.B. (1978) American Midwives: 1860 to the Present. Westport, Connecticut: Greenwood Press. # Blackwell Publishers Ltd/Editorial Board 2000

Delivering the `new' Canadian midwifery 195 MacDonald, M. and Bourgeault, I.L. (1999) The politics of representation: doing and writing `interested' research on midwifery. Paper presented to the First International Interdisciplinary Conference: Advances in Qualitative Methods, Edmonton: February. Macleod, L. (1987) Battered but not Beaten: Preventing Wife Battering in Canada. Ottawa: Health and Welfare Canada. Mason, J. (1987) The history of midwifery in Canada. In Eberts, M., Schwartz, R., Edney, R. and Kaufman, K. (eds) Report of the Task Force on the Implementation of Midwifery in Ontario. Toronto: Queen's Park Printer. Mason, J. (1988) Midwifery in Canada. In Kitzinger, S. (ed) The Midwife Challenge. London: Pandora Press. Mason, J. (1990) The Trouble with Licensing Midwives. Ottawa: CRIAW/ICREF. McCool, W.F. and McCool, S.J. (1989) Feminism and nurse-midwifery: historical overview and current issues, Journal of Nurse-Midwifery, 34, 6, 323±34. McDermott, P. (1996) Pay and employment equity: why separate policies? In Brodie, J. (ed) Women and Canadian Public Policy. Toronto: Harcourt Brace. O'Brien, M. (1981) The Politics of Reproduction. New York: Routledge. O'Connor, B.B. (1993) The home birth movement in the United States, The Journal of Medicine and Philosophy, 18, 147±74. Peterson, K.J. (1983) Technology as a last resort in home birth: the work of lay midwives, Social Problems, 30, 3, 272±83. Reid, M. (1989) Sisterhood and professionalization: a case study of the American lay midwife. In Shepherd, McClain C. (ed) Women as Healers: Cross-cultural Perspectives. London: Rutgers University Press. Rothman, B.K. (1982) In Labor: Women and Power in the Birthplace. New York: W. W. Norton and Co. Rothman, B.K. (1989) Recreating Motherhood: Ideology and Technology in a Patriarchal Society. New York: Norton. Rushing, B. (1991) Market explanations for occupational power: the decline of midwifery in Canada, American Review of Canadian Studies, Spring, 7±27. Rushing, B. (1993) Ideology and the re-emergence of North American midwifery, Work and Occupations, 20, 1, 46±67. Ruzek, S.B. (1978) The Women's Health Movement: Feminist Alternatives to Medical Control. New York: Praeger. Saks, M. (1983) Removing the blinkers? A critique of recent contributions to the sociology of professions, Sociological Review, 31, 1±21. Smart, C. (1989) Feminism and the Power of the Law. London: Routledge. Sullivan, D.A. and Weitz, R. (1988) Labor Pains: Modern Midwives and Home Birth. New Haven: Yale University Press. Teasley, R. (1983) Birth and the Division of Labor: the Movement to Professionalise Nurse-midwifery, and its Relationship to the Movement for Home Birth and Lay Midwifery. A Case Study of Vermont. Unpublished PhD, Michigan State University. Van Wagner, V. (1988) Women organizing for midwifery in Ontario, Resources for Feminist Research, 17, 115±18. Ventre, F. (1978) The lay midwife, Journal of Nurse-Midwifery, 22, 4, 32±5. Wardwell, W.I. (1981) Chiropractors: challenges of medical dominance, Research in the Sociology of Health Care, 2, 207±50. Wertz, R.W. and Wertz, D.C. (1977) Lying-In: a History of Childbirth in America. New York: Schocken Books. # Blackwell Publishers Ltd/Editorial Board 2000

196 Ivy Lynn Bourgeault Willis, E. (1989) Medical Dominance: the Division Of Labour in The Australian Health Care System (2nd Edition). Sydney: George Allen and Unwin. Witz, A. (1990) Patriarchy and professions: the gendered politics of occupational closure, Sociology, 24, 4, 675±90. Witz, A. (1992) Professions and Patriarchy. London: Routledge.

# Blackwell Publishers Ltd/Editorial Board 2000