Daughter of time: the postmodern midwife (Part 1)

Hija del tiempo: la partera pos-moderna (Parte un)

Filha do tempo: a parteira pós-moderna (Parte 1)

ESTUDO TEÓRICO

Daughter of time: the postmodern midwife (Part 1)

Filha do tempo: a parteira pós-moderna (Parte 1)

Hija del tiempo: la partera pos-moderna (Parte un)

Robbie Davis-Floyd^I

^I PhD. Senior Research Fellow in the Department of Anthropology, Univer-sity of Texas, Austin, USA. [e-mail]

^{Correspondência}

ABSTRACT

This article presents the notion of the postmodern midwife, defining her as one who takes a relativistic stance toward bio-medicine and other knowledge systems, alternative and indigenous, moving fluidly between them to serve the women she attends. She is locally and globally aware, culturally competent, and politically engaged, working with the resources at hand to preserve midwifery in the interests of women. Her informed relativism is most accessible to professional midwives but is also beginning to characterize some savvy traditional midwives in various countries. Thus the concept of the postmodern midwife can serve as a bridge across the ethnic, racial, and status gaps that divide the professional from the traditional midwife, and as an analytical focal point for understanding how the members of each group negotiate their identities and their roles in a changing world.

Key words: Nurse midwives. Midwives, practical. Professional role.

RESUMO

Este artigo busca conceituar a parteira pós-moderna, definindo-a como aquela que tem uma postura realista em relação à bio-medicina e a outros sistemas de conhecimento, movendo-se fluidicamente entre eles para ajudar as mulheres que assiste. É consciente, culturalmente competente e politicamente engajada. Trabalha com recursos do seu conhecimento específico, aliados aos interesses da mulher. Seu relativismo informado é mais acessível para as parteiras profissionais, mas o que se observa, ao redor do mundo, é que esta atitude está atingindo as parteiras tradicionais, em diversos países. Assim, o conceito de parteira pós-moderna representa uma ponte para as brechas étnicas, raciais e de status, que separam as parteiras profissionais das tradicionais, e um ponto focal e analítico para a compreensão da forma de negociação de identidades e papéis de cada um dos membros no grupo, no mundo em transformação.

Descritores: Enfermeiras obstétricas. Parteira leiga. Papel profissional.

RESUMEN

Este artículo busca conceptuar la partera pos-moderna, definiéndola como aquella que tiene una postura en relación a la biomedicina y a otros sistemas de conocimiento, moviéndose fluidificado entre ellos para ayudar a las mujeres que asiste. Es consciente, culturalmente competente y políticamente enganchada. Trabaja con recursos de su conocimiento específico, aliados a los intereses de la mujer. Su relativismo informado es más accesible para las parteras profesionales, pero lo que se observa, alrededor del mundo, es que esta actitud está atingiendo las parteras tradicionales, en diversos países. Así, el concepto de partera pos-moderna representa una puente para las brechas étnicas, raciales y de status, que separan las parteras profesionales de las tradicionales, y un punto focal y analítico para la comprensión de la forma de negociación de identidades y papeles de cada uno de los miembros en el grupo, en el mundo en transformación.

Descriptores: Enfermeras obstétrices. Parteras tradicionales. Rol profesional.

For past millennia, midwives have served women in childbirth. In premodern times, midwives were usually the only birth attendants. With the Industrial Revolution and the arrival of modernism, male physicians either replaced midwives or superceded them in the modernist medical hierarchy, leaving them with plenty of women to attend but with relatively little autonomy. As the new millennium dawns on a growing worldwide biomedical hegemony over birth, midwives, the daughters of time and tradition, find themselves negotiating their identities, searching for appropriate roles, and seeking new rationales for their continued existence.

Modernity is a narrow canal through which the vast majority of contemporary cultures have passed or are passing. It arrived in various parts of the world at different times; first in the industrializing countries of the North, and more slowly in the colonized and exploited countries of the South. So anthropologists consider modernism not to be a particular point in time but rather a univariate (single-pointed, single-minded, unvarying) orientation toward progress, defined in terms of Westernized forms of education, technologization, infrastructural development (highway, rail, water, and air systems etc.), factory production, economic growth, and the development of the global marketplace. This univariate orientation identifies a single point in a given area toward which development should be progressing: in economics, that single point is capitalism; in health care, it is Western biomedicine. Thus in modernizing societies traditional systems of healing, including midwifery, have become increasingly regarded by members of the growing middle and upper classes as premodern vestiges of a more backward time that must necessarily vanish as modernization/biomedicalization progresses.

MODERNITY'S PROGRESSION TOWARD UNIVARIATE POINTS

• In economics, capitalism

• In national development, the building of infrastructures: water, sewage, electricity, telephones, and transportation systems (water-, air-, rail-, and highways).

• In production, the elimination of the small in favor of the large: industrial agriculture and the factory production of goods

• In health care, biomedicine

SOME OF THE COSTS OF MODERNITY

• The colonization of most of the world by a few Western capitalist and industrial countries

• The ongoing elimination of subsistence agriculture and indigenous cultures

• Massive worldwide pollution of the environment and its concomitant health costs to people and the planet

• The supervaluation of the modern and the devaluation of indigenous cultures and knowledge systems

Yet around the world, the univariate orientation of modernization is increasingly contested in the new post-modern era. Postmodern thinking widens the narrow canal of modernization beyond uncritical acceptance of modernization as good, noting the enormous environmental, social, and cultural damage modernization entails, and seeking to generate more polymorphous societies in which multiple knowledge and belief systems can coexist and complement each other. In postmodern societies and groups, conservation and preservation of the environment and of indigenous or traditional languages, cosmologies, health care, and economic systems take on particular urgency and importance, and such endeavors are sometimes considered to be more important than expanding the reach of industrialization, capitalism, and biomedicine.

These postmodern efforts at conservation are fueled both by global organizations and by myriad local grass-roots social movements. In the cultural arena of childbirth, for example, as some governments and development planners urge the elimination of traditional birthways, other international workers seek to conserve these. Thus many indigenous women who have tried out the government-funded hospitals and clinics subsequently reject them because of the impersonal care they receive there, and deliberately return to traditional midwives for out-of-hospital birth. In some regions, midwives trained in a modernist ideology of biomedical superiority act, in fact, superior, while other professional and traditional midwives are displaying a variety of creative and highly relativistic responses to biomedical encroachment and constraints.

My familiarity with midwives and midwifery systems in many countries leads me to see the midwife/traditional birth attendant (TBA) distinction not as a dichotomy but as a continuum, so I prefer the labels professional midwives (to indicate those who have had professional, accredited training) and traditional midwives, to indicate those who practice within the traditions of their communities, without professional degrees or culturally valued certifications.

INFORMED RELATIVISM: THE CHARACTERISTICS OF THE POSTMODERN MIDWIFE

Around the world we are witnessing the emergence of a phenomenon that I call postmodern midwifery - a term aimed at capturing those aspects of contemporary midwifery practice that fall outside easy distinctions between traditional birthways, professional midwifery, and modern bio-medicine. With this term, I am trying to highlight the qualities that emerge from the practice, the discourse, and the political engagement of a certain kind of contemporary midwife-one who often constructs a radical critique of unexamined conventions and univariate assumptions. Postmodern midwives as I define them are relativistic, articulate, organized, political, and highly conscious of both their cultural uniqueness and their global importance. By postmodern midwife I specifically do not mean midwives who accept without criticism either their own folk system or that of biomedicine, but rather midwives who fully understand these in a relative way, as different ways of knowing about birth, discrepant systems that often conflict but can be complementary.

Postmodern midwives are scientifically informed: they know the limitations and strengths of the biomedical system and of their own, and they can move fluidly between them. These midwives play with the paradigms, working to ensure that the uniquely woman-centered dimensions of midwifery are not subsumed by biomedicine. They are shape-shifters, knowing how to subvert the medical system while appearing to comply with it, bridge-builders, making alliances with biomedicine where possible, and networkers attending conferences and meetings and making connections with other midwives in other parts of the world. Such networking increases their ability to translate between systems, and to gain consciousness of midwifery as a global movement. These transnational interlinkages among midwives work to create a global culture of midwifery as well as to preserve, carry forward, and teach to others the best of one's own cultural traditions around birth.

Lacking or actively rejecting a sense of structural inferiority to biomedicine, the post-modern midwife is free to observe the benefits of traditional midwifery practices common in many cultures such as massage, external version, eating and drinking during labor, birthing in upright positions, birthing at home, and uninterrupted contact between mother and baby. A comparison with what takes place in the hospital and what can be learnt from scientific evidence results in the conclusion that there is value in the midwifery approach that biomedicine does not recognize. The post-modern midwife then develops a sense of mission around preserving that approach in the face of biomedical encroachment, and an understanding that for a midwife, the professional is always political: midwives and their colleagues must have an organized political voice if they are to survive. So postmodern midwives work to build organizations in their communities, join national and international midwifery organizations, and work within them for policies and legislation that support midwives and the mothers they attend. It would be easy to conclude that only professional midwives, with their greater access to high technologies and international networking systems can achieve the informed relativism I am highlighting as the primary characteristic of the postmodern midwife. But traditional midwives in many countries are undergoing radical changes, to which an emergent postmodern consciousness sometimes characterizes their responses.

CHARACTERISTICS OF THE POSTMODERN MIDWIFE

• An informed relativism that encompasses science, tradi-tional midwifery knowledge, professional midwifery knowledge, and complementary or alternative practice systems

• Local, global, and historical awareness

• Cultural competence

• A sense of mission around preserving midwifery in the interests of women

• A sense of autonomy as practitioners

• Dedication to the midwifery model of care in its humanistic and transnational sense and to midwifery and women's health care as social movements

• Political engagement, including work with governmental authorities and participation in local, regional, national, and international organizations

THE TRADITIONAL MIDWIFE AS POSTMODERN

Previous studies of traditional midwives have shown them to be unselfconscious participants in their local folk systems and/or in structurally subordinate relationship to modern biomedical practitioners or as phased out altogether by the advent of biomedicine. To me, these descriptions seemed inadequate to capture the self-awareness, relativistic perspective, political savviness, and drive toward autonomy I was encountering in my research on American and Mexican midwives^(1-6). I formulated the notion of the postmodern midwife not only to encompass the informed relativism of various internationally oriented professional midwives, but also of increasing numbers of traditional midwives who are trying to re-negotiate their identities and to articulate new ways of practice and new rationales for their continued existence.

Anthropological research on birthing has shown the heterogeneity in the roles of folk specialists who provide birth assistance worldwide. Some are respected healers who provide both maternity and general health care. Others are low status birth attendants who simply perform the polluting tasks associated with birth, while decisions about how to manage labor rest with the family, as in some parts of South Asia. Some perpetuate physiologically harmful traditions like using dung to seal the umbilical stump or wiping the baby with dirty rags; others (or sometimes those same practitioners) perpetuate physiologically beneficial traditions like breastfeeding and birth in upright positions. Some folk or traditional midwives operate from within relatively closed knowledge systems⁽⁷⁾, while others expand their traditio nal systems to encompass a wide range of concepts and practices from other systems. Where some traditional midwives are compassionate and woman-centered; others crossly order women to comply with their commands. For example, researcher⁽⁸⁾ reported how midwives in the Yucatan sometimes stuffed a birthing woman's braid down her throat to make her gag so her pushing would be more effective, and another author⁽⁹⁾ documented the occasional slap a traditional Ugandan midwife may administer to snap a woman out of self-pity during labor. Traditional midwives do not all share in the midwifery model of woman-centered care and the only real unity that can be found among them is their international classification as traditional birth attendants.

By contrast, the traditional midwives I am identifying as postmodern hold and adhere to the midwifery model of care - indeed, I developed the concept of the postmodern midwife as a way of bridging the definitional gap between TBA and professional midwives who share the same essential characteristics, including humanism, a sense of autonomy, a high level of political engagement, and most especially, informed relativism.

POSTMODERN TRADITIONAL MIDWIVES IN MEXICO: NEGOTIATING KNOWLEDGE SYSTEMS

For example, imagine my surprise when I rounded a corner in a birth center owned by Doña Facunda, a partera tradicional (traditional midwife)in Morelos, Mexico, and encountered a flat marble delivery table, complete with metal stirrups. Laughing as I expressed my amazement, Doña Facunda, with a mischievous glint in her eye, pointed out that the fathers, mothers-in-law, and grandmothers who accompany her clients believe in the efficacy of the hospital and its procedures, including giving birth in the lithotomy position. If they want me to act like a little doctor (mini-médico), she said, holding up her blue hat and booties,

I can do that! But when the mother-in-law says, Shouldn't she get up on the table now? I say, No, it's not time yet, and I encourage her to keep walking around or to rest comfortably in my big double bed. Most of my mothers give birth sitting, kneeling, or squatting. Very few want the table. It's here if they do, but its main use is just for show!

She added,

If having an IV makes them feel safer, for an extra 100 pesos I'm happy to insert it . . . But I encourage them to wait before they get up on the table, until they are really pushing well, and then they find they like being upright.

In what I have since come to think of as the perfect postmodern midwifery moment, Doña Facunda added,So this is what we mostly use the IV pole for! as she grabbed the metal handles from which the IV bag would be suspended and used them to support herself in the birth position known as a hanging squat.

Irony compounds irony in the postmodern midwifery world! Doña Facunda was fully aware that the hanging squat (which involves the woman squatting in front of a support person, who sustains her under the arms and sometimes by the knees) is not per se a traditional birthing position, most of which involve the woman squatting or kneeling alone or on a birthing stool or chair, often pulling on a pole or rope. Rather, the hanging squat had been named and displayed around the world by French physician and author Michel Odent. Facunda had attended one of his lectures a few years before. Her self-conscious transformation of the biomedical IV pole into a support mechanism for the hanging squat perfectly exemplifies what I mean by postmodern midwifery: a traditional midwife appropriates a biomedical artifact (1) to implicitly critique its normative use in modernist medicine; (2) to reinforce her traditional birthing system (which has long utilized upright positions for birth); and (3) to expand it to include a birthing technique currently in vogue in the international birth activist and midwifery communities.

Such examples (I could cite many!) confound the over-determined association of midwife with tradition. They confront us with novel combinations, ironies, and unexpected juxtapositions. They highlight the fact that exchanges of knowledge and technology across locales increasingly muddle our attempts to find authentic cultural practices and value systems. Most of all, they underscore the inadequacy of the modernist tale of linear progress that has for so long been used to narrate the relationship of midwifery to the biomedical management of birth.

TBA training courses and other forms of exposure to biomedicine have resulted in fundamental alterations in practice for many traditional midwives in Mexico. Across the country, it is now common for traditional midwives to give pitocin injections to hurry labor, insert IVs for hydration, and wear blue biomedical garb when attending births-practices that they themselves think of as modern. Combining such practices with the traditional sobada (massage), herbal treatments, and religious beliefs, Mexico's contemporary traditional midwives practice at the inter-section of various cultural domains. These trends have particularly influenced midwives who practice in urban areas, as my extensive interviews with Doña Facunda and her colleagues who live and practice in the city of Cuernavaca (in central Mexico) reveal. Most of these traditional midwives are in their forties or fifties, attended only elementary school, and became fully literate in their thirties. For at least a decade, they have been incorporated into the state health care system in Morelos through bi-monthly seminars on family planning and other topics. All of them went through a period of using allopathic interventions like oxytocin injections and experiencing complications as a result, so they have returned to the use of traditional herbs-in other words, they went through a process of modernization and have come out, as they themselves say, on the other side. Marina Rodriguez, who is both a nurse and a traditional midwife, explained the difference between the biomedical and traditional systems as follows:

Allopathy is powerful, but it does too much. Its interventions are too extreme. Our traditional herbs take longer to work, but their effects are much more subtle and more precise.

Today traditional Mexican midwives like Marina routinely send women out for ultrasounds when they diagnose a breech or transverse presentation and offer their clients an eclectic potpourri of traditional and biomedical techniques. Into this mix they add multiple New Age or alternative modalities that they have studied (reflexology, homeopathy, iridology, Reiki, etc.).They all have birth centers attached to their houses, complete with autoclaves, sterile equipment, and two double beds, one for the birthing woman plus an extra one for family members. Some of them own Dopplers, and use them with delight to exhibit their technological expertise and to let the pregnant woman and family members hear the baby's heartbeat. Their walls are covered with laminated diagrams of fetal positions and the female reproductive cycle, and with certificates from the dozens of continuing education courses they have taken at local universities on topics from anatomy to aromatherapy (even though many of them never attended high school). Their shelves are filled with homeopathic remedies and herbal oils and salves they have learned to make in such courses. A few of them have computers and email addresses. Dancing fluidly at the interface of biomedicine, holistic alternatives, and traditional birthways, these midwives are strategically negotiating the boundaries between knowledge systems and creatively producing a hybrid and increasingly well-articulated knowledge system of their own. These postmodern midwives of Cuernavaca elide and confound the usual distinctions between professional and traditional midwives: trained through traditional apprenticeships, they are presently engaged in a visible process of self-professionalization. Their efforts constitute a very conscious attempt to preserve home birth in the face of biomedical hegemony: practicing as they do in a city whose hospitals have cesarean rates of over 70%, they are very aware that they often constitute the only alternative to a cesarean.

Many traditional midwives still practice autonomously, except when they need to transport a client to the hospital⁽⁵⁾. Thus their major desire is not for autonomy, which they have, but for some form of governmental or professional recognition above and beyond the status of TBA. Aware that professional midwives have such recognition, and of the many benefits it confers, postmodern traditional midwives like Doña Facunda, Doña Irene, and Doña Nieves long for national certification and state licensure as the professionals they feel themselves to be, in spite of their lack of governmentally accepted training. But their status as TBA has kept them in limbo, blocking them from recognition as professionals.

I have personally met and spoken with traditional midwives from Guatemala and Brazil who also exemplify my profile of the postmodern midwife, so I know that the postmodernity of these Mexican midwives is not unique in the world. I suspect that their efforts to renegotiate their identities and restructure their practice to meet the demands of a changing world are mirrored by other postmodern traditional midwives in many countries, and therefore I suggest that much more ethnographic research on such postmodern traditional midwives should be conducted. In the second half of this article, which will appear in the following issue, I will discuss the professional midwife as postmodern, giving examples of postmodern professional midwives in Japan, the Netherlands, and Mexico.

ENDNOTE

1. This article is a thinkpiece that stems from other publications that I have either authored or co-authored, in which I have only partially elaborated my notion of the postmodern midwife, which I develop fully here for the first time^(3-5,10-11). The title for this article, Daughters of Time, originated in a song written in 1977 by American midwife Mary Offerman. The image expresses a hope that women today will be empowered to recuperate knowledges and skills maintained by women in the past, revitalize them for the present, and preserve them for the future. The phrase was further cemented in American midwifery lore in the early 1980s through a film about nurse-midwives called Daughters of Time⁽¹²⁾ and through⁽¹³⁾ article by that title.

Recebido: 14/05/2006

Aprovado: 25/10/2006

• 1. Davis-Floyd R. The ups, downs, and interlinkages of nurse- and direct-entry midwifery: status, practice, and education. In: Tritten, J, Southern J, editors. Paths to becoming a midwife: getting an education: 4^th ed. Eugene, OR: Midwifery Today; 1998. p. 67-118.
• 2. Davis-Floyd R. Types of midwifery training: an anthropological overview. In: Tritten J, Southern J, editors. Paths to becoming a midwife: getting an education. 4^th ed. Eugene, OR: Midwifery Today; 1998. p. 119-33.
• 3. Davis-Floyd R. Mutual accommodation or biomedical hege-mony? Antropological perspectives on global issues in midwifery. Midwifery Today Int Midwife. 2000;(53):12-6, 68-9.
• 4. Davis-Floyd R. La partera profesional: articulating identity and cultural space for a new kind of midwife in Mexico. Med Anthropol. 2001;20(2-3):185-244.
• 5. Davis-Floyd RE. Home birth emergencies in the U.S. and Mexico: the trouble with transport. Soc Scienc Med. 2003;56(9): 1911-31.
• 6. Davis-Floyd R. Qualified commodification: consuming midwi-fery care. In: Taylor J, Wozniack D, Layne L, editors. Consuming motherhood. New Brunswick: Rutgers University Press; 2004.
• 7. Davis-Floyd R. Ways of knowing: open and closed systems. Midwifery Today Int Midwife. 2004;(69):9-13.
• 8. Jordan B. Birth in four cultures: a cross-cultural investigation of childbirth in Yucatan, Holland, Sweden and the United States. 4^th ed. Prospect Heights: Waveland; 1993.
• 9. Graham S. Traditional birth attendants in Karimoja, Uganda [PhD thesis]. London: South Bank University; 1999.
• 10. Davis-Floyd R, Davis E. Intuition as authoritative knowledge in midwifery and home birth. Davis-Floyd RE, Sargent C, editors. In: Childbirth and authoritative knowledge: cross-cultural perspectives. Berkeley: University of California Press; 1997. p. 315-49.
• 11. Davis-Floyd R, Cosminsky S, Pigg SL Daughters of time: the shifting identities of contemporary midwives. Med Anthropol. 2001;20(2/3):105-39.
• 12. Durrin G. Daughters of time: the classic film on nurse-midwives today. Washington, DC: Durrin; 1982.
• 13. Rothman BK. Daughters of time. In: Tritten J, Southern J. Getting an education: paths to becoming a midwife. Eugene, OR: Midwifery Today; 1998.

Correspondência:

Robbie Davis-Floyd

808 Crystal Creek Drive - Austin

USA - Texas - 78746

Publication Dates

• Publication in this collection
  20 Feb 2008
• Date of issue
  Dec 2007

History

• Accepted
  25 Oct 2006
• Received
  14 May 2006