Vol. 32 No. 4 (April 2022) pp. 43-47 BIRTHING A MOVEMENT: MIDWIVES, LAW, AND THE POLITICS OF REPRODUCTIVE CARE, by Renée Ann Cramer. Stanford: Stanford University Press, 2021. pp.288. Cloth $90.00. ISBN: 978-1-503-60983-9. Paper $30.00. ISBN: 978-1-503-61449-9.
Reviewed by Carol Nackenoff. Richter Professor Emerita. Department of Political Science. Swarthmore College. Email: cnacken1@swarthmore.edu.
Midwifing is embodied work, and Cramer’s Birthing a Movement engages in embodied scholarship. This project began in California in 2006 and itself has been a labor of love, with storytelling front and center.
Cramer has been personally engaged in the effort she studies. Locating herself in this story, Cramer recounts her own intellectual journey, birthing her own son, the friendships she forged along the way, and even the dog she acquired in the course of this work. She is self-conscious about her positionality, making her own commitments to feminist scholarship and reproductive justice clear. The book is engaging, provocative, and well-written. The introduction and conclusion are richly theoretical, and the interior chapters contribute to theorizing from experience. Becoming part of the discourse in an academic discipline is part of her story, and Cramer draws parallels between developments in the midwifery movement and changes in methods, substantive areas of research, and shifts toward multidisciplinarity among law and society scholars.
BIRTHING A MOVEMENT aims to join legal mobilization scholarship and social movement studies, demonstrating in this context how law and consciousness are mutually constitutive. Focusing on the everyday life of the law and on the production of legal consciousness, Cramer finds inspiration in the work of MIT Anthropologist Susan Silbey (2005, 2019). Cramer looks at the expression of legal consciousness that develops in the “...daily, lived experiences [of] midwives, mothers, people-who-give-birth, and consumers” (p. 15). She seeks to understand midwives and advocates who view themselves as political and legal actors seeking to end the twentieth century criminalization of lay midwifery spurred by the AMA and state regulators. Cramer tells the stories of people and of organizations involved in efforts to enable and expand safe practices of midwifery without the fear of prosecution and incarceration.
Cramer recognizes that her story is part of a larger narrative involving laws regulating reproduction in the United States. However, this study fits well with other state-level histories of forced sterilization, anti-miscegenation, and marriage regulation in which motherhood has been used to advance state goals. It is also part of a saga about inequality, including long-term racially disparate birth outcomes for laboring mothers and their offspring in hospital settings—not just indignities but in mortality rates—though the medical establishment touts hospital births as far safer than home births.
BIRTHING A MOVEMENT examines a period of rapid change in the legal status of midwifery at the state level, which is still ongoing. During the 1980s, a renaissance of midwifery was underway, in part driven by feminist organizing and publishing around reproductive issues and reproductive care. The movement was also influenced by counter-cultural and back-to-the-land movements, along with efforts to combat sexism and racism in the medical profession. In response to consumer demand, states took a few steps toward being more hospitable to mothers. But resistance from certified nurse midwives and obstetricians to further the expansion was stiff, as the profile of those seeking alternatives to hospital birth experience rose, and prosecutions of lay midwives increased in some states.
In the 2000s, there was an increasing emphasis on attainment of professional status for midwives. Lay midwives wanted to have their skills recognized and many had concluded that legal status would allow them to practice openly and expand their services. Yet, not all were eager to be regulated and governed by the state, or to give up apprentice-based certification for acquisition of more formal training requirements. The turn towards legal recognition was, therefore, also a source of concern and tension in the movement, especially affecting direct-entry midwives who had learned through apprenticeship rather than through formal educational credentialing. Nevertheless, embracing US Midwifery Education, Regulation, and Association (US-MERA) certification requirements proved important in getting some formerly opposed constituencies on board with legalization. This was an attempt to standardize pathways for training those who want the Certified Professional Midwife credential by 2020, insisting upon the educational, as opposed to portfolio accredited route to licensure. Cramer says she has “witnessed no change with as great an impact as the adoption, since 2016, of US-MERA language in state bills” (p. 76). Cramer shows how complex the movement to offer women birth options continues to be.
As Cramer considers several state-level battles to gain legal status for lay midwifery, I was at times reminded of Jane Mansbridge’s account of how Phyllis Schlafly mobilized and trained the antis in the ERA battle, who then generally waged a disciplined, strategic and tactical campaign (Mansbridge,1986). Many of the women featured in BIRTHING A MOVEMENT had been thrown into unexpected activism, interacting with government and politics for the first time in the process of pro-midwifery organizing (p. 102). Some felt that if they had been less innocent and naïve, they might not have started what, in many places, became a decade-long fight (p. 112). They learned that those seeking to prevent legislative change had a far easier time than those seeking the change. They were instructed on how to dress, what not to say, and how to make a grass-roots movement. The women seeking recognition and licensure of midwifery also became quite strategic, including policing their image and sometimes seeking help from lobbyists. Those at the center of this study appear both to need and fear the state; some expressed the wish merely to be left alone and to be free of the fear of prosecution. Many view the law instrumentally. To seek legal recognition also invites the gaze of the state.
The struggles of midwives and their advocates also reveal the limits of law and what legal accomplishments fail to resolve. Activists were encouraged to rely on later rulemaking rather than legislative specificity if they wanted to get bills passed (p. 118); details could be left to the regulatory process. However, activists often found out that just when they thought they had won their battle, the work had just begun. Cramer teaches us about “the often-flawed implementation of potentially transformative regulatory policy” (p. 26).
BIRTHING A MOVEMENT is an investigation that richly employs mixed research methods. The book compares case studies, focusing chiefly on Iowa, South Dakota, and Missouri, all of which were undergoing struggles to make midwifery legal, but Cramer occasionally brings in evidence and interview data from California and other states. A state focus reveals pluralism in experience and legality. Chief methods were “participant-observation, ethnographic fieldwork, formal semi-structured interviews, long and unstructured conversations, and online interaction via email lists, Facebook, and Twitter” (p. 17). There were sixteen in-depth interviews with midwives and advocates. She interviewed Certified Nurse Practitioners and Certified Professional Midwives—frequently at odds with each other—as well as uncredentialed midwives, consumer advocates, and lobbyists; interviews took place both before and after legalization. Data included state-level legislative records, legal briefs, trial records, and newspaper coverage of political activism and of prosecutions of midwives for home births. Cramer attended conventions and gave talks at conferences. For eighteen months, she got involved in a scholarly project that mapped the integration of care in each state onto birth outcomes.
If readers expect quantification and prediction, this is not the study for them. The interpretive approach Cramer takes, she notes, is not good for predicting which states will pass bills. She also helps the reader understand why interpretive data are often not helpful for generalization. Activists did gain from borrowing tactics from each other across state lines. They joined national organizations, attended conferences, used electronic communications, and developed certain strategies in common. Cramer makes some use of Political Scientist John Kingdon’s (1984) notion of policy windows, where agenda-setting moments are presented only when problems, politics, and policies align. Yet, one of Cramer’s important points is that one never knows what will turn the tide in the struggle for legalization in a state—it is often highly individualistic and serendipitous. A wonderful little vignette (pp. 95-96) drove this point home: adopting a word “tocology” that meant or included midwife but was not “midwife” helped supporters finally pass a bill in Missouri, without that language being interrogated by the legislators. The word was suggested by a homeschooled teenager who was tagging along with the Missouri activists.
Storytelling was essential to the project of expanding access to out-of-hospital birth experiences, and it is central to what Cramer does as well. Midwives and activists constructed arguments that offer up a “critical history of obstetrics-gynecology and a critical view of the commonplace assumption that the hospital is the best (that is, the safest, most family friendly, most empowering) locale for birth” (p. 40). They tell stories that recount the history and delegitimation of midwifery care by the medical profession. These meaning-making narratives are not to be analyzed as simply true or false since they are advocacy tools. Cramer notes without elaboration: “I am aware of gaps and lapses in their recounting, because I find these stories about their history to be a key component of their mobilization for and against legal status” (p. 41).
I suggest that there is also a story here about professionalization and controlling access to a field of endeavor (such as the social sciences) that may have parallels to the professionalization of medical practice beginning in the late nineteenth century. Some attention to the drive for professionalization and monopolization of service provisions among doctors and nurses might have yielded insights about the impetus to choose professionalization as a means of acceptance for midwives. I would have liked to hear more about how physicians and medical establishment organizations mobilized in response to the movement, and especially how their arguments and tactics may have shifted as the language, strategies, and bills supported by midwives and their allies changed in the years under investigation.
The movement to offer women birth options is complex. Direct-entry midwives who have learned through apprenticeship rather than through formal educational credentialing have frequently been in tension with nurse midwives. Moving toward credentialism, professionalization, and didactic approaches to certification for providers of care for laboring women had different meaning for different sorts of practitioners. Embracing US Midwifery Education, Regulation, and Association (US-MERA) certification requirements proved important in getting some formerly opposed constituencies on board with legalization. Cramer says she has “witnessed no change with as great an impact as the adoption, since 2016, of US-MERA language in state bills” (p. 76). This is an attempt to standardize pathways for training those who want the Certified Professional Midwife credential by 2020, insisting upon the educational, as opposed to portfolio accredited, route to licensure.
BIRTHING A MOVEMENT is fascinating because it deals with a disparate movement with complex alliances. Midwives and their supporters cut across ideological divisions and political parties. They are pro-life and pro-choice. They include elite white urban liberals and also conservatives, rural people, and libertarians who want their state out of their birthing experiences. They are Amish, Mennonite, black, Native American, Orthodox Jews, born again Christians, and Muslim. Some are self-conscious feminists, and some want to talk about reproductive justice. Some conservatives and libertarians in the movement are anti-statists. There are mothers in the movement who are anti-vaxxers (Cramer characterizes these last as neither left nor right, leaving me curious about how she might write about them in the COVID-19 era.) The inclusion of transgender people causes tension. Talking about abortion is discouraged because it divides women in the movement. Conservative legislators were sometimes more predictable allies than liberals. Even the Trump victory in 2016 seems to have been useful in the South Dakota struggle: “The new president brought with him a wave of anti-government sentiment contained within a group of legislators who wanted to promote radical individualism untethered to government control. They found that midwifery provided that for many families” (p. 119).
Storytelling is advocacy, Cramer argues. Thus, telling the birth story is “a potentially counter-hegemonic practice meant to disseminate particular forms of knowledge about contemporary maternity care” (p. 22). Telling law and society stories, she adds, create spaces for justice. Just how counter-hegemonic their potential, and how much space for justice is created, however, strikes this reader as uncertain—especially because engagement with the state and identity shifts have their costs. It is sometimes hard to know what victory looks like.
There is a rich and painful ambiguity about engagement with the state in Cramer’s account. Fighting on the terrain of liberal legality has costs. Licensing will likely help some midwives. Many of those who train by apprenticeship are worried that legalization, certification, and regulation of their practice will mean the loss of traditional knowledge. The mainstreaming of the midwifery movement has meant growth and heightened visibility, efforts to remake the image of midwives, and increasing self-policing, but licensing and legalization do not simply warrant a victory lap in BIRTHING A MOVEMENT. Legalization and attendant rulemaking can still make home birth very difficult to obtain, and can still be frowned upon by doctors, friends, and neighbors. It can leave lay midwives no better off than they were before—and possibly even worse off.
REFERENCES:
Kingdon, John. 1984. AGENDAS, ALTERNATIVES, AND PUBLIC POLICY. Boston: Little, Brown & Co.
Mansbridge, Jane J. 1986. WHY WE LOST THE ERA. Chicago: University of Chicago Press.
Silbey, Susan S. 2005. AFTER LEGAL CONSCIOUSNESS. Annual Review of Law and Society 1: 323-368.
Silbey, Susan S. 2019. THE EVERYDAY WORK OF STUDYING THE LAW IN EVERYDAY LIFE. Annual Review of Law and Social Science 15: 1-18.
© Copyright 2022 by author, Carol Nackenoff.
