Midwives on the Margins: Stigma Management among Out-of-Hospital Midwives

ABSTRACT

Out-of-hospital midwives’ occupational practices can be interpreted as “dirty work” because of their responsibility to touch women’s genitals and the perceived danger of providing healthcare separate from a hospital. Thus, midwives experience prejudice in their interactions with healthcare providers and the public alike. Using 30 interviews with out-of-hospital midwives, this research explores sources and forms of prejudice and techniques with which participants managed their stigmatized professional identity. Specifically, midwives used strategies of information control, including controlling disclosure and controlling interactions. While previous research documents such techniques, I add theoretical complexity by expanding our knowledge on concealable stigmatized identities.

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Notes

¹ This literature review focuses on the “dirt” of women’s genitals, but midwives also assist with breastfeeding and the care of newborns. Although breasts are a fetishized body part (Palmer 2009), breast milk is viewed as a body excretion that is under limited control and that can serve to transmit diseases, such as HIV or hepatitis (Battersby 2007; Callaghan 2007). Newborn babies have also been theorized as dirty. Callaghan (2007) uses Enzensberger’s (1972) characteristics of dirt to note that newborns are typically born wet, slippery, or greasy from urine, blood, vernix, and/or meconium.

² Because of numerous data limitations (e.g., unreliable data collected from birth certificates and the inability to randomly assign laboring women to a birth site), it is difficult to reach a definitive conclusion about the safety and risks of planned home births as compared to birth-center or hospital births (Hendrix et al. 2009; Northam and Knapp 2006; Vedam 2003). For example, some research concluded that women who plan a birth-center birth have lower rates of intervention (e.g., Pitocin, C-section, forceps) and no increase in poor outcomes (Cheyney et al. 2014; Stapleton, Osborne, and Illuzzi 2013). Snowden et al. (2015) concluded that the risk of perinatal death was higher, although minimal, with planned OOH birth compared with in-hospital birth.

³ A birth center is freestanding facility that provides maternal and infant healthcare.

⁴ Working in home and birth-center settings means the midwife can be self-employed and/or a permanently hired employee.

⁵ By “advocates” I mean professionals who are closely aligned with midwifery. Both of the advocates included within the sample worked in OOH birth support; both advocates worked part-time as doulas, but one had full-time responsibilities serving a midwifery education nonprofit, and the other had full-time responsibilities as a staff member at a birth center. Collecting data from “advocates” is a common practice among qualitative scholars. For example, Fothergill and Peek’s (2015) examination of the children affected by Hurricane Katrina includes interviews with advocates who were separate from children, but worked actively with or on behalf of this population. The child–advocate relationship in their study parallels this project’s midwife–advocate relationship.

⁶ The gender and racial diversity of my sample of midwives parallels the diversity of the broader profession’s demographics (see Sipe, Fullerton, and Schuiling 2009).

⁷ Because formal complaints are embarrassing, I expect that the data underreports such experiences. Although I asked midwives how they were perceived by the general and health professional community, I never asked explicitly about complaints. Only Imogene specifically referenced such a complaint, but the majority of home-birth providers did mention that they feared formal complaints.

⁸ Some OOH birth midwives rarely came into contact with the same hospital personnel and thus remained undetected. The OOH birth midwives in this sample referenced a client transfer rate of 10–15%; a midwife with a small number of clients (i.e., 10 per year) might not frequent a single hospital or interact with the same staff repeatedly.

⁹ The International Confederation of Midwives (2014) affirms that abortion-related services are within the scope of midwifery care, but the legal scope of care and types of abortions performed by U.S. midwives changes across states and credentials.

¹⁰ There are two main reasons for an OOH healthcare provider to transfer care from the setting of a home or birth center to a hospital setting with hospital-based healthcare providers. Most transfers are for non-emergencies, usually when a laboring woman is in need of interventions for exhaustion or pain management, such as Pitocin or an epidural (Cheyney et al. 2014; Stapleton, Osborne, and Illuzzi 2013). A second, and less common, cause for transfer might be a medical emergency, like fetal distress or postpartum hemorrhage (Cheyney et al. 2014; Stapleton, Osborne, and Illuzzi 2013). Transfers can occur while the woman is in labor, delivering, or in the immediate postpartum phase; however, most occur during the intrapartum phase (Cheyney et al. 2014). Many participants expressed concern that transfers are often the first or only time that OOH midwives interact with hospital staff, and they feared that these extreme experiences likely reinforced hospital staff members’ fears that OOH midwives are ill-prepared and that their practices risk client safety, thereby strengthening midwives’ low occupational status.

¹¹ Participants used the terms “transport” and “transfer” interchangeable.

¹² Midwives never mentioned a uniform, and I only had the opportunity to interact with a small group of midwives while they were “on the clock.” But I have watched as birth centers worked to brand their company; as a branding strategy, the midwives at this birth center wore t-shirts with the company’s logo during their work hours. Such a t-shirt is easily covered with a sweatshirt, although none suggested they would do this.

¹³ Home-birth midwives and birth-center staff can only take on low-risk clients; low risk is defined differently from state to state. For example, home-birth and birth-center midwives are often barred from serving clients outside of a specific age range and/or those diagnosed with gestational diabetes.

Additional information

Notes on contributors

Adelle Dora Monteblanco

ADELLE DORA MONTEBLANCO is a Postdoctoral Research and Teaching Fellow at the University of Texas at El Paso. Dr. Monteblanco’s scholarship has focused on health and environmental sociology, particularly through the lens of midwives.