Sociology of Health & Illness Vol. 25 No. 2 2003 ISSN 01419889, pp.

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Blackwell Oxford, Sociology SHIL 0141 March 0 2 25 Original 000 Legitimation Lara 00 Blackwell Foley 9889 2003 UK Article Publishing of and Publishers in Health the Christopher work & Ltd Illness Ltd/Editorial narratives A. Faircloth of Board midwives 2002

Medicine as discursive resource: legitimation in the work narratives of midwives Lara Foley1 and Christopher A. Faircloth2
Department of Sociology, Department of Tulsa Rehabilitation Outcomes Research Center, Malcolm Randall V.A. Medical Center, Florida
2 1

Abstract

This article examines the work narratives of midwives practicing in the United States, specically in the State of Florida. We focus analytic attention on how the discourse of medicine is used as a resource in constructing a sense of legitimation for midwifery. Data are drawn from in-depth interviews with 26 direct-entry, licensed midwives and certied nurse-midwives. Historically, social scientic literature on midwifery has placed a midwifery, or a holistic, model of childbirth in polar opposition to a technocratic or medical model. In practical work, however, midwives demonstrate knowledge of, and make use of, a discourse of medicine to serve their purpose-at-hand. In these narratives of legitimation, the medical model does not emerge as an entity denable as separate and necessarily at odds with the midwifery model. Rather, the medical model is a resource through which midwives work narratively to construct the validity of their profession. The midwives interviewed use the discourse of medicine in three specic ways. First, they draw upon it as a contrast device, setting themselves and their work apart from the medical establishment. Second, midwives use the medical model to communicate necessary daily aspects of their work. Finally, they construct a story of medical collaboration to equate their work with that of physicians.

Keywords: midwifery, identity, narrative, occupations, boundary work

Introduction Many feminist and social scientic critiques of the medicalisation of childbirth have placed a medical model of care and a midwifery model of care in
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direct opposition (see, for example, Rothman 1982, Oakley 1984, Kitzinger 1988, Davis-Floyd 1992, Campbell and Porter 1997). In this article, we heed the call of Annandale and Clark (1996, 1997) to recognise the discourse of midwifery and the discourse of obstetrics as relational and likely to elide and collide in response to local contexts (1996: 31). We show that while there is an inherent theoretical tension between medicine and midwifery, in practice, the medical model is not simply an oppositional framework used for the discrediting of a holistic approach. Rather, it is a discursive resource that can be artfully used in the crediting of the profession of midwifery. In this article, we draw on interviews conducted with 26 US midwives practising in the State of Florida. We show ways that the midwives juggle discourses of midwifery and medicine in order to legitimate their own work. At times their narrative work is performed in a way that reies the opposition of a midwifery model and a medical model, yet at other times, the midwives use a medical discourse as a resource to give meaning to their own work and occupational identities. In the following analysis, we demonstrate three specic ways that midwives use a discourse of medicine in constructing a legitimising narrative of midwifery. First, it is used as a contrast device to set midwifery practice apart from the medical establishment. Second, the discourse is employed in the description of the midwifes daily work, building bridges with the medical community while having the best of both worlds. Third, we suggest that midwives use a discourse of collaboration to establish themselves as professional equals of physicians. This is accomplished by characterising aspects of midwifery work as the same as doctors and by describing the process of midwives training medical students in labour and delivery. This last circumstance is a particularly interesting turn considering the 19th century campaign by physicians to de-skill and eventually eliminate the practice of midwifery. The article is organised around these three themes. In addition, we also discuss the historical, occupational, and educational context of midwifery in Florida. We outline interpretive practice and narrative legitimation (Gubrium and Holstein 1997, Holstein and Gubrium 2000), the approach we take in regard to narrative analysis. Finally, we conclude with a brief discussion of our ndings and their implications for the study of midwifery.

Historical, occupational and educational context Midwifery is the ancient practice of women attending other women in childbirth. Although widely practiced throughout the world, a burgeoning medical profession nearly eliminated midwifery in the United States in the late 19th century. The current climate for midwifery nationwide is ambiguous. While nurse-midwives practice legally in every state in the United States, direct-entry midwifery is legal in some states, illegal in other states, and not clearly dened in a few states. However, midwives from around the country
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are organised and pressing for professional recognition, licensure and legal standing. Primarily, two different types of midwives practice in the State of Florida, where this study was conducted: direct-entry, licensed midwives (LM) and certied nurse-midwives (CNM). Certied nurse-midwives have a Bachelors degree in nursing and a Masters degree in midwifery. The training of CNMs typically takes place in a hospital setting, and the majority practice in a hospital setting, although some practice in independent birth centres. In the State of Florida, CNMs are licensed as Advanced Registered Nurse Practitioners (ARNP). This provides them with the professional capacity to prescribe medicine and provide well-woman care. CNMs must work under the supervision of a physician. There are currently more than 500 CNMs registered in the State of Florida (American College of Nurse Midwives 2000). The term direct-entry is taken from the European model of midwifery in which the midwife enters directly into practice without rst becoming a nurse. In Florida, direct-entry midwives are licensed under the Midwifery Practice Act (Chapter 467 F.S.), and are called licensed midwives (LM). Since 1992, the requirements for student midwives include three years of intense academic and clinical training based on core competencies established by the Midwives Alliance of North America (MANA) and the American College of Nurse Midwives (ACNM). Licensed midwives may provide care for women with normal, low-risk pregnancies in a variety of settings, including hospitals, birth centres, and clients homes, although in Florida, very few LMs practice in hospitals. There are currently more than 80 LMs in the State of Florida (Midwives Alliance of North America 1999). Florida is one of the most progressive states in the United States in terms of direct-entry midwifery education, licensure and regulation. The state has had licensing requirements for direct-entry midwives since 1931. With a resurgence of interest in midwifery and home birth in the 1960s and 1970s, the state revised its Midwifery Practice Act in 1982. Two years later, the Meyers Act placed restrictions on licensing. Finally, in 1992, under the leadership of the late Governor Lawton Chiles, the Midwifery Practice Act was revised again and licensing of direct-entry midwives reopened in October 1992. Based on the distinctive political, social, and legal climate surrounding midwifery in Florida, the state is a relatively unique environment in which to conduct the present research. Education As one respondent suggested, where youre trained and how youre trained makes a huge difference on how you practice and where youre comfortable practicing and how you perceive birth (Helen, LM). Midwives in the United States are divided over the issue of education. Is a college degree necessary? Must one rst be a nurse? What are the advantages and disadvantages of self-study or an apprenticeship model? In addition to disagreement among individual midwives, there is a historical conict between the American
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College of Nurse Midwives (ACNM) and the Midwives Alliance of North America (MANA) over the most appropriate educational route for midwives (Tritten and Southern 1998). Davis-Floyd (1998a, 1998b) outlines and evaluates several different types of midwifery training. At one end of the spectrum are formal university programmes, and at the other are apprenticeship and self-study. Middlerange education programmes include distance-learning, university afliated programmes, college-based direct-entry programmes, and private midwifery schools. Most of these types of programme to some degree combine didactic learning and experiential learning (Benoit et al. 2001). ACNM has tended to insist on formal university training and has moved toward requiring a Bachelors degree and even a Masters degree, although they have very recently taken the position that ones Bachelors degree does not necessarily have to be in nursing. An evaluation of the rst direct-entry programme accredited by the ACNM shows clearly that students without a nursing background achieve the same standards of academic excellence and clinical competency as students who are nurses (Fullerton et al. 2000). MANA, on the other hand, insists that a university degree is not necessary for becoming a midwife, and recognises the value of apprenticeship and self-study as legitimate forms of learning. The upside to standardised education in midwifery includes recognition, legitimacy, access to government funding and the possibility of training larger numbers of midwives (Davis-Floyd 1998b, Myers-Ciecko 1999, Osborn and Esty 1998). A downside to mandated standardised education is that it serves as an important means of social control (DeVries 1996). For many traditional midwives and advocates of an apprenticeship model, there is also concern that standardised education is increasingly moving in the direction of the medical model and that it will lead to the diminishing of the autonomy and independence of midwifery practice.

Interpretive practice and narrative legitimation Interpretive practice (Holstein and Gubrium 2000) represents the varied ways in which we construct reality and the specied sites in which we do so. Interpretive practice, as an analytic vocabulary, is used to simultaneously characterise the activities of storytelling, the resources used to tell stories, and the auspices under which stories are told (Holstein and Gubrium 2000: 104). At the heart of this is narrative practice. This approach allows us to analyse both the discursive resources available to the storyteller and the ways in which these resources are narratively put into play. Stories are assembled by artfully using discursive resources, or anchors, that are available to the storyteller. The practical use of discourse, however, is not something conveyed in a narrative vacuum. Rather, it is an occasioned happening based on the interpretive wants and needs of the teller and what
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is available to convey meaning. Midwives, often under attack by the medical profession, the media, etc., might feel a need to legitimate their profession and its activities. The question is how they convey this, in an accountable fashion, to the listener and wider audience as a whole. The discourses of medicine and midwifery form a narrative environment, anchoring the space from which stories can unfold. In developing a narrative of legitimation, the medical model, that which is most often construed as antagonistic to the practice of midwifery, becomes a requisite resource for building the case for legitimacy. While there are a vast array of resources available to tell this tale, the midwives choose to build their case by incorporating a discourse that one would anticipate as being antagonistic to legitimising practice. Given the working objective, a culturally recognisable and available resource, medicine, fullls the needs and concerns of the task-legitimation. While narrative analysis is the lens through which we focus on our data, we are aware that narrative analysis as a sole research strategy can commit a cardinal sin overlooking context. It has the inherent problem of missing the locally meaningful context of reality production gained through ethnographic eldwork (Gubrium and Holstein 1995, 1999). We have attempted to alleviate this analytic quandary in two ways. First, our primary focus has been on the wider discursive environments, medicine and midwifery, not specically on locally-situated discourse. That said, we did not want to overlook the importance of local environment. Because of this, one author, as we discuss in more detail in the methods section, participated in the local midwifery community for roughly two and a half years.

Research method The study discussed in this article is based on data obtained from interviews with 26 direct-entry licensed midwives and certied nurse midwives. It is part of a larger project which combines both participant observation in the midwifery community in Florida and in-depth, open-ended interviews with direct-entry, nurse-midwives and midwifery students at various stages in their careers. In the nal count, interviews were conducted with ve practicing LMs, four direct-entry student midwives, and three retired LMs. The respondents also include ve practicing CNMs, two student nurse-midwives and four retired CNMs. In each group, the women who claimed to be retired may no longer be catching babies, a term midwives use to describe their work during birth, but all are still working in different areas of womens health, (including gynaecology and well-woman care, and maternal and infant health nursing), teaching midwifery students, teaching childbirth education classes and engaging in research. One retired respondent is currently in the process of writing her memoirs.
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The rst author was a participant observer in the midwifery community in Florida from April 1999 to August 2001, volunteering at a particular site, as well as serving on committees, participating in workshops, meetings and various events and attending births. Through these activities, respondents were met and recruited for interviews. The goal was to interview both nursemidwives and direct-entry midwives at various stages in their practice. The broad categories used were student midwives, practicing midwives and retired midwives. The rst several interviews were with midwives met at local workshops. From these initial contacts, further midwives were then contacted for inclusion in the study. In-depth interviews were primarily conducted in peoples homes, though some were conducted at local restaurants and the midwifes own ofce. The interviews lasted from one to three hours, were tape recorded and transcribed shortly after. Questions were adapted, depending on whether respondents were students, practising or retired midwives and whether they were nurse, licensed or empirical midwives. Each interview began by asking respondents to tell the story of how they came to be involved with midwifery. In many cases, this question led to a long narrative, incorporating their training and their practice of midwifery. If respondents did not address these issues on their own, they were asked to talk about their training and practice. Respondents were also asked to talk about the relationship they had had with the medical community and whether this relationship had changed over time. Many other questions came up over the course of the interviews, but these are the ones that are directly addressed in this article. Data collection and analysis unfolded in relation to each other. As a general framework for the project began to take shape, respondents were sought who could further extend and elaborate a developing theoretical framework. The approach taken here is similar to the theoretical sampling of grounded theory (Charmaz 1983, Glaser 1978, Glaser and Strauss 1967). Condentiality was a real concern. The midwifery community in Florida is relatively small and close-knit. All the participants in this study know one another, most have worked together in different capacities in the past and many currently work together. This creates a situation in which, despite our best efforts to maintain condentiality, it is quite possible that when the midwives of Florida read the results of this study, they may be able to identify individual respondents. As a result, we chose to identify respondents by ctional names and to delete any potentially identifying information. I have consulted several of the respondents regarding this admittedly imperfect approach and they agreed that it was the best strategy. Gubrium and Holstein (1999) describe the analytic tension between ethnography and narrative. They characterise ethnographic excess as ignoring dissenting voices and narrative excess as missing the patterned range of narrative possibilities that, in some ways, exert narrative control over storytelling. Because we are focusing on narrative, we heed their warning to consider the circumstances and conditions of storytelling that may not be evident in
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the individual narrative account. As the researchers, we must be careful to contextualise these accounts through ethnographic description and comparison. As already indicated, the rst author has followed this advice. As well as participating in various events, she has attended childbirth education classes, received preliminary certication training in labour support, served in a labour support role at a birth centre birth and been involved in an effort to start a labour support co-operative. After being involved in these various activities for about one year, she was asked to serve in an administrative position at one of the sites. Three of the primary eld sites include what is called doula (labour support) training and a subsequent doula co-operative, a school for directentry midwifery and a birth centre staffed by both LMs and CNMs. Many of the respondents either currently or in the past have served in the role of doula. Doulas are trained to provide emotional support, comfort measures and advocacy for the labouring woman and her partner. They work as volunteers or paid support people in hospital, birth centre and home birth settings. This caregiving role has emerged as an occupation over the past decade (Morton 2000). The training in which the rst author participated involved a two-day workshop in the summer of 1999 and a follow-up, day-long workshop in the summer of 2000. The second workshop was specically geared toward providing labour support for women who were survivors of sexual abuse. Following the initial workshop, several women who attended attempted to initiate a doula co-operative. There were many meetings in which the participants learned from experienced doulas, watched video tapes of doulas at work, and discussed advertising and trying to gain entry into the hospital. The school, in its current manifestation, began in 1995. It provides a three-year midwifery education curriculum that includes both academic and clinical training. The school also offers a midwifery assistant programme, continuing education courses, and training that leads to provisional certication in childbirth education, lactation counselling, and labour support. Many of the original founders of the school are still involved as administrators and board of director members. The rst author began as a volunteer at this school. After data collection was completed, she was asked to serve in a paid position as the academic director. She also taught research methods as part of a course entitled Issues in Professional Midwifery to the senior students at the school. One particular birth centre was also integral to this study. It is owned by a CNM and her husband and staffed by the owner and a licensed midwife, along with direct-entry and nurse-midwifery students. They also have an obstetrician who signs their protocol and serves as a back-up physician. The birth centre houses a library with books and videos on pregnancy, birth and parenting. It also offers childbirth education classes, which the rst author attended, and weekly gatherings for new parents and their children. Women go to the birth centre for all their prenatal care as well as during labour and
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delivery. There are two birthing rooms at the centre. Both rooms are very homey with king-size beds, rocking chairs and soft lighting. One of the rooms also includes a large whirlpool tub. The rst author had the privilege of attending a birth of a friend and colleague in the role of doula at this birth centre.

Contrasting midwifery and medicine The midwives interviewed often made use of the discourse of medicine to show what they decidedly were not. In the following discussion, two directentry midwives and a nurse-midwife distance themselves from the medical establishment, creating a sense of legitimacy in contrast to what they consider a less legitimate enterprise mainstream medicine. Sandra is an independent licensed midwife (LM) with a homebirth practice. At the end of the interview, she is asked if there is anything else she would like to add. Sandra talks of the political direction that direct-entry midwives in Florida are taking. She is concerned that many people do not realise the potential consequences of mainstreaming the profession. Listen as she describes the costs: And sometimes I think that Florida midwives are really loath to recognise what the price is and to stay cognisant of like what are we paying for this and is it worth it? Like lets keep checking in with that because the desire to reach women is so strong here and to be legal and get the benets of that so that nobody can harass you, arrest you, so that you can, at least in theory, transfer your patients without a hassle, you know without the fear of like going to jail. But the cost of that is that we run the risk of being made to practice by the standards of practice which are the dominant standards which are the very ones that we are trying to get away from for a very good reason. I mean, by their own obstetrical studies, published in obstetrical journals, obstetricians do not practice scientically, we do. You know, were the ones who dont do continuous, electronic fetal monitoring, who dont do routine episiotomies, who dont do routine IVs, even though their journal literature says over and over and over again that they will put you at higher risk for C-sections and you know bad babies and for bad outcomes for mothers, blah, blah, blah, they dont practice that way (Sandra, LM). Sandra rst distances midwifery from medicine by explaining that the cost of [mainstreaming midwifery] is that we run the risk of being made to practice by the standards of practice which are the dominant standards which are the very ones that we are trying to get away from. Here she refers to a dominant medical standard which historically and theoretically is in polar opposition to a traditional midwifery model, yet with increasing
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standards for education and licensure, the two, according to this respondent, run the risk of becoming virtually indistinguishable. The second distancing strategy she uses is to employ a language of us and them when she says that by their own obstetrical studies . . . obstetricians dont practice scientifically, we do. In this statement and in what follows, she problematises the practice of science by claiming that physicians do not practice scientically, but midwives do. She describes a situation in which obstetricians reliance on and hypervaluation of technology makes them scientically irresponsible. While Sandra speaks of standard of medical care in a negative way, suggesting that this is exactly what direct-entry midwifery wants to move away from, Laura takes a different direction with the idea of a standard of medical care: Weve got to be doing standard of medical care and the only way that youre going to do that is by having an academic background. So, were kind of caught. You cant be legitimate on the one hand and still be traditionally based on the other. So, what the school is trying, what the [school name, includes the word traditional] is trying to do, as shown by its name, is preserve that kind of traditional basis, not turn it completely into academic and medical model care, but to preserve the traditional components of care with the personal relationships, the education that midwives do with their clients, and seeing pregnancy as the state of health rather than a disease state. So, trying to keep those traditional components whilst being current with whats going on in the elds of medicine and current with whats going on in practice. So, its a balance (LM). Laura begins with the same idea of standard of medical care, but speaks of it in a more positive way than Sandra. Laura also contrasts a medical model of care with a more traditional midwifery model, but suggests that balancing the two is important for midwives today. She calls upon medicine and education to legitimate contemporary midwifery, but also invokes tradition to justify her own identity as a midwife. Andrea is a recent graduate of a nurse-midwifery programme, currently working in private practice with two physicians and two certied nursemidwives (CNM). She remembers her training this way: Once I began training, I was disappointed in how much medicine interferes with midwifery. Ive learned that this profession requires a constant battle to survive and remain autonomous. The natural practice of midwifery is very difcult to practise in a policy-ridden private practice and hospital setting. I understand the desire to deliver in a hospital, I would choose the same. However, I do not agree with being strapped to a bed, poked and prodded, starved, and being treated as though ones labour is an illness which must be treated in a timely manner (Andrea, CNM).
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Sandra is a homebirth midwife and Laura works in an independent birth centre. Both, therefore, are physically separate from doctors. Andrea, however, is a certied nurse-midwife who is in practice with physicians. Physically, she shares space with doctors. She begins her narrative separating midwifery and medicine, to some degree, by claiming that medicine interferes with midwifery. Yet, using the language of battle, she brings midwifery and medicine back into the same space, a conictual space. She ends her narrative by contrasting the natural practice of midwifery with various hospital practices. While medicine and midwifery share narrative space, these three respondents also work to create boundaries that distance or separate themselves and the profession of midwifery from medical practice.

The daily work of midwifery The midwives construct a story of medical collaboration to describe and attribute meaning to their daily work. Particularly, direct-entry midwives nd themselves attempting to build bridges with the medical community when they are starting a new practice, for the good of their patients, and simply as a means of maintaining a professional practice. Nurse-midwives must have their protocols signed by a physician. Many nurse-midwives consider their relationship with the physician to be a team relationship. Because these physician-midwife relationships are already well established, there is little need to do the bridge-building work that is described below. Thus, the excerpts in the section Building bridges are primarily from interviews with direct-entry midwives. However, narratives of daily work can be heard from both LMs and CNMs in the subsequent section, Best of both worlds. Building bridges Nadine is a licensed midwife who at the time of the interview was waiting to start a practice until she moved, with her family, to another state. In the course of the interview, Nadine is asked where exactly she sees herself, in terms of her work, ve years from now. Here, she describes the efforts that she foresees in establishing a practice: Nadine: So, in ve years, I would love to have like an active birth centre. But, I think, for the place that Im moving to, that will require really building a lot of bridges with the medical community. Cause theyre not really very good right now. So, theres a lot of like ground work that has to be done rst. Lara: Is that something that you work, like learn about in your training, in school? How to build those bridges with the medical community? Nadine: Mmmm-hmmm. Yeah, we have one whole course in, well we have courses in politics on how to change the laws and stuff and then we do have one whole class in collaborative management
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which is like how do we work with doctors and hospitals and other medical professionals. And even within that we, we put together a packet of this is what I would present to a doctor when Im asking him to be my back-up (Nadine, LM). Nadines response demonstrates her understanding that building a lot of bridges with the medical community will be important to her midwifery practice. In the responses that follow, we will see midwives recognition that a positive relationship with the medical community is a vital aspect of midwifery practice and that it is particularly consequential for the patients. Nadine explains that the development of this relationship is a foremost concern in the initial establishment of a practice. She follows by explaining the preparation she received in school for establishing and maintaining this relationship. Jeanne is a recently-retired licensed midwife. She continues to teach midwifery students in the classroom and in clinical settings. Jeanne sees herself as a link between the modern midwife and the traditional midwife. Here, she describes her ongoing concerns with the mainstreaming of midwifery: But its becoming more and more professionalised and more and more mainstream, which in some ways is good and in some ways isnt. So, I feel like I need to stay actively involved in teaching so that I can be a link between the modern midwife and the traditional midwife, because I think thats very important and I dont think theres very many midwives out there that actually have a grip on what the traditional midwife is about. The traditional midwife in my world view is a shaman in her community. Shes not just a medical resource. To me, birth is not a medical event. Its a life event, its a body event, but its not a medical event (Jeanne, LM). Jeanne contrasts midwifery and medicine, saying that the midwife is not just a medical resource. She explains her alliance with the medical community in the following manner when asked about her professional relationship with back-up physicians: Well, thats actually what I teach at this school is how to have a good relationship with back-up. And its kind of interesting because me of all people, youd think I wouldnt interact that well with the medical community, but I do. I was very well respected and I had a lot of good help. I had nurse midwives that worked with me, doctors, I had two back-up doctors in the course of my tenure practice. The rst doctor I had for about six years maybe, about half each, ve and ve. And one of them had a nurse-midwife who worked with him and that was really great for me. And then I had many other doctors that I used as needed, you know high-risk docs, ultrasound, diagnostic docs, family practice docs, you know all kinds of doctors that I worked with (Jeanne, LM).
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Jeanne begins by establishing that she has a good relationship with back-up. However, immediately following this statement she gives a disclaimer that although no one would expect her to have a good relationship with the medical community, she in fact does. One might have these expectations about her because, as she admits earlier in the interview, the dominant culture does not please me, so if I am becoming more and more a part of the dominant culture, then I am less pleased with myself. If one associates the medical establishment with dominant culture, then one would expect Jeannes story to follow a path leading away from the medical establishment. Instead, we see Jeanne describing relationships with doctors and nurses throughout her years of midwifery practice. Carol is a licensed midwife with an independent homebirth practice serving two large, rural counties. In the following excerpt, she describes what is likely to happen interactionally when she has to transfer a patient to the hospital during the birthing process: Obviously people come to you for a home birth, they really want to have a home birth, you want them to have that. So, when something happens and things change and you have to go, it really is a really stressful time. Its sad and sometimes its scary, its really hard. And midwives especially, especially direct-entry midwives with no previous hospital interaction, are really stressed out and really uncomfortable and its very much out of their element. And Ive just heard that over and over. But for me its really the opposite because I can go in there and know exactly whats going on, and I hate to say it, but its like how you play the game when you get in there. And I do that really just for my clients, because now that everything has shifted, I still want it to be as good of a birth experience, even though I know its gonna be very medicalised, so I try to really preserve that, kind of preserve and guard all the relationships, you know I dont want the husband screaming at the doctor. So, I feel like I play a little role of mediator at times, but if it helps somebodys experience, then its a good thing (Carol, LM). While Nadine and Jeanne speak of the importance of building bridges with the medical community in order to establish a practice or because one must work with doctors over the course of a practice, Carol expresses a different agenda. She knowledgeably moves between homebirth and hospital settings because she know[s] exactly whats going on. She tries to ensure that her clients birth experiences are not subsumed by the medicalisation of childbirth that is typical in the hospital. All this, she recognises, is important for the good of her clients, I do that really just for my clients. The best of both worlds Carol, who described herself above as playing the role of the mediator, continues by sharing how she feels her background as a medical technician is an asset in interactions with hospital staff:
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So, youve gotta kind of have both worlds. And then just kind of live in one and be able to oat in and out of the other. So, I feel like my whole, I mean after being a med tech for a long, long time and being in hospitals since 1978, I was very comfortable with all of the terminology, the hierarchy and believe me that there is that, and know how to weave myself in and out of that. I didnt have to gure that out. So, I felt like for me I had a pretty huge, I felt like it was a huge advantage. Thats just pretty unique (Carol, LM). Carols tale is an intriguing one of technocracy and holism. Based on her story, she is capable of moving between the two frames of reference, just kind of live in one and be able to oat in and out of the other. Carol has the benet of having been trained under a medical model due to past employment at a hospital. This very important knowledge, certainly capital in relations with physicians, provides her with an advantage other midwives do not have, I didnt have to gure it out. So, I felt like for me I had a pretty huge, I felt like it was a huge advantage. Lisa, a direct-entry student midwife, has worked in administrative positions in hospitals. She was asked if she thought this background was useful to her as a midwife. She responded in this way: Absolutely. I think its given me a lot more open minded philosophy kind of thing as opposed to some of my classmates who dont, who either had poor hospital experiences or who have not had any hospital experiences and wont even consider that that could be a good experience. Because it can be a good experience, a hospital birth can be a beautiful experience. Ive been to many of them. Ive been to caesarean sections where the womans been in four days of prodromal labour and we danced at three oclock in the morning to UB40 and did candlelight rituals in the front yard at six am, and she ended up with a caesarean section and she said she would not have done it any other way. She got to do absolutely everything that she wanted to do. And just because it ended up as a caesarean, doesnt mean that it was not a successful delivery. It was awesome for her. And I am very proud that I got to be her support person. I think, denitely, having seen good hospital births gives me an advantage over people that wont give it a chance. I think theres people that have seen bad homebirths, you know with poor outcomes that wont give that a chance. And you know, thats not right either. First of all, its up to the parents, with medical guidance, but also the womans choice is paramount. One of the rst things that they teach us in the structured doula teaching is to put your own values aside. And one of the things they teach us in midwifery school is put your own values aside (Lisa, direct-entry student). Lisa draws upon her previous hospital experience to characterise herself as a exible midwife. This is taught in both doula [labour support] training
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and midwifery school, and she is able to accomplish it because of her more open-minded philosophy. In this portion of her narrative, Lisa also invokes two different, yet related, legitimising discourses. She starts with telling a birth story which leads into a discourse of feminism or womens choice. Because a womans choice is paramount in deciding how to birth, it is vital for the midwife to respect that choice and put aside everything that you believe and focus on what she thinks and believes. Bridgette is a certied nurse-midwife working in a large practice. Toward the end of the interview, she asked the interviewer about her research. The interviewer explained the research and how qualitative methodology approaches the research project. Bridgette continued to probe deeper, obviously intrigued by the research. The interviewer spoke of how the social scientic literature divides the technocratic and holistic models of birth. According to Bridgette though, it is not like that: Well, I guess it is where, see my education is not that. My education and how I was introduced and what was, was that the nurse-midwife is on an equal basis in the team. So, really what youre offering the woman, and where I worked at it was a team approach. And so I think, what we can bring to a woman is the best of both, and I can give you an idea. The way it worked before was that we met a woman and she was pregnant, her rst interview was with a nurse-midwife. So the nurse-midwife did the history, the nurse-midwife also did the rst physical. Of that time that was set aside, there was 15 minutes set aside where the physician therefore was introduced to this, anything that the nurse-midwife had discussed or evaluated. And at that point, so the woman knew who her care providers were. It may not be that particular person because of the size of the practice. But it was that she had an idea of what the philosophy of the nurse-midwife. And the philosophy of midwifery which is that this is a normal process, but it dovetails with the medical model (Bridgette, CNM). Bridgette argues that her training provided a sense of pride in being a midwife and her place in the birth team, where each member, the physician and the midwife, is responsible and works in collaboration with the other. According to Bridgette, both approaches are necessary and build upon one another, dovetailing each other, thus creating a more complete birthing experience.

The equal of physicians Lastly, midwives use a discourse of medical collaboration to establish themselves as equal to physicians by describing their work, or the work of other midwives, as similar to doctors or by placing themselves in a co-operative,
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team relationship with physicians, in which each profession must rely on the other. Further, several midwives describe their experiences of training medical students in labour and delivery. This inverts the traditional hierarchy which places physicians at the top and turns it into a teacher-student relationship in which a student is typically in the more subordinate position. Doing the same work as doctors Bridgette, who explained her sense of a team approach above, explains what typically happens when a woman comes to the hospital in labour. Here, she points out similarities between her role and that of the physician she works with: Well, remember, this is a practice. So that, not that we know all the women because we dont. We have two practice sites and so, and it is that we ask a woman to call us rst so theres a midwife on-call 24 hours. So you may have contacted, this woman may have contacted you earlier and youve discussed, shes telling you whats going on and you offer her to come into the hospital. So you are expecting her. The labour and delivery situation is that the supporting nurses and the staff, they do the same thing for the nurse-midwife as they do for the physician. So, we function very much in that capacity. So that they get the patients ready for us and theyll call us and tell us when shes there (Bridgette, CNM). Bridgette frames her argument within the activities that are part of the labour and delivery situation, as she puts it. According to Bridgette, staff support the midwife in a similar manner as that which they support the physician, they do the same thing for the nurse-midwife as they do for the physician. So, we function very much in that capacity. Dawn is a student direct-entry midwife, doing her clinical training in a birth centre that employs several certied nurse-midwives. In the excerpt below, she responds to a question about what she sees as the biggest difference between direct-entry or licensed midwives and nurse-midwives. Follow her narrative as she establishes that though the midwife is certainly on an equal footing with the attending physician, she should not be performing the same type of care as the medical model demands. The midwife must remain true to the midwifery model of birth: So, its almost like the out-of-hospital birth centre is being put on the back burner, and birthing at the hospital with a midwife is now trendy and its what everybody is doing. And so, okay we have that option, instead of you being with the doctor, you can be with a midwife. Well, what does that mean? It means nothing because if the midwife is in clinic at the time that youre in the hospital labouring, shes not going to be over there labouring with you because youre that hospitals property so to speak, youre being managed by those labour and delivery nurses, and the nurse-midwife is
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sitting over in the ofce, rst-hand experience, sitting over in the ofce, checking in by the phone, just like the doctor does. And to me, that is just not midwifery, that is not midwifery care. Coming after the woman has laboured and you know the heads about to crown, and you come to catch the baby, thats being an OB/GYN, thats not being a midwife. Thats not what midwifery is about. Midwifery is about being with a woman and you cant be with a woman if youre not present for labouring with the woman (Dawn, direct-entry student). Here, we have two different examples, both characterising the work of midwifery as the same as that of a doctor. One narrator, a CNM, describes this in a positive light. The other, an LM, describes a CNM behaving just like the doctor does and argues that this is antithetical to midwifery. So, in addition to juggling discourses of medicine and midwifery, midwives also draw on a discourse of medicine to negotiate boundaries (Allen 1997, 2000, 2001, Gieryn 1983, 1999, Mesler 1991) amongst themselves. This further complicates the debate surrounding midwifery and medical discourses as either polarised or relational. Midwives training medical students Two certied nurse-midwives related their experiences of teaching medical students about normal birth. This phenomenon is probably much more common among CNMs because of their hospital privileges. However, just a few months before the start of this project, Ina May Gaskin, a direct-entry midwife and president of the Midwives Alliance of North America, was invited to do grand rounds at a teaching hospital in Florida, specically to teach her method for handling shoulder dystocia1. Further, while LMs may not formally teach medical students, there are examples of informal teaching, as illustrated in this quote by a retired LM now working as a childbirth educator in a hospital: Now, you know I work at [hospital] and I work with a bunch of residents and I work with some of the doctors who would have screwed me to the wall before, so its kind of interesting. We all kind of keep our distance from each other because we know were in politically different places, but I really like working with the residents because I feel like I do have an effect on them and they all know Im a midwife and sometimes theyll come up and say, well what would you guys have done about this. So, there is an interest, I think. And I think that medicine is a place that theyve got to make some changes, just like any of the big systems, and some medical schools and facilities are better at offering change than others. But thats really where medicine has to go. They have to incorporate alternative medicine or complementary medicine and they need to have an understanding of that. I think its time to make changes (Barbara, retired LM).
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Samantha is a CNM. She currently works part time for a state funded programme, delivering gynaecological and prenatal services to women in rural counties. She also works part time teaching medical students how, in her words, to do a normal birth. She is asked if the students have been receptive to this. She responds that, Yes. I think medical school must be hell. They throw them in there and they dont tell them anything. I mean they say, read the book and do it. So, I mean and were talking about delivering a baby. So, when I go in there with someone and Im practising with them and showing them, and then I put my hand on top of their hand and say press this hard, this hard, pull this hard, you know pull this hard you know, things you cant read, you cant read in a book how much pressure. And, or Ill do a pelvic exam and say, its a little to the left, you know things you cant read in a book how to do that kind of thing. They are so grateful. They just walk out of that room and they go, wow thank you so much, youre so patient, youre so kind. And you know, you just know no one has held their hand and led them along at all. Whereas midwifery school is really different. Theres someone with you, showing you that. And you know Id rather people learn by me sharing my knowledge then have them have to make all my same mistakes. You know? It doesnt seem like a good process. I dont really understand medical school, why they do that, it just seems cruel. But, theyre very grateful (Samantha, CNM). Samantha describes the lack of one-on-one teaching that she sees in medical training. She contrasts this to midwifery school where there is someone with you, showing you. So, while this is in some ways a narrative of collaboration, working with medical students, there is also a contrasting of two different approaches to teaching with the midwifery model prevailing in her story. Karen is a certied nurse-midwife and also a Ph.D. candidate in public health. She too has had the experience of training medical students in the practice of normal birth and here explains the benets of these types of programmes. According to Karen, the training is important for midwifery because it provides the physicians with useful information about midwifery as a profession, and introduces knowledge of the birth procedure that they would have been unable to gain in medical school: And the more physicians that are coming out of school who have trained with midwives, you know in tertiary care centres where you have residents and you have nurse-midwifery students or at least a nurse-midwife practice. Theres been that exposure which takes away the fear of the unknown. Nurse-midwives learn from the physicians, but you see if you are nurses rst, youve already learned the physician game. But for the physicians who have been socialised into medicine, which is a very different society of its own, for them to work next to the midwives, dont
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have to do anything with them, but they can then watch and see what they do and listen to how they explain things, and watch how they do a birth without using a million tools other than their hands and their voice, it takes away some of the fear and drops some of the barriers there are between these groups (Karen, CNM).

Legitimating midwifery Midwives must balance a world of medicine and a world of midwifery. At times they distance themselves from medicine, reifying the theoretical polarisation of the two models. Yet at other times, they draw on a discourse of medicine, medical culture or medical collaboration as a resource to legitimise their own work and occupational identities. They uidly shift between the two as needed in the everyday pragmatics of midwifery. It is important to note that there is not a clear-cut difference between the narrative practice of certied nurse-midwives and licensed midwives. Structurally, the two are in very different positions in relation to physicians. LMs are independent practitioners, whereas CNMs work under the supervision of a physician. In the State of Florida, LMs work primarily in home or birth centre settings while CNMs work primarily in hospital settings. For these reasons, one might expect LMs to be more likely to distance themselves from medicine and CNMs more likely to embrace it. Our data however suggest that both groups of midwives draw upon a discourse of medicine and collaboration and use it in different ways depending on the context and the purpose-athand. Further, both LMs and CNMs are engaging in boundary work, not only dening, managing and negotiating boundaries between midwifery and medicine, but also between different types of midwifery practice. Our work in this article serves to document empirically the theoretical argument of Annandale and Clark (1996), who posit that both a discourse of midwifery and a discourse of medicine are constructed in relation to one another. We have noted three specic ways in which midwives work to construct a narrative legitimation through the interpretive blending of midwifery and medicine. First, the discursive horizons of the medical model are established as a contrast structure through which they can legitimate their own work. The second manner is that midwives use a discourse of collaboration to communicate necessary aspects of their mundane work. Third, midwives continue to build a sense of medical collaboration in the tales they tell to equate their own work with that of physicians. In two recent works, Gubrium and Holstein (1997, Holstein and Gubrium 2000) have argued for an understanding of identity that is conditioned by working senses of what we should be at particular times and places (2000: 3). A self we live by, as they term it. Todays midwife must construct an identity she lives by. She nds herself located at points where discourses intersect, where the language games (Wittgenstein 1953) of midwifery and
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medicine interact. These two discourses, often seen as competing, provide important, interpretive resources for the midwives to construct a sense of identity that legitimates their very work and occupation. The contemporary midwife is an agentic subject, capable of reecting on her work and substantiating it through the discursive constructs available to her midwifery and medicine. Address for correspondence: Lara Foley, Department of Sociology, University of Tulsa, 600 S. College Ave, Tulsa, OK 74104, USA e-mail: lara-foley@utulsa.edu

Note
1 Shoulder dystocia is a serious delivery complication that occurs when a babys anterior shoulder is impacted behind the mothers pubic bone (Davis 1997).

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