Midwifery licensing: is it a consumer issue?Two weeks ago I wrote about midwifery licensing and rhetorical tricks. Reduced to its basic elements, the arguments for licensing a second, inferior class of midwife with less education and training than any midwives anywhere else in the industrialized world is not particularly compelling. Therefore, American DEMs and their supporters have been forced to resort to rhetorical tricks to mislead the public and legislators about direct entry midwifery. These tricks include obscuring the fact that DEMs have deficient training by claiming they are "experts" in normal birth, muddling the distinctions between certified nurse midwives and DEMs, and using the wrong statistics (infant mortality rate) to make the false claim that the US lags behind other industrialized countries in indicators of obstetric care.
These tactics have been reasonably successful in confusing the issue, but there are other rhetorical tricks that have been met with greater skepticism. This second group of rhetorical tricks represents efforts to portray the issue of DEM licensure as an issue of "choice" or an issue of "consumer rights".
Katherine Beckett and Bruce Hoffman have written in Challenging Medicine: Law, Resistance, and the Cultural Politics of Childbirth:
Midwives and their supporters consistently frame this debate as one centrally about individual choice, arguing vigorously that women have the right to choose where and with whom they will give birth. As the legislative sponsor in California stated, "At the core of this issue are two simple beliefs: first, that childbirth is a natural process of the human body and not a disease. And second, that a parent has the responsibility and the right to give birth where and with whom the parent chooses ..."Homebirth advocates are trying frame the "choice" of homebirth as similar to the choice of abortion and therefore guaranteed. Ironically, they want to trade on the widespread and widely acknowledged support for abortion rights despite the fact that many homebirth advocates (and many legislators) do not support the right to choose abortion.
... Notably, birth activists avoided linking this choice to the right to choose abortion by avoiding more general terms such as reproductive choice or the right to choose.
The connection between homebirth and "consumer rights" is even more tenuous. As Christa Craven, a professor of sociology and a homebirth advocates, writes in an article entitled Is Reproductive Healthcare Access a "Consumer Rights" Issue? in a publication of the American Anthropological Society:
... [M]any homebirthers have begun to adopt the rhetoric of "consumer rights" to defend their right to midwifery care... Through challenging the authority of biomedicalized childbirth, all homebirthers are engaging in dissident political acts, which has forced many ... to justify their actions as an issue of ideological choice (that is "every woman should have the right to use a homebirth midwife"). However, as midwifery advocates have been forced to "legitimize" their choices ... their arguments have become more centered upon "consumer choice" to enhance childbirth options (such as "every woman should have the right to hire a homebirth midwife").Craven is concerned that the rhetoric of consumer rights speaks only to the concerns of middle class and affluent women:
Although this consumer model offers some midwifery advocates a useful metaphor to describe themselves as political actors, it does not always speak to the experiences of women who have restricted financial options for birthcare. In fact, most middle-class, affluent participants in my study felt strongly that it was their right to have choices in their childbirth experience, while most low-income participants indicated an interest in choices for their birthcare, but also a dependence upon midwives as a low-cost childbirth option...In other words, when homebirth advocates talk about consumer rights, they mean that women with money have a "right" to spend it how they see fit, not that all women have a right to DEM care.
Homebirth advocates cannot make a compelling argument for licensing a second, poorly trained class of midwife, so they attempt to confuse the issue. Typically they do so by obscuring the poor training of DEMs, by implying that DEMs are the same as CNMs and by falsely accusing American obstetrics of providing substandard care. However, they also attempt to do so by trading on support for "choice" when many do not actually support true reproductive choice, and by asserting a non-existent "consumer right" to buy whatever they can pay for.