Cooperation Or Competition? The Choice is Ours


  • Linda Baxter C.N.M., M.S.

Why are we behaving as if we were in competition with each other, with physicians and with other types of midwives? A pervasive spirit of competition seems to have developed within the American College of Nurse-Midwives leading us to spend many hours and much energy debating the merits of remaining a part of the nursing profession, joining medicine, or, now, joining lay-midwifery. Endless discussions over a possible change in title from nurse-midwifery to plain “midwifery” will not alter our practice or our place in the current medical establishment. To conquer by dividing has always been a good tactic–has this happened to us?

It's easy to see how this has developed. Nurse-midwifery in this country has historically struggled to find a foothold in the hierarchy of medical/maternity care. Achieving professional recognition and acceptance by the public as well as by the medical establishment has seemed, at times, to be a next to impossible feat. However, we are finally beginning to see the fruits of our pioneers’ work. More doors are open to us, more hospitals are creating midwifery services, and more private physicians are employing CNMs.

We now see in some parts of the country, a proliferation of nurse-midwifery practices in all types of settings, such that no one service is so unique as when they were the only midwives available. Clients may now select which midwife to go to, instead of selecting a midwife or a doctor. We often feel a need to explain why our service is better than another midwifery service. We've begun to play one-ups-manship with each other by comparing who does more births, or who has greater freedom or control over their practice. This type of competition benefits no one. One wonders if the directors of services have so much of their egos invested in the success of their practice that they are afraid to be open with each other? Honest sharing of successes and failures, problems, and their solutions would be beneficial to all. The educational directors have begun this process with their regular meetings–perhaps service directors should do the same!

Now we have new issues: the lay-midwife and home birth. Are we afraid they will damage our reputation as safe practitioners? Are we afraid we will lose clients to them? Are we so concerned about how our attitude toward them will be viewed by those with power over us? Many CNMs know very little about empirical midwives’ practice, or have any real knowledge of safe home birth practices. Are we negating this type of midwifery out of ignorance or out of fear of competition? Some, mainly consumers, have implied that CNMs are less true midwives, and that lay-midwives are the real midwives. This attitude has pushed us further apart, and is detrimental to all midwives. We do not need to compete with each other.

Non-nurse-midwives have much to offer if we will listen, just as we have much to offer them, if we will give. Nevertheless, we tend to indiscriminately reject any new ideas and practices which may appear unorthodox to our profession as it is now established. A case in point is the negative reaction many CNMs have had to Ina May Gaskin's book, Spiritual Midwifery, despite the potential merit of some of the author's concepts. We have also been unresponsive as a group when lay-midwives have asked for our teaching or back-up.

Some of our educational programs remain too medically oriented and provide no opportunity for students to develop that special relationship with clients which is unique to midwifery. This may come in part from our fears for future acceptance in the medical community, but it may also stem from our faculty's limited range of experience. Perhaps faculty members should be required to spend time in alternative settings. If we choose cooperation rather than competition we can invite empirical midwives to our schools to explain their practices, to help us teach the “art” of midwifery. This will not make us lay-midwives, nor will it make them nurse-midwives, but it should make us all better midwives.

As our practices grow and our caseloads become more heterogeneous we can become as diverse as our clients. There will always be those who feel safest in a hospital, those who feel safest in their own homes, and those who feel safest with a physician. When given a variety of options and some assistance in evaluating them, consumers are quite capable of selecting appropriately. It really is nonsensical to assume that only one type of professional in one type of setting could ever meet the needs of all healthy childbearing families. If a spirit of cooperation prevails, we will feel more comfortable referring clients to whichever service or setting is appropriate for them; and we, in turn, will feel more free to practice our profession as we choose.

Our main responsibilities are limited to ourselves and our clients. We cannot continue to shoulder responsibility for the practice of all who call themselves midwives or nurses, any more then we can for physicians who provide maternity care. We must define our position for ourselves and clarify it for consumers. We must ensure minimum safe care from each other while not impinging on our freedom to practice differently.

We must work toward a greater public awareness of diverse types of maternity care providers with their unique perspectives and practices, so that consumers can make informed decisions. The more informed they are, the less they will tolerate poor care, whether provided by physicians, nurse-midwives, or lay-midwives. We must also use our growing strength in institutions to encourage practices that we, as midwives, believe are essential to the family-centered care all women have a right to expect.

We also need to work toward cooperation with nursing leaders, who are often philosophically aligned with us, and who could assist us with their support. We need to be practical–to build coalitions rather than fences.

Nurse-midwives deliver only 2% of the babies in this country. Cooperation could help to dramatically increase that number. There is a unique place for each of us–and plenty of babies for all of us. If we stand together we can neither be divided nor conquered.