Download SOCIAL PROBLEMS, Vol. 30, No. 3, February 1983

SOCIAL PROBLEMS, Vol. 30, No. 3, February 1983
MIDWIVES IN TRANSITION:
THE STRUCTURE OF A CLINICAL REVOLUTION*
BARBARA KATZ ROTH MAN
Baruch College and the Center for the Study of
Women and Sex Roles, City University of New York
This paper examines the influence of settings of practice on the construction and
reconstruction of medical knowledge, specifically the development and uses of
timetables for labor and birth. I reviewed the medical literature and interviewed 12
hospital-trained nurse-midwives who had begun to do home births. I argue that the
medically managed hospital setting structures the birth process in social and
ideological terms that are in many cases unrelated to the process itself.
* The author thanks Maren Lockwood Carden, Leon Chazanow, Sue Fisher, Betty Leyerle, Judith Lorber,
Eileen Moran, and the anonymous Social Problems reviewers. Correspondence to: Box 511, Baruch College,
New York, New York 10010.
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There has been considerable interest in the United States in recent years in the medical management of the reproductive processes in healthy women. Much of this interest represents a growing
recognition by many mothers that hospital births impose structures upon the birth process
unrelated to and in many cases disruptive of the process itself.
This paper contends that changing the setting of birth from hospital to home alters the timing
of the birth process, a result of the social redefinition of birth. Through an analysis of the medical
literature on birth, I compare the social construction of timetables for childbirth — how long normal labor and birth takes —by hospital and home-birth practitioners. I argue that, like all
knowledge, this knowledge is socially determined and socially constructed, influenced both by
ideology and social setting.
This paper is based on interviews I conducted in 1978 with one subgroup of the home-birth
movement: nurse-midwives certified by the State of New York to attend births. I located 12
nurse-midwives in the New York metropolitan area who were attending births in homes and at an
out-of-hospital birth center. Nurse-midwives in the United States are trained in medical institutions one to two years beyond nursing training and obtain their formative experience in hospitals.
They differ from lay midwives, who receive their training outside of medical institutions and
hospitals. Once nurse-midwives are qualified, most of them continue to practice in hospitals. I
use the term nurse-midwives throughout this paper to distinguish them from lay midwives. I
discuss those parts of the interviews with these nurse-midwives which focus on their reconceptualization of birth timetables as they moved from hospital to home settings.
This sample was selected for two reasons: first, because of the position that nurse-midwives
hold in relation to mothers compared with that held by physicians; while physicians in hospital
settings control the birth process, nurse-midwives in home settings permit the birth process to
transpire under the mother's control. Second, because nurse-midwives have been both formally
trained within the medical model and extensively exposed to the home-birth model, data gathered
in monitoring their adjustment to and reaction to the home-birth model provide a crosscontextual source for comparing the two birth settings.
Observation of the reactions of nurse-midwives to the home-birth setting demonstrates the
degree to which their medical training was based on social convention rather than biological constants. The nurse-midwives did not embrace their non-medical childbirth work as ideological enthusiasts; rather, they were drawn into it, often against what they perceived as their better
medical judgment. The nurse-midwives were firmly grounded in the medical model. Their ideas
Midwives in Transition
263
(1)TERM: THE END OF PREGNANCY
The Hospital Approach
In the medical model, a full-term pregnancy is 40 weeks long, though there is a two-week
allowance made on either side for "normal" births. Any baby born earlier than 38 weeks is
"premature;" after 42 weeks, "postmature." Prematurity does not produce any major conceptual
anomalies between the two models. If a woman attempting home birth goes into labor much
before the beginning of the 38th week, the nurse-midwives send her to a hospital because they,
like physicians, perceive prematurity as abnormal, although they may not agree with the subsequent medical management of prematurity. In fact, few of the nurse-midwives' clients enter labor
prematurely.
Post-maturity however, has become an issue for the nurse-midwives. The medical treatment
for postmaturity is to induce labor, either by rupturing the membranes which contain the fetus,
or by administering hormones to start labor contraction, or both. Rindfuss (1977) has shown that
physicians often induce labor without any "medical" justification for mothers' and doctors' convenience.
Induced labor is more difficult for the mother and the baby. Contractions are longer, more frequent, and more intense. The more intense contractions reduce the baby's oxygen supply. The
mother may require medication to cope with the more difficult labor, thus further increasing the
risk of injury to the baby. In addition, once the induced labor (induction) is attempted, doctors
will go on to delivery shortly thereafter, by Cesarian section if necessary.
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of what a home birth should and would be like, when they first began doing them, were based on
their extensive experience with hospital births. While they believed that home birth would provide
a more pleasant, caring, and warm environment than that ordinarily found in hospital birth, they
did not expect it to challenge medical knowledge. And at first, home births did not. What the
nurse-midwives saw in the home setting was screened through their expectations based on the
hospital setting. The medical model was only challenged with repeated exposures to the anomalies
of the home-birth experience.
The nurse-midwives' transition from one model to another is comparable to scientists' switch
from one paradigm to another —a "scientific revolution," in Kuhn's (1970) words. Clinical
models, like paradigms, are not discarded lightly by those who have invested time in learning and
following them. The nurse-midwives were frequently not prepared for the anomalies in the
timetable that they encountered at home. These involved unexpected divergences from times for
birthing stages as "scheduled" by hospitals. Breaking these timetable norms without the expected
ensuing "complications" provided the nurse-midwives attending home births with anomalies in
the medical model. With repeated exposure to such anomalies, the nurse-midwives began to
challenge the basis of medical knowledge regarding childbirth.
The medical approach divides the birth process into socially structured stages. Each of these
stages is supposed to last a specific period of time. Roth (1963) notes that medical timetables
structure physical processes and events, creating sanctioned definitions and medical controls.
Miller (1977) has shown how medicine uses timetables to construct its own version of pregnancy.
Similarly, medical timetables construct medical births: challenging those timetables challenges
the medical model itself.
There are four parts of the birth process subject to medical timetables: (1) term (the end of
pregnancy); (2) the first stage of labor; (3) delivery; and (4) expulsion of the placenta. I describe
the hospital and home-birth approaches to these four parts and how each part's timetable issues
arise. Then I consider the function of these timetables for doctors, hospitals, and the medical
model.
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ROTHMAN
(2) THE FIRST STAGE OF LABOR
The Hospital Approach
Childbirth, in the medical model, consists of three "stages" that occur after term. (In this paper
I consider term as the first part of the birth process, occurring at the end of pregnancy.) In the
first stage of childbirth, the cervix (the opening of the uterus into the vagina) dilates to its fullest
to allow for the passage of the baby. In the second stage, the baby moves out of the open cervix,
through the vagina, and is born. The third stage is the expulsion of the placenta. The second example of a point at which anomalies arise is in "going into labor," or entering the first stage.
The medical model of labor is best represented by "Friedman's Curve" (Friedman, 1959). To
develop this curve, Friedman observed labors and computed averages for each "phase" of labor.
He defined a latent phase as beginning with the onset of labor, taken as the onset of regular
uterine contractions, to the beginnings of an active phase, when cervical dilation is most rapid.
The onset of regular contractions can only be determined retroactively. Williams Obstetrics
(Hellman and Pritchard, 1971), the classic obstetric text, says that the first stage of labor (which
contains the two "phases") "begins with the first true labor pains and ends with the complete dilation of the cervix" (1971:351). "True labor pains" are distinguished from "false labor pains" by
what happens next:
The only way to distinguish between false and true labor pains, however, is to ascertain their effect on the
cervix. The labor pains in the course of a few hours produce a demonstrable degree of effacement (thinning of the cervix) and some dilation of the cervix, whereas the effect of false labor pains on the cervix is
minimal (1971:387).
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The Home-Birth Approach
These techniques for inducing labor are conceptualized as "interventionist" and "risky" within
the home-birth movement. The home-birth clients of the nurse-midwives do not want to face
hospitalization and inductions, and are therefore motivated to ask for more time and, if that is
not an option, to seek "safe" and "natural" techniques for starting labor. Some nurse-midwives
suggest nipple stimulation, sexual relations, or even castor oil and enemas as means of stimulating
uterine contractions. As I interviewed the 12 nurse-midwives about their techniques it was unclear
whether their concern was avoiding postmaturity per se or avoiding medical treatment for
postmaturity.
The nurse-midwives said that the recurring problem of postmaturity has led some home-birth
practitioners to re-evaluate the length of pregnancy. Home-birth advocates point out that the
medical determination of the length of pregnancy is based on observations of women in medical
care. These home-birth advocates argue that women have been systematically malnourished by
medically ordered weight-gain limitations. They attribute the high level of premature births experienced by teenage women to malnourishment resulting from overtaxing of their energy
reserves by growth, as well as fetal, needs. The advocates believe that very well nourished women
are capable of maintaining a pregnancy longer than are poorly nourished or borderline women.
Thus, the phenomenon of so many healthy women going past term is reconceptualized in this
developing model as an indication of even greater health, rather than a pathological condition of
"postmaturity."
The first few times a nurse-midwife sees a woman going past term she accepts the medical
definition of the situation as pathological. As the problem is seen repeatedly in women who
manifest no signs of pathology, and who go on to have healthy babies, the conceptualization of
the situation as pathological is shaken. Nurse-midwives who have completed the transition from
the medical to home-birth model, reject the medical definition and reconceptualize what they see
from "postmature" to "fully mature."
Midwives in Transition
265
The concept of "false" labor serves as a buffer for the medical model of "true" labor. Labors
which display an unusually long "latent phase," or labors which simply stop, can be diagnosed as
"false labors" and thus not affect the conceptualization of true labor. Friedman (1959:97) says:
The latent phase may occasionally be found to be greater than the limit noted, and yet the remaining portion of the labor, the active phase of dilatation, may evolve completely normally. These unusual cases may
be explained on the basis of the difficulty of determining the onset of labor. The transition from some
forms of false labor into the latent phase of true labor may be completely undetectable and unnoticed. This
may indeed be an explanation for the quite wide variation seen among patients of the actual duration of
the latent phase.
In creating his model, Friedman obtained average values for each phase of labor, both for
women with first pregnancies and for women with previous births. Then he computed the
statistical limits and equated statistical normality with physiological normality:
Once the equation is made between statistical abnormality and physiological abnormality, the
door is opened for medical intervention. Thus, statistically abnormal labors are medically
treated. The medical treatments are the same as those for induction of labor: rupture of membranes, hormones, and Cesarian section.
"Doing something" is the cornerstone of medical management. Every labor which takes "too
long" and which cannot be stimulated by hormones or by breaking the membranes will go on to
the next level of medical management, the Cesarian section. Breaking the membranes is an interesting induction technique in this regard: physicians believe that if too many hours pass after
the membranes have been ruptured, naturally or artificially, a Cesarian section is necessary in
order to prevent infection. Since physicians within the hospital always go on from one intervention to the next, there is no place for feedback; that is, one does not get to see what happens when
a woman stays in first stage for a long time without her membranes being ruptured.
Hospital labors are shorter than home-birth labors. A study by Mehl (1977) of 1,046 matched,
planned home and hospital births found that the average length of first-stage labor for first births
was 14.5 hours in the home and 10.4 hours in the hospital. Williams Obstetrics reports the
average length of labor for first births was 12.5 hours in 1948 (Hellman and Pritchard, 1971:396).
For subsequent births, Mehl found first-stage labor took an average of 7.7 hours in the home and
6.6 hours in the hospital. Hellman and Pritchard reported 7.3 hours for the same stage. Because
1948 hospital births are comparable to contemporary home births, and because contemporary
hospital births are shorter, it is probable that there has been a increase in "interventionist
obstetrics," as home-birth advocates claim. These data are summarized in Table 1.
The Home-Birth
Approach
Home-birth advocates see each labor as unique. While statistical norms may be interesting,
they are of no value in managing a particular labor. When the nurse-midwives have a woman at
home, or in the out-of-hospital birth-center, both the nurse-midwife and the woman giving birth
want to complete birth without disruption. Rather than using arbitrary time limits, nursemidwives look for progress, defined as continual change in the direction of birthing. A more
medically-oriented nurse-midwife expressed her ambivalence this way:
They don't have to look like a Freidman graph walking around, but I think they should make some kind of
reasonable progress (Personal interview).
Unable to specify times for "reasonable" progress, she nonetheless emphasized the word
"reasonable," distinguishing it from "unreasonable" waiting.
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It is clear that cases where the phase-durations fall outside of these (statistical) limits are probably abnormal in some way . . . . We can see now how, with very little effort, we have been able to define average
labor and to describe, with proper degree of certainty, the limits of normal (1959:97).
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ROTHMAN
TABLE 1
Labor Timetables for the First and Second Stages of Birth,
for First and Subsequent Births
Length of First Stage of Labor (hours)
Birth
First
Subsequent
Home 1970s
Hospital 1948
14.5
12.5
7.7/8.5a
7.3b
Hospital 1970s
10.4
6.6/5.9*
Length of Second Stage of Labor (minutes)
80
30 b
63.9
19/15.93
A nurse-midwife with more home-birth experience expressed more concern for the laboring
woman's subjective experience:
There is no absolute limit —it would depend on what part of the labor was the longest and how she was
handling that. Was she tired? Could she handle that? (Personal interview).
A labor at home can be long but "light," uncomfortable but not painful. A woman at home may
spend those long hours going for a walk, napping, listening to music, even gardening or going to
a movie. This light labor can go for quite some time. Another nurse-midwife described how she
dealt with a long labor:
Even though she was slow, she kept moving. I have learned to discriminate now, and if it's long I let them
do it at home on their own and I try and listen carefully and when I get there it's toward the end of labor.
This girl was going all Saturday and all Sunday, so that's 48 hours worth of labor. It wasn't forceful labor,
but she was uncomfortable for two days. So if I'd have gone and stayed there the first time, I'd have been
there a whole long time, then when you get there you have to do something (Personal interview).
(3) DELIVERY: P U S H I N G T I M E LIMITS
The Hospital Approach
The medical literature defines the second stage of labor, the delivery, as the period from the
complete dilatation of the cervix to the birth of the fetus. Hellman and Pritchard (1971) found
this second stage took an average of 80 minutes for first births and 30 minutes for all subsequent
births in 1948. Mehl (1977) found home births took an average of 94.7 minutes for first births
and, for second and third births, 48.7 to 21.7 minutes. Contemporary medical procedures
shorten the second stage in the hospital to 63.9 minutes for first births and 19 to 15.9 minutes for
second and third births (Mehl, 1977).
The modern medical management of labor and delivery hastens the delivery process, primarily
by the use of forceps and fundal pressure (pressing on the top of the uterus through the abdomen)
to pull or push a fetus out. Friedman (1959) found the second stage of birth took an average of 54
minutes for first births and 18 minutes for all subsequent births. He defined the "limits of
normal" as 2.5 hours for first births and 48 minutes for subsequent births. Contemporary
hospitals usually apply even stricter limits, and allow a maximum of two hours for first births and
one hour for second births. Time limits vary somewhat within U.S. hospitals, but physicians and
nurse-midwives in training usually do not get to see a three-hour second stage, much less anything
longer. "Prolonged" second stages are medically managed to effect immediate delivery.
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First
94.7
Subsequent
48.7/21.7*
Note:
a. Second births and third births.
b. Second and all subsequent births.
Midwives in Transition
267
Mehl (1977) found low forceps were 54 times more common and mid-forceps 21 times more
common for prolonged second-stage and/or protracted descent in the hospital than in planned
home births. This does not include the elective use of forceps (without "medical" indication), a
procedure which was used in none of the home births and 10 percent of the hospital births (four
percent low forceps and six percent mid-forceps). Any birth which began at home but was
hospitalized for any reason, including protracted descent or prolonged second stage (10 percent
of the sample), was included in Mehl's home-birth statistics.
The Home-Birth
Approach
If she's honestly fully dilated I do count it as second stage. If she has a rim of cervix left, I don't count it
because I don't think it's fair. A lot of what I do is to look good on paper (Personal interview).
Looking good on paper is a serious concern. Nurse-midwives expressed their concern about
legal liability if they allow the second stage to go on for more than the one- or two-hour hospital
limit, and then want to hospitalize the woman. One told of allowing a woman to stay at home in
second stage for three hours and then hospitalizing her for lack of progress. The mother, in her
confusion and exhaustion, told the hospital staff that she had been in second stage for five hours.
The nurse-midwife risked losing the support of the physician who had agreed to provide emergency and other medical services at that hospital. Even when a nurse-midwife's experiences cause her
to question the medical model, the constraints under which she works may thus prevent her from
acting on new knowledge. Nurse-midwives talked about the problems of charting second stage:
If I'm doing it for my own use I start counting when the woman begins to push, and push in a directed
manner, really bearing down. I have to lie sometimes. I mean I'm prepared to lie if we ever have to go to
the hospital because there might be an hour or so between full dilation and when she begins pushing and I
don't see —as long as the heart tones are fine and there is some progress being made —but like I don't
think —you'd be very careful to take them to the hospital after five hours of pushing — they [hospital staff]
would go crazy (Personal interview).
All my second stages, I write them down under two hours: by hospital standards two hours is the upper
limit of normal, but I don't have two-hour second stages except that one girl that I happened to examine
her. If I had not examined her, I probably would not have had more than an hour and a half written down
because it was only an hour and a half that she was voluntarily pushing herself (Personal interview).
Not looking for what you do not want to find is a technique used by many of the nursemidwives early in their transition away from the medical model. They are careful about examining a woman who might be fully dilated for fear of starting up the clock they work under:
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Nurse-midwives and their out-of-hospital clients were even more highly motivated to avoid
hospitalization for prolonged delivery than for prolonged labor. There is a sense of having come
so far, through the most difficult and trying part. Once a mother is fully dilated she may be so
close to birth that moving her could result in giving birth on the way to the hospital. Contrary to
the popular image, the mother is usually working hard but not in pain during the delivery, and as
tired as she may be, is quite reluctant to leave home.
Compare the situation at home with what the nurse-midwives saw in their training. In a
hospital birth the mother is moved to a delivery table at or near the end of cervical dilation. She is
usually strapped into leg stirrups and heavily draped. The physician is scrubbed and gowned. The
anesthetist is at the ready. The pediatric staff is in the room. It is difficult to imagine that situation continuing for three, four, or more hours. The position of the mother alone makes that impossible. In the medical model, second stage begins with complete cervical dilation. Cervical dilation is an "objective" measure, determined by the birth attendant. By defining the end of the first
stage, the birth attendant controls the time of formal entry into second stage. One of the ways
nurse-midwives quickly learn to "buy time" for their clients is in measuring cervical dilation:
268
ROTHMAN
I try to hold off on checking if she doesn't have the urge to push, but if she has the urge to push, then I
have to go in and check (Personal interview).
My second stage measurement is when they show signs of being in second stage. That'd be the pushing or
the rectum bulging or stuff like t h a t . . . . I usually have short second stages [laughter]. Y'know, if you let
nature do it, there's not a hassle (Personal interview).
I would not, and this is really a fine point, encourage a mother to start pushing just because she felt fully
dilated to me. I think I tend to wait till the mother gets a natural urge to push . . . . the baby's been in there
for nine months (Personal interview).
It may be that buying time is the first concern. In looking for ways to avoid starting the clock,
nurse-midwives first realize that they can simply not examine the mother. They then have the experience of "not looking" for an hour, and seeing the mother stir herself out of a rest and begin to
have a strong urge to push. The first few times that hour provokes anxiety in the nurse-midwives.
Most of the nurse-midwives told of their nervousness in breaking timetable norms. The experience of breaking timetable norms and having a successful outcome challenges the medical
model; it is a radicalizing experience. This opportunity for feedback does not often exist in the
hospital setting, where medicine's stringent control minimizes anomalies. A woman who has an
"arrested" second stage will usually not be permitted to sleep, and therefore the diagnosis remains
unchallenged. Forceps and/or hormonal stimulants are introduced. The resulting birth injuries
are seen as inevitable, as if without the forceps the baby would never have gotten out alive.
(4) EXPULSION OF THE PLACENTA
The Hospital Approach
Third stage is the period between the delivery of the baby and the expulsion of the placenta. In
hospitals, third stage takes five minutes or less (Hellman and Pritchard, 1971; Mehl, 1977). A
combination of massage and pressure on the uterus and gentle pulling on the cord are used
routinely. Hellman and Pritchard (1971:417) instruct that if the placenta has not separated within
about five minutes after birth it should be removed manually. In Mehl's (1977) data, the average
length of the third stage for home births was 20 minutes.
The Home-Birth
Approach
For the nurse-midwives, the third stage timetable was occasionally a source of problems.
Sometimes the placenta does not slip out, even in the somewhat longer time period that many
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With more home-birth experience, the nurse-midwives reconceptualized the second stage itself.
Rather than starting with full dilatation, the "objective" measure, they measured the second stage
by the subjective measure of the woman's urge to push. Most women begin to feel a definite urge
to push, and begin bearing down, at just about the time of full dilatation. But not all women have
this experience. For some, labor contractions ease after they are fully dilated. These are the
"second-stage arrests" which medicine treats by the use of forceps or Cesarian section. Some
nurse-midwives reconceptualized this from "second-stage arrest" to a naturally occurring rest
period at the end of labor, after becoming fully dilated, but before second stage. In the medical
model, once labor starts it cannot stop and start again and still be "normal." If it stops, that calls
for medical intervention. But a nurse-midwife can reconceptualize "the hour or so between full
dilation and when she starts pushing" as other than second stage. This is more than just buying
time for clients: this is developing an alternative set of definitions, reconceptualizing the birth
process.
Nurse-midwives who did not know each other and who did not work together came to the same
conclusions about the inaccuracy of the medical model:
Mldwives in Transition
269
nurse-midwives have learned to accept. Their usual techniques — the mother putting the baby to
suckle, squatting, walking —may not have shown immediate results:
I don't feel so bad if there's no bleeding. Difficult if it doesn't come, and it's even trickier when there's no
hemmorhage because if there's a hemmorhage then there's a definite action you can take; but when it's retained and it isn't coming it's a real question —is it just a bell-shaped curve and that kind of thing —in the
hospital if it isn't coming right away you just go in and pull it out (Personal interview).
I talked with my grandmother —she's still alive, she's 90, she did plenty of deliveries —and she says that if
the placenta doesn't come out you just let the mother walk around for a day and have her breastfeed and
it'll fall out. And I believe her. Here I would have an hour because I am concerned about what appears on
the chart (Personal interview).
If there was no bleeding, and she was doing fine, I think several hours, you know, or more could elapse, no
problem (Personal interview).
The Hospital Approach
There are both medical and institutional reasons for speeding up the birth. The medical reasons
are: (1) A prolonged third stage is believed to cause excessive bleeding. (2) The second stage is
kept short in order to spare the mother and the baby, because birth is conceptualized as traumatic
for both. (3) The anesthetics which are routinely used create conditions encouraging, if not requiring, the use of forceps. The position of the woman also contributes to the use of forceps
because the baby must be pushed upwards.
There are several institutional reasons for speeding up birth. Rosengren and DeVault (1963)
discussed the importance of timing and tempo in the hospital management of birth. Tempo
relates to the number of deliveries in a given period of time. The tempo of individual births are
matched to the space and staffing limitations of the institution. If there are too many births, the
anesthetist will slow them down. An unusually prolonged delivery will also upset the hospital's
tempo, and there is even competition to- maintain optimal tempo. One resident said, "Our [the
residents'] average length of delivery is about 50 minutes, and the pros' [the private doctors'] is
about 40 minutes" (1963:282). That presumably includes delivery of baby and placenta, and
probably any surgical repair as well. Rosengren and DeVault further note:
This "correct tempo" becomes a matter of status competition, and a measure of professional adeptness.
The use of forceps is also a means by which the tempo is maintained in the delivery room, and they are so
often used that the procedure is regarded as normal (1963:282).
Rosengren and DeVault, with no out-of-hospital births as a basis for comparison, apparently
did not perceive the management of the third stage as serving institutional needs. Once the baby is
quickly and efficiently removed, one certainly does not wait 20 minutes or more for the spontaneous expulsion of the placenta.
Hospitals so routinize the various obstetrical interventions that alternative conceptualizations
are unthinkable. A woman attached to an intravenous or a machine used to monitor the condition of the fetus cannot very well be told to go out for a walk or to a movie if her contractions are
slow and not forceful. A woman strapped to a delivery table cannot take a nap if she does not feel
ready to push. She cannot even get up and move around to find a better position for pushing.
Once the institutional forces begin, the process is constructed in a manner appropriate to the institutional model. Once a laboring woman is hospitalized, she will have a medically constructed
birth.
Therefore, not only the specific rules, but also the overall perspective of the hospital as an institution, operate to proscribe hospital-birth attendants' reconceptualization of birth. Practi-
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WHY THE RUSH? THE FUNCTIONS OF TIMETABLES
270
ROTHMAN
tioners may "lose even the ability to think of alternatives or to take known alternatives seriously
because the routine is so solidly established and embedded in perceived consensus" (Holtzner,
1968:96).
The Home-Birth
Approach
SUMMARY AND CONCLUSIONS
The hospital setting structures the ideology and the practice of hospital-trained nursemidwives. Home birth, by contrast, provides an ultimately radicalizing experience, in that it
challenges the taken-for-granted assumptions of the hospital experience. Timetables provide
structure for the hospital experience: structures — statistical constructions, models, or attempts at
routinization or standardization — are not necessarily bad in and of themselves. Medical
timetables, however, have termed pathological whatever does not conform to statistical norms,
which are themselves based on biased samples and distorted by structural restraints imposed in
the interests of efficiency. Thus, the range of normal variation does not permeate the model.
One final conclusion to be drawn from this research is a reaffirmation that knowledge, including medical knowledge, is socially situated. Medical reality is a socially constructed reality,
and the content of medical knowledge is as legitimate an area of research for medical sociology as
are doctor-patient relations, illness behavior, and the other more generally studied areas.
REFERENCES
Friedman, Emmanuel
1959 "Graphic analysis of labor." Bulletin of the American College of Nurse-Midwifery 4(3):94-105.
Hellman, Louis, and Jack Pritchard (eds.)
1971 Williams Obstetrics. 14th edition. New York: Appleton-Century-Croft.
Holtzner, Bukart
1968 Reality Construction in Society. Cambridge, MA: Schenkmann.
Kuhn, Thomas S.
1970 The Structure of Scientific Revolutions. Chicago: University of Chicago Press.
Mehl, Lewis
1977 "Research on childbirth alternatives: What can it tell us about hospital practices?" Pp. 171-208 in
David Stewart and Lee Stewart (eds.), Twenty-First Century Obstetrics Now. Chapel Hill, N.C.:
National Association of Parents and Professionals for Safe Alternatives in Childbirth.
Miller, Rita Seiden
1977 "The social construction and reconstruction of physiological events: Acquiring the pregnant identi-
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In home births the institutional supports and the motivations for maintaining hospital tempo
are not present; birth attendants do not move from one laboring woman to the next. Births do
not have to be meshed to form an overriding institutional tempo. Functioning without institutional demands or institutional supports, nurse-midwives are presented with situations which are
anomalies in the medical model, such as labors stopping and starting, the second stage not
following immediately after the first, and a woman taking four hours to push out a baby without
any problems —and feeling good about it. Without obstetrical interventions, medically defined
"pathologies" may be seen to right themselves, and so the very conceptualization of pathology
and normality is challenged.
In home or out-of-hospital births, the routine and perceived consensus is taken away. Each of
the nurse-midwives I interviewed stressed the individuality of each out-of-hospital birth, saying
that each birth was so much "a part of each mother and family." They described tightly-knit
extended-kin situations, devoutly religious births, party-like births, intimate and sexual
births —an infinite variety. The variety of social contexts seemed to overshadow the physiological
constants. That is not to say that constraints are absent, but that at home the constraints are very
different than they are within hospitals. At home, the mother as patient must coexist or take second place to the mother as mother, wife, daughter, sister, friend, or lover.
Midwives in Transition
271
ty." Pp. 87-145 in Norman K. Denzin (ed.), Studies in Symbolic Interaction. Greenwich, CT: JAI
Press.
Rindfuss, Ronald R.
1977 "Convenience and the occurrence of births: Induction of labor in the United States and Canada."
Paper presented at the 72nd annual meeting of the American Sociological Association, Chicago,
August.
Rosengren, William R., and Spencer DeVault
1963 "The sociology of time and space in an obstetric hospital." Pp. 284-285 in Eliot Friedson (ed.), The
Hospital in Modern Society. New York: Free Press.
Roth, Julius
1963 Timetables: Structuring the Passage of Time in Hospital Treatment and Other Careers. Indianapolis: Bobbs Merrill.
Rothman, Barbara Katz
1982 In Labor: Women and Power in the Birthplace. New York: Norton.
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