Do midwives put their needs ahead of their patients?


Yesterday I asked whether promoting unmedicated vaginal birth is unethical. Today I’d like to ask a corollary: do midwives put their own needs ahead of the needs of their patients. I’m not the first to wonder whether this has compromised the care that midwives provide to women.

Canadian midwife Mary Sharpe and colleagues have written about the situation in Ontario in Essentialism as a Contributing Factor in Ideological Resonance and Dissonance Between Women and Their Midwives in Ontario, Canada. Sharpe starts with a definition of essentialism:

Essentialism is understood as the tendency to view entities according to a set of distinct and limiting characteristics, or essences. Furthermore, an essentialist approach regards these characteristics or essences as inherently true or correct…

Sharpe details how essentialism is expressed in the foundational documents of Ontario midwives:

While the values embedded within the document, when viewed pragmatically, simply set ideals for practice, they also tend to support the culture of essentialism within the midwifery community by making certain assumptions about the meaning of midwifery care, the women who seek midwifery care and the nature of the woman-midwife relationship…

But those beliefs and assumptions are not shared by a large proportion of women. Instead of acknowledging that essentialist beliefs are not held by all women, the Ontario midwives react with disdain and an unwillingess to care for women who have different beliefs.

While some midwives interviewed stated that they were delighted to be able to provide care for the more diverse group of women seeking midwifery care … they nevertheless noted that they remained wary of those who do not overtly behave in ways that correspond to Ontario midwifery’s stated values and philosophies… Some Ontario midwives indicated that they felt there are “ideal” or “peak” midwifery clients and that certain women are therefore particularly “deserving” of midwifery…

As midwife Vicki Van Wagner explains:

There is a real tension in the midwifery community between narrow essentialist views of women, midwives and birth, connected with the lure of the “natural” and other concepts such as choice and diversity… In a countercultural movement such as midwifery, the need for strength to combat outer forces can create narrow views, dogmatism and a fear of diversity…

Sociologist Helen Lenskyj notes:

It does not serve women’s interests well for midwifery supporters to essentialize women as either mothers or midwives… Where does this leave the non-conforming mother who does not view the midwife as her best friend … One [also] needs to consider the messages that [such] rhetoric convey[s] to a woman who has no … regrets about her conventional medicalized birth experience. Is she less female/ feminine/ feminist because she does not … reflect on [her] birth experiences with feelings of anger, regret, mourning and loss?


Ontario’s model of midwifery care reflects the essentialist tendencies of the feminist movements of the 1970s and 1980s that led to the legislation of midwifery in Ontario… The essentialist tendencies revealed by midwives and women in Sharpe’s study tend to pose dilemmas for midwives in the manner in which care is provided, the manner in which women are selected for care and the ways in which the philosophy of midwifery care is upheld.

Helen Lenskyj offers midwives advice that they should take to heart:

It is not productive for midwifery’s advocates to cling to exclusory or essentialist notions of woman and midwife. Rather, it is important to respect the feminist principle of choice … and to allow for diversity and difference among women, both midwives and clients.

What I find most intriguing about the views expressed in this paper is that they highlight the fact that midwifery has become obsessed with the feelings of midwives to the detriment of patients. It suits certain midwives and virtually all midwifery theorists to claim that “the natural” represents the pure essence of what women should want and how women should behave.

The profession of midwifery has been led astray from the values that have preserved midwifery across time, place and cultures. Those values were to minimize the risk of death to baby and mother by observing the ways that treatments and preventive measures could improve outcome. In contrast, contemporary midwifery often seems devoted to a stylized piece of performance art where the process is viewed as more important than the outcome. It is ironic that a profession that proposed in the mid-twentieth century to offer women more choices has devolved into a profession that insists that only one choice is acceptable.

A version of this piece first appeared in December 2010.