Modern Midwifery: A Conversation with a Midwife-in-Training

Daniel Hautzinger
Barbara, Trixie, and Patsy of 'Call the Midwife.' Photo: Neal Street Productions 2016
Photo: Neal Street Productions 2016

Recap various seasons of Call the Midwife.

Even though Call the Midwife is set only 50 or so years ago, the world it portrays seems very distant from the America of today. Socialized medicine, regular house visits by medical professionals intimately involved in a community, only the beginnings of the birth control pill, and perhaps most significantly, midwives themselves. Many viewers might assume midwives are a thing of the past in this country, only remaining in small numbers to lead home births for the type of natural-minded women who obsess over homeopathic medicine and organic food.

Yet midwifery is alive and well today in America. While there are midwives who primarily specialize in those out-of-hospital births, another type often works in hospitals, clinics, or medical practices. This latter kind, called a Certified Nurse-Midwife (CNM), receives the same basic training as a nurse practitioner and is licensed to practice in most medical institutions.

“CNMs are the most broadly recognized type of midwife, especially by the medical community, and they have the least legal or state-by-state restrictions,” explains Ronni Getz, RN, who is studying to be a CNM at the Yale School of Nursing. “As a nurse-midwife, I’ll cover ‘women’s health through the lifespan,’ meaning both obstetric and gynecologic care, including family planning and often some primary care as well.

Patsy attends a home birth in Call the Midwife. Photo: Red Productions Ltd 2015Midwives today still lead home births, but they also work in most medical institutions, and some provide gynecologic care in addition to obstetrics. Photo: Red Productions Ltd 2015 “That’s different from a Certified Professional Midwife, or CPM, who focuses solely on obstetrics: from prenatal visits during the pregnancy, through to labor, birth, and postpartum. They don’t have prescriptive powers, so the work that they do is completely un-medicated. They care for people who want to have a physiologic, un-medicalized birth either at home or in a birth center. It’s a valuable option that many would agree should be accessible to women with low-risk, uncomplicated pregnancies.”

While a CNM is licensed to practice in all 50 states, 26 states regulate the practice of CPMs. “The laws are meant to provide regulation in the interest of keeping women and babies safe, though some people interpret them as being overly restrictive and biased towards medicalized birth,” Getz says.

That debate over medicalized birth is a major part of the history of midwifery. As medicine began to be professionalized in the 18th and through the 19th and early 20th centuries, lay midwives were depicted as incompetent and dangerous. The specialty of obstetrics arose, bringing with it a new model of care that was fundamentally different from midwifery’s focus on birth as a normal and healthy function of the body.

“There began to be an outlook of needing to manage and intervene in the process of birth, in an attempt to make birth safer and reduce maternal and infant mortality,” Getz explains. “This went alongside notions of the body as a problem, specifically the female reproductive system as being inherently pathological, and the need for medicine to intervene and fix things. Out of this comes the idea that the female body essentially can’t deliver a baby effectively on its own.”

Trixie in 'Call the Midwife.' Photo: Neal Street Productions 2015As medicine began to be professionalized, models of care shifted and obstetricians began to displace midwives. Photo: Neal Street Productions 2015 This led to a very rapid shift from home births to hospital births and from midwives to obstetricians. Anesthesia and interventions such as forceps or caesarean sections became increasingly commonplace, tools that CNMs today will use in the case of potential health complications or a woman’s own informed choice.

“I think it’s important to note that in the early 20th century, hospitals were accessible primarily to white, middle- to upper-class women, especially in urban areas, so these changes toward medicalization mostly applied to them,” Getz points out. “Poor women and women of color, especially in the South, continued to be cared for by midwives in their homes. The history of black midwives in communities of color is often forgotten when we talk about the medicalization of birth in America.”

We often see interventions in the case of health problems in Call the Midwife, as with Penny Reed’s caesarean section in the most recent episode. (The midwives of the show are not CNMs; it is obviously set in a different time period, and the UK’s certification is not the same as in the US.) “The medical conditions that come up in Call the Midwife are very accurate, as far as I can tell,” says Getz.

Sister Julienne during a home visit in 'Call the Midwife.' Photo: Neal Street Productions 2015The midwives of 'Call the Midwife' provide not just medical care, but also help women with the other difficulties in their lives. Photo: Neal Street Productions 2015 But the midwives of Nonnatus House go above and beyond simple medical care. “I love that their work is not just doing prenatal care, they’re really doing social medicine in the ways that they help find resources or help people get out of difficult situations. They assess people’s home life and relationships and financial stability. We really should be doing more of that, but when you have a fifteen minute appointment with somebody and there are seventeen other things to do, that falls by the wayside. The midwifery model of care puts an emphasis on caring for the patient holistically, but still, there is never enough time to address everything.”

Regardless of the differences in era, the show is still relevant today. “All of the storylines about what’s going on in each woman’s life as she’s pregnant and delivering, the various medical problems that arise: all of that is still stuff that I’m seeing every day in the clinics and on the labor floor. Pregnancy has a way of shining a spotlight on other struggles that women have in their lives, whether it has to do with finances or domestic violence. It’s a period piece, but so much of what they address is timeless.”