Claiming Respectable American Motherhood: Homebirth Mothers, Medical Officials, and the

State
Author(s): Christa Craven
Source: Medical Anthropology Quarterly, Vol. 19, No. 2 (Jun., 2005), pp. 194-215
Published by: Wiley on behalf of the American Anthropological Association
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CHRISTACRAVEN

Universityof MaryWashington

Claiming Respectable American Motherhood:

Homebirth Mothers, Medical Officials,
and the State
Based on ethnographicresearchregardingpublic policy and grassroots
organizingfor midwiferyin Virginia,this article explores how medical
discourses aroundappropriatehealth care practices intersectwith state
discourses about what practices are considered "respectable"versus
"pathological"for its citizens. In recent legislative debates about the
legalization of direct-entrymidwifery,medical officials have extended
their criticism of midwiferyand homebirthto motherswho resist statesanctioned childbirthpractices. This article examineshow medical officials challenge the respectablemotheringpractices of homebirthersby
linking them with women they deem pathological-child abusers, negligent mothers,and drug users-and placing them outside the cadre of
"normal"Americanmotherswho acknowledgethe "logical"and "natural" superiorityof biomedicalchildbirthpractices. I also addresshomebirth mothers' responses, which assert that their political advocacyfor
midwivesis a respectablemotheringpractice because theyare responsible citizens who desire what they deem the best care for their children.
[medicaldiscourse,motherhood,authoritativeknowledge,healthcareactivism, midwifery]

Introduction
ince medical licensing campaignsgained governmentsupportin the early
1900s, challenges and alternativesto the biomedical paradigmhave fallen
underthe scrutinyand control of the state (Baer 2001; Morgen 2002:130).
Throughthe regulationand licensure of health care professionals,judicial cases
involvingalternativepractitioners,andlegislativeattemptsto legalize the practices
of alternativehealthcare providers,medical discoursesaroundappropriatehealth
care practices have often intersectedwith state discourses about what practices
are considered"respectable"versus "pathological"for its citizens.1 In particular,
biomedical metaphorsand beliefs about health that incorporatecore American
values, such as the authorityof technologicalprogressand mechanisticmodels of
MEDICALANTHROPOLOGY
Vol. 19, Issue 2, pp. 194-215, ISSN 0745-5194, elecQUARTERLY,
tronic ISSN 1548-1387. ? 2005 by the AmericanAnthropologicalAssociation. All rights reserved.
Please directall requestsfor permissionto photocopyor reproducearticlecontentthroughthe University of CaliforniaPress's Rights and Permissionswebsite, www.ucpress.edu/joumals/rights.htm.
194

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HOMEBIRTH
MOTHERS,MEDICALOFFICIALS,ANDTHESTATE

195

the body andits repair(Davis-Floyd1992;Martin1987;Stein 1990), allow medical

officials to assume an authoritativerole regardinghealthcare practiceswithin the
legislative arena. In this article, I address ways in which dominantbiomedical
and stateideologies aroundchildbirthandmotheringcollude to regulatewomen's
reproductiveoptions, in this case by restrictingaccess to homebirthmidwives.
Medical and state officials have historically justified state regulation and
biomedicalmanagementof reproductivehealthcareby highlightingthe "pathological" practicesof mothers-particularly motherswho challenge dominantAmerican trends and ideologies aroundchildbirth(Cruikshank1999; Edwards 1999;
Hyatt 1999; Lopez 1997; Morgen 1988; Whiteford 1996; Williams 1996). By
accusing mothersof bad behaviortowardor in relationto their children,medical
officialsjoin the stateto contendthatthey arebetterequippedto makedecisions regardingchildbirthandmotheringpracticesthanthe mothersthey deem delinquent.
Definitionsof whatconstitutegood childbirthdecisions andrespectablemothering
practices,however,are not always in agreement.For example, conflicting advice
from medical experts aboutthe efficacy of breast-feedingversus formulafeeding
puts mothersin a precariousposition; whetherthey choose to breast-feedor use
heavily marketedinfant formula,they are often castigatedfor not doing what is
"right"for theirchildren(Ward2000:37). The constructionof what is and what is
not a respectablemotheringpractice and women's responses to these categories
and reprimandsare issues of concern in this article.
In particular,I examine the presentationof respectableversus pathological
motherhoodin debates aroundthe legalization and licensure of direct-entrymidwives (DEMs), non-nursemidwives who specialize primarilyin homebirths,in
Virginia.2Unlike the vocal midwives advocating for their profession in many
states, Virginiamidwives have been relativelyquiet on the political frontbecause
of a statutethatprohibitedDEMs fromreceivingcompensationfor midwiferyservices between 1977 and2003. Afterthis statutewas struckdown in 2003, midwives
became more public in legislative efforts (see the Epilogue for furtherinformation). Prior to 2003, however, it was primarilymothers who sought homebirth
midwifery services who supportedDEM in public debateswith medical officials.
I have followed these grassrootsorganizing efforts and the legislative developments aroundmidwifery in Virginia since 1999 and have conducted interviews
with 40 midwifery proponentsthroughoutthe state.3In addition,I recordedand
transcribedlegislativehearingsin the VirginiaGeneralAssembly wheremidwifery
proponents,medical officials, and lawmakershave debatedthe efficacy of homebirthand the licensure of DEMs. The testimony I discuss in this article occurred
between 2000 and 2002-when homebirthmotherswere at the forefrontof public
advocacyfor DEMs.
Publishedaccounts of legislative debates in other states indicatethat the assessment of good and bad midwives has been a primaryconcern during efforts
to license midwives (Lay 2000b; Miller 1999). In the Virginialegislature,however, it has been activist mothers who have borne the brunt of the attacks against

midwifery and homebirthin Virginia, as medical and state officials evoked the
image of "badmothers"and their "badbabies"to make a case againstmidwives.
Conversely,homebirthershighlightedthe links between bad, interventionist,corporatized biomedicine and what they perceived as ill-informed state sanctions
against midwives. For homebirthers, claiming respectable American motherhood

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also rested on core Americanvalues-those of self-reliance, independence,and

pragmatismaroundtheirhealthcare decisions.
In this article, I first analyze the testimony of medical officials opposing
the legalizationof DEM in Virginia'sstate legislatureto illuminateways in which
medicaldiscourseunderminesproponents'effortsby challengingnotjust the childbirthpracticesbut also the motheringpracticesof homebirthmothers.I highlight
the pervasiveuse of pejorativestereotypesby medical officials to framecontemporarymidwifery supportersas bad mothersfor participatingin homebirthand,
thus, as bad citizens for participatingin political advocacyfor an illegal activity.I
also examine homebirthmothers' responses to this discreditingdiscourse within
the state legislatureand among their own communityof midwifery advocates. I
demonstratehow midwifery supporterslink theirnegativeexperienceswithin the
legislative arenato their disempowermentin medical settings. I drawattentionto
the self-presentationof midwiferyadvocatesas volunteersandmothersin contrast
to the paid lobbyists representingmedical societies and the government.Even as
midwifery advocatespoint out how medical discoursespathologize resistantand
politically active mothers,they also identify individualswithin state and medical
institutionswho supportmidwifery.By aligning themselves with lawmakersand
healthcareofficialswho aresympatheticto theircause,midwiferyadvocatesassert
their respectabilityas mothersand citizens. In contrastto medical officials, who
questionhomebirthmothers'good citizenshippractices,midwiferyadvocatessee
themselves as respectablecitizens because they are active in the political process
as mothers,pursuingwhat they believe is best for themselves and theirchildren.
Authoritative Knowledge and Medical Discourse
BrigitteJordan'sresearchon authoritativeknowledge in obstetricsand midwifery (1978, 1989, 1990, 1997) describes how the ascendanceand legitimation
of the biomedicalmodel as the authoritativeknowledge system aroundhealthcare
and childbirthin much of the world has resultedin the devaluationof alternative
knowledgesystems as backward,naive, andpotentiallytroublesome.The constitution of biomedicalideologies as authoritativeknowledge is a social process-one
throughwhich "all participantscome to see the currentsocial order,that is, the
way things (obviously) are"(Jordan1997:56).Moreover,in the medical discourse
between a doctor and a patient, participantsare often not consciously aware of
these assumptions.
Theconventions
foratraditional
betweendoctorsandpatients
typeof consultation
embody"common-sense"
assumptionswhichtreatauthorityandhierarchyas
natural-thedoctorknowsaboutmedicineandthepatientdoesn't;thedoctoris
in a positionto determinehow a healthproblemshouldbe dealtwithandthe
thatthedoctorshouldmakethedecisions
patientisn't;it is right(and"natural")
andcontrolthecourseof theconsultation
andof thetreatment,
andthatthepatient
shouldcomplyandcooperate;
andso on. [Fairclough
2001(1989):2]
Physicians who oppose the legalization of DEM rely on the biomedical
model's firmlyentrenchedrole as the authoritativesystem for healthcare in American society, as well as their own unquestionedprofessionalauthoritywithin this
model in theirlobbying efforts with the state. They do so in partby allying themselves with state concerns for public health and safety and by assuming the role

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197

of arbitersof societal standardsaroundmotheringand childbirth.Thus, together

with state officials, physicians create a sharedauthoritativeknowledge regarding
the managementof health care for mothers and babies. Public commentaryby
these opponentsof homebirthmidwives not only addressesproposedlegislation
to legalize DEMs, but also makes broaderpejorativestatementsabouthomebirth
as an alternativeknowledge system for childbirthand the mothers who support
this alternativesystem. As Jordanand Faircloughpropose,this discoursemakes it
"obvious"and naturalthathospitalbirthis a normto be maintained.4
In this section, I analyze several excerpts from medical officials' testimony
before the VirginiaGeneralAssembly regardingproposedpro-midwiferybills to
show how ideas of pathological motherhoodwere constructed.The examples I
present highlight three themes in this discourse and appearin chronological order to reflectthe progressionfrom commonsensediscussionsof medical authority
aroundchildbirthto an emphasison homebirthmothers'divergencefrom authoritative trendsin Americanchildbirthto the explicit constructionof homebirthas
an example of negligent and pathologicalmotherhood.
Background:A Brief History of Midwives in Virginiaand the CurrentLegislative
Debates
In AfricanAmericanMidwivesin the South, GertrudeFraser(1998) reviews
how state and medical officials workedin partnershipto systematicallyeliminate
midwives in Virginia,as well as in many other southernstates, duringthe early
to mid-1900s. Particularlyduringthe movement to improvematernaland infant
health care in the early 1900s, midwives came underthe scrutinyof increasingly
stringentpublic health regulations,and affluentand middle-class white women,
and lateraffluentAfricanAmericanwomen, began to employ physiciansto attend
their births.Although it was primarilyAfrican Americanand low-income white
women who had homebirthswith midwives into the mid-1900s, homebirthersin
Virginianow representa primarilywhite constituencyfrom a broadrangeof class
backgrounds(CravenIn press).
As Fraser (1998:103) reminds us, when African American women finally
gained access to hospitals after being denied even basic medical care for many
years,most rejectedhomebirthas a way to distancethemselvesfromthe pejorative
racialstereotypesassociatedwith the AfricanAmericanmidwife. Conversely,after
manymiddle-classwhite womenbecame dissatisfiedwith hospitalbirthduringthe
naturalchildbirthmovement of the 1960s and 1970s, the subsequent"homebirth
renaissance"in the 1980s prompteda resurgenceof interestin midwives to attend
childbirthin the home (Davis-Floyd,Pigg, and Cosminsky2001:106).
By the 1990s, a cross-class movement for midwifery had begun to develop
in Virginia,formingan unexpected,and at times uneasy,alliance between largely
middle-classandaffluentnaturalchildbirthproponentsandthe low-incomewomen
who continuedto rely on midwives for prenatalcare and deliveries in many rural
areasof the state(CravenIn press).One rurallybasedVirginianurse-midwife,who
operateda homebirthservice from 1984 to 1997, recalledher surpriseat learning
the diversemotivationsfor women who sought midwives in her publisheddiary:
Oneof my firstlessonswasthatmanypeoplewhocalledformy servicesdidnot
necessarilysubscribeto the philosophyof the homebirthmovement.I learned

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quicklythatjustas not all midwivesarealike,notall peoplewhochoosehome

birtharealike.Not all of thepeoplewhocalledwantedtheprivacy,thedignity
andthe "naturalness"
thatcome withhavinga babyat home.A lot of people
calledmebecausetheydidn'thaveinsurance
andtheycouldn'taffordthedoctor
orthehospital.[vanOlphen-Fehr
1998:103]
Althoughmanyundergroundmidwivesattendedhomebirthsduringthe 1980s
and 1990s in Virginiawith little interferencefromthe state,increasedinvestigations
of midwives in the 1990s and the prosecutionof a prominentVirginiamidwife
escalatedconcernsfor undergroundpractitionersandtheirclients (Craven2003:815). Homebirthersbegan to organizelocally in many areasof the state and, by the
late 1990s, homebirthproponentswere actively pursuinglegislation that would
makeDEM legal in Virginia.Respondingto theirconstituents,lawmakersinitiated
the Joint Commission on Health Care (JCHC)Midwifery Study in 1999, which
concludedthatit was advisableto legalize DEM in Virginiaandthatthe stateshould
license certified professional midwives (CPMs) as a mechanism for doing so.5
However, duringthe following three years (2000, 2001, 2002), when midwifery
proponentsintroducedlegislationto thateffect, the bills were rejectedbefore even
reachingthe House or Senatefloor.The stronglobby of variousmedical groupsin
Virginiawas instrumentalin effecting these decisions.
Each year, attendingmembersof the Health,Welfare,and InstitutionsCommittee (HWICommittee)listenedto 15 minutesof testimonyfrombothopponents
and proponentsof the bills before defeating the bills. Opponentsincludedrepresentativesof the VirginiaObstetriciansand Gynecologists Society (VA OB/GYN
Society), the VirginiaSection of the AmericanCollege of ObstetriciansandGynecologists (VA-ACOG),and the Medical Society of Virginia.Proponentsincluded
representativesof grassrootsorganizationssupportingmidwifery,CPMs who had
practicedlegally in otherstates,andsupportiveVirginiacertifiednurse-midwives.6
After each presentation,delegates were given time to ask questions of speakers
regardingthe specifics of their presentationand the bill in general. On several
occasions, these questionsprovokedlengthy conversationsamongparticipantsregardingthreemain themes:the safety and risks of homebirth,the trainingof midwives, and, as I highlightin this article,the rightsof parentsto choose appropriate
health care for theirchildren.
It would oversimplifythe legislative process-as well as the persuasiveness
of unregulatedcampaigncontributionsby well-fundedmedical organizationsand
individualphysicians in Virginia-to account for any of these examples as the
single definingargumentthatwon the case for opponentsof midwiferylegislation.
However, it was clear that legislators gave at least tacit approvalthiough nods
and affirmativegestures when medical officials presented"commonsense"arguments that linked the medical managementof childbirthto governmentcontrol
over motheringpractices.In contrast,legislatorswere generallyinattentiveto the
presentationsof midwiferyproponents.7
"BirthIs, by Nature,a Medical Event":Medical Authorityas "CommonSense"
In the first HWI Committee hearing regarding CPM licensure in 2000,
Dr. John Partridgespoke in opposition to House Bill 1470 (Commonwealthof
Virginia 2000; hereafterHouse Bill is referredto as HB), representingthe VA

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OB/GYN Society and VA-ACOG. He began his presentation by touting the medical advances in maternity care over the past hundred years:
Modem medicine has broughtmaternitycareto an ever-saferlevel and loosening
the standardwould place mothers and babies at risk.... Birth is, by nature,a
medical event. /In contrast,homebirth is/ a slippery slope, like driving a car
withoutbrakes.Youmay do okay on level groundwith no turns,butwhen the road
startsgoing downhill,andyou startmakingsome turns,it gets very dicey.... Isn't
it logical to think hospitals and doctors have made birth safer?/I hope that you
will/ preservethe public health of mothersand babies by preservingthe current
statutes.You'll hearmotherstalk aboutpreservingtheir rightto choose, butI ask
you, what about the baby's choice? [John Partridge,HWI Committeemeeting,
February8, 2000]8
Drawing on an ideology of medical superiority embedded within his discourse
(Fairclough 2001 [1989] :65), Partridge primed his audience for his "commonsense"
assertion: Birth is, by nature, a medical event. Thus, when Partridge invoked nature
as an analogy for medicalized childbirth, he spoke to assumed societal standards
of risk in childbirth, as well as the naturalization of the contemporary power of the
biomedical model in the United States. Partridge's analogy, which linked driving a
car without brakes to the dangers he associates with homebirth, served as additional
reinforcement of the authority and hierarchy of the biomedical system by applying
to homebirth with midwives the long-established medical metaphor of the body as
machine and the physician as mechanic (Martin 1987:56; Rothman 1989:55-57,
171). Clearly, Partridge suggested, CPMs lack the tools to deal with complications in labor. As Jordan reminds us, what is so persuasive about authoritative
knowledge is that "it seems natural, reasonable, and consensually constructed"
(Jordan 1997:57). Therefore, it came as no surprise when Partridge suggested,
commonsensically, that homebirth mothers are unnecessarily risky in their choice
to birth outside the hospital: Isn't it logical to think that hospitals and doctors have
made birth safer? In answer to his rhetorical question, Partridge asked delegates
to join him to preserve the public health of mothers and babies, linking his role
as a physician and the state's role as protector of the health of its citizens. This
strategy is doubly effective because the statement places the power and authority
of good outcomes with physicians and the state, while bad outcomes remain the
responsibility of the mother.
Further, Partridge countered women's right to choose nonmainstream reproductive health care with a familiar slogan from the pro-life movement: What about
the baby's choice? This final statement draws attention to connections between advocacy to gain access to midwives and social movements around other reproductive
health issues. As Pamela Klassen reminds us:
Argumentsagainsthomebirththatbelittlewomen'sexperiencesof birth(of the "if
you want an experience,ride a rollercoaster"variant)and refuse to acknowledge
women's right and responsibilityto choose their desired place to give birth, fit
along a continuumwith... fetal rightsarguments.They downplaya woman'srole
and experience giving birthin place of emphasizingthe "outcome"of the baby.
However, in a society that proclaims passionate interest in healthy babies, but
then fails to find solutionsto the problemsof child povertyonce those babies age,
these are not so much positive argumentsguardingthe baby as they are negative
argumentscircumscribingthe autonomyof the birthingwoman. [2001:61]

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The "logic,""nature,"and"commonsense"of medicalauthorityaroundchildbirthwas centralto medical officials' devaluationof homebirthand more importantly,homebirthmothers.
"InHomebirthsEitherMyselfor My ChildrenWouldHave Been at Risk":Biomedically ManagedChildbirthas a Signifierof RespectableAmericanMotherhood
Dr. Anne Petersen, commissioner of the VDH, coordinatedthe testimony
of the opposition to the bill reintroducedto legalize the licensure of CPMs in
the 2001 HWI Committeehearing (Commonwealthof Virginia2001:HB 1582).
She opened the opposition's commentaryby explaining her own position as a
mother who made the mainstreamchoice to deliver her childrenin the hospital.
It was an importantfeature in the personal testimony and childbirthnarratives
offered by female physicians that they were able to claim authoritativeknowledge aboutchildbirthandmotherhoodas both physiciansand respectablemothers
themselves.9Female medical officials reliedon theirown experienceof childbirth
andmotherhoodas a mechanismto questionthe legitimacyof homebirthmothers'
childbirthdecisions. In this excerpt,Petersenuses herown experiencein childbirth
to reaffirmPartridge'sstatementfrom the year before that the decisions of homebirth mothers are dangerousto themselves and their babies. Further,she places
homebirthmothersoutside the cadreof normalAmericanmotherswho accept the
biomedical managementof labor and delivery as the only way to reduce risks
associatedwith childbirth.
I myselfhadlow-riskpregnanciesandhigh-riskdeliveriesandin homebirths
eithermyselformychildrenwouldhavebeenatrisk... /Birth/is a placewhere
Americanshave spokenvery stronglyabouttheirwillingnessto takeon risk
relativeto deliveries.OB/GYNdoctorspay moremalpractice
thanmostother
whodo laboranddeliveryservicespaymore
physiciansandfamilypractitioners
thanfamilypractitioners
whodo notdo it. So, Americanshavereallyspokento
theamountof risktheyarewillingto acceptin thisarena.[AnnePetersen,HWI
Committee
30, 2001]
meeting,January
Petersenseparateshomebirthmothers'fromAmericanmotherswho acknowledge highrisksin pregnancyby theirwillingnessto go to the hospital(andto litigate
when things go awry, as indicatedby rising malpracticerates). She also implies
thathomebirthmothersdo not accuratelyassess the risksassociatedwith childbirth
and do not upholdAmericanvalues when they refuse to abide by the mainstream
childbirthparadigmto lessen those dangers.
The strategy of rebuking homebirthmothers' for their inability to assess
risk was also common among physicians seeking the elimination of midwives
in the early 1900s. For example, early 20th-centurymedical reportsin Virginia
impugnedAfricanAmericanwomen for their"inattention"to theirprenatalcare,
their"failure"to report"dangersignals"duringpregnancy,andtheir"insensibility"
to the health of their newborns(Fraser 1998:132). These mothers' "failure"and
"insensibility"was often considereda result of their continueduse of midwives,
particularlyamongpoor women as segregatedhospitalclinics became availableto
middle-classandaffluentAfricanAmericansin the mid-1900s.Few of thesereports
ever addressedthe economic impoverishmentin African Americancommunities

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at the time as a factor in high infant and maternal mortality statistics (Fraser
1998:86). In contrast, medical reports at the turn of the 21st century rarely mention
the relatively good health of most contemporary homebirth mothers, or the betterthan-average health of their babies (Declerq, Paine, and Winter 1995:480).10

"It Only Takes One Bad Baby": Constructing the Choice to Homebirth as
Pathological Motherhood
Throughout the recent debate over legalizing DEMs in Virginia, physicians
have maintained that mothers who choose homebirth were bad mothers. For example, the president of the VA-OB/GYN Society explained to lawmakers in 2000,
"I call homebirth the earliest form of child abuse" (LeHew as cited in Forster
2000:A1). As the public debates waged on from 2000 to 2002, the medical opposition became more insistent that it was indeed state and medical officials who
were more competent than mothers and parents to judge the "best interests" of
Virginia's future citizens.
In the 2002 HWI Committee hearing regarding several bills to license DEMs
through different state regulatory structures (Commonwealth of Virginia 2002a:HB
889; Commonwealth of Virginia 2002b:HB 890; Commonwealth of Virginia
2002c:HB 891),11 a state delegate asked Dr. Steven Bentheim, a representative
of VA-ACOG and the VA-OB/GYN Society: "But doctor, any patient has the right
to consent to treatment, and if it is a minor child, then I, as the parent, am the one
responsible for giving consent for that minor unless you want to go through a legal
process to take my parental rights away. That is the current law, am I correct?"
In response, Bentheim constructed the mother's choice to homebirth-not just the
practice of midwifery-as a pathological behavior by linking it with criminal acts,
such as negligent motherhood and illegal drug use.
I think that sometimes uh- that the mother's decision to deliver at home is not
always in the baby's best interest, although, I think she might think it is. I'm
not sure it is.... I do thinkthat we also have to have minimalrequirementsover
parentsin the care of theirchildren.We don't let them be-, in the news, a parent
that goes to the store and leaves her child at home, the house bums down, she,
you know, it was her prerogativeto leave the child at home while she went. She
thoughtthatit was okay for the child to do so, but she is then-, you know Social
Services or whoevermay come in and investigatethat. She may be /responsible/
or something. So, I think, once again, we have to-, hopefully try to find what
we think is in the best interestof the motherand also in the best interestsof the
child.... But life is precious. And I'm telling you that these are childrenand it
only takes one bad baby, or two bad babies to make you realize-.... I'm trying
to thinkof how to say this uh, I'm not sure thatjust because it is going to happen
that you have to-, you have to go along with it. Just the same way that we don't
legalize drugs and I mean we don't say "okay,you know what, people are going
to use drugs"andagainthis is probablya bad analogyagain,butpeople aregoing
to make decisions for themselves and they're going to do it even though it isn't
in their best interest. [Steven Bentheim, HWI Committeemeeting, January24,
2002]
In his answer to a delegate's question about the rights of parents regarding
their children's health care, it is notable that Bentheim shifts to the use of a feminine

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pronounin his response;he invokes the idea of the pathologicalparent that goes
to the store who leaves her child unattended,therebyspecifying the motheras the
negligent or bad parent.Bentheimalso transitionsfrom a parent leaving her child
at home, to best interests of the indefinite the child and the mother, effectively
removing the individualmother'sagency, possibly because of her "badchoices"
for her child. This strategyserves to legitimize the state's and medical system's
responsibilityfor the welfare of theircitizens, both motherand child, and delegitimizes those motherswho do not follow theirregulations.
The mother'sdeparturefrom the privatespace of the home is also important
when she leaves her child at home to go to the store. Ultimately,a public state
body, Social Services or whatever,must intervenein the mother'sprivatespace to
investigatewhethershe may be held responsibleand ensure her good mothering
behavior.This admonishmenteffectively argues against women's legal rights to
make motheringand childbirthchoices in the home by linkinghomebirthmothers
to negligent mothers.Notably,Bentheim'stestimonycontradictsthe currentstate
regulationsaroundhomebirth,that he wishes to uphold, which maintainit as a
legal choice for Virginiawomen (albeit withouta compensatedpractitioner).
Additionally,Bentheim's use of oppositionaldiscourse against an unidentified them in the beginning of his answer extends his personaltestimony against
midwiferyto evoke the responsibilitiesof both physiciansandthe stateas a whole
to protectVirginians:we have to do what is in the best interestsof the motherand
the child. Bentheimemphasizesthe role of the state and physicians in regulating
the motheringpractices, and by extension the birthingpractices, of potentially
negligent mothers.Bentheimalso transitionsfrom talkingabouta/the motherneglecting her/the children in the last passage, to returnto the potential hazards
motherspose to their babies. Similarto ways in which pro-life advocateshumanize babies (as opposed to fetuses) whose lives are ended by abortions,Bentheim
drawson the sympathiesof the audience against a motherwho would choose alternativesto mainstreamchildbirthpractices that he deems unsafe for her baby.
In fact, he cautions against producingbad babies, instead of, perhaps,bad outcomes, which conveys the pathology ascribed to homebirthingmothers further
onto theirchildren.As Susan Hyatt suggests in her study of the medicalizationof
motherhoodamongpoor women in Britain,medical and state officials often identify the mother"not primarilyas an individualin her own right but... rather,as
someone who [stands]in a metonymicrelationshipto the entirepopulation... the
conduit throughwhich her children [are] to be made into productiveand healthy
citizens of the state (or not)" (1999:103). Therefore, if a mother is risky or
otherwise deemed unfit, her unfitness could potentially be passed along to her
children.
Further,Bentheim'sequationofpeople who are going to use drugsandpeople
who are going to makedecisionsfor themselves,presumablyto homebirth,shows
how he links negligent mothers,illegal drug users, and homebirthmothers.Ultimately, Bentheim implies a metonymic connection between individualwomen's
"bad choices" in childbirthand the health of society at large by likening homebirthto practicesthatmost audiencemembers(includingdelegates andhomebirth
proponents)would agree are indeed bad choices. This strategyallows Bentheim
to markhomebirthingsimultaneouslyas a symptomof pathologicalmotherhood
and a practiceto be restricted,if not abolished,by the state.

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The state's regulationand punishmentof women whom it deems pathological mothers is hardly a new phenomenon-consider the discreditingdiscursive
constructionsthat have become emblematicof "undeserving"women in the media, such as "welfarequeens,""crackmoms,"and "promiscuousunwed mothers"
(Cruikshank1999; Edwards 1999; Morgen 1988; Naples 1998; Whiteford 1996;
Williams 1996). It is also nothingnew thatwomen who do not follow mainstream
childbirthnorms are labeled bad mothersand bad citizens (Feldstein2000; Fraser
1998; Gordon 1994; Hyatt 1999). In one example, Linda Whitefordshows how
drug-addictedmothers(and their fetuses) are punished"forbeing poor, pregnant,
anddrugaddictedin a society thatdenigrateseach of those conditions"(1996:249).
Particularly,she argues that drug-addictedwomen who attemptto protectthemselves andtheirfetuses fromgoing to jail by avoidingprenatalcareareidentifiedas
pathologicalcriminalsif it is provedthattheyhave used certaindrugsin pregnancy.
Ironically,the state punishes these women (and their fetuses) furtherby denying them both prenatalcare and addiction treatmentwhile they serve jail terms.
AlthoughI would not equatehomebirthwith drug addictionduringpregnancy,as
Bentheim seemed content to do in front of the VirginiaGeneral Assembly, both
examplesilluminatehow pejorativestereotypesaboutmotherswho attemptto protect themselves and their childrenoutside of state-sanctionedmodels are used to
devaluetheir statusas good mothersand good citizens.
Midwifery Advocates' Responses to Medical Discourse in the Legislature
Midwifery advocates' testimonyduringlegislative hearingsand their subsequent accounts of the hearings in conversationwith each other were important
features of the political mobilization aroundmidwifery in Virginia. During the
hearings, speakers in favor of the legislation presented studies on the safety of
homebirth,outlined CPMs' extensive training,and respondedto claims by medical officials that they were pathological mothers. Afterward,in my interviews,
many participantscited their attendancewith other advocates at legislative hearings as one of their most importantcontributionstowardgaining access to DEMs
in Virginia.
Midwifery advocates' frustrationwith state and medical officials' portrayal
of homebirthingwomen as pathologicalmothersand the disregardof their rights
as citizens were dominantthemes in theirnarratives.Participantsexposed medical
officials' attemptsto link stateandmedicalideologies aroundchildbirthandmothering practices. They challenged medical claims to authoritywith the state over
the stewardshipof mothersand babies. Further,midwifery advocateschallenged
medical claims that their desire to homebirthnegated their status as respectable
mothers.In fact, manyhomebirthmothersarguedthattheirchoice to birthat home
actuallyreinforcedtheirclaims to respectablemotherhood,as they protectedtheir
babies from what they deemed unnecessarymedical and state interventions.
"We've Decided for Ourselves and Our Babies": Reclaiming Respectable
AmericanMotherhood
Speaking for the grassrootspro-midwiferyorganization,Virginia Birthing
Freedom(now VirginiaFriendsof Midwives), Ellen Hambletformallychallenged

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opponents' claims against homebirth and homebirth mothers in the HWI Commit-

tee meetings.Like female doctorswho reliedon theirown statusas mothersas well

as theirprofessionalcredentialsto bolstertheirclaims to authoritativeknowledge,
Hambletpresentedherself as a motherconcernedwith the safety of her children
alongside her professionalcredentials-her service in the U.S. Navy and her po-

sition as the codirector of a grassroots pro-midwifery organization. Challenging

physicians' assumptions of what normal Americans desire in childbirth, Hamblet
argued that women who desire homebirth are indeed concerned with the health
and safety of babies, and by extension, are also normal respectable American
citizens.
When it comes down to the bottom line, we are all, everybody in this room,
concerned with the health and safety of babies. So, we should be able to start
with this bottom line and build something that we all can be proudof as a way,
as Dr. Petersonsaid, to supportmidwives in Virginia,and also to allow families
to make the informedlegal choice to have theirbabies at home, to be able to hire
a midwife.... Most of us neverhave the occasion to even wonderaboutwhether
the hospitalis a safe place to be in birth.That'sthe way we do it in this country.
That'sthe way most of us did it for our firstpregnancies.Most women neverhave
a chance to come back and question that decision, never have reason to come
back and question it because their experience in the hospital is great.They have
a greatdoctor,they have a greathospital,everythingworksthe way it's supposed
to be, they feel well served by the system. Those are not the women in this room
today.We are mostly women who have gone and have had bad experienceswith
hospitalbirthand feel thatthese experienceswere unnecessarilydangerous,that
they were at a minimumdisrespectful,and they scaredus and made us feel that
this is not the place we wantedto go necessarilyfor birth.... I'll tell you, we're a
bunchof Moms here and what we know is thatwe've done a lot of research,that
we've decided for ourselves and our babies that we want to have a homebirth.
We'retelling you thatwe need to be able to hire a midwife to do that.We'retelling
you that we can't hire midwives right now because there is no path, there's no
way to do thatin Virginia... legally. And so, we're telling you thatwe need your
help. [Ellen Hamblet,HWI Committeemeeting, January30, 2001]

Unlike physicians' accountsof risky and ill-informedmothers,Hambletportrays homebirthparents as normal American moms who have rationallychosen
to question childbirthin the hospital, especially after their negative experiences
in hospitals duringprevious births. Hamblet challenges the commonsense logic
that all births are medical events and need to be attendedby physicians in hospitals. By focusing on the logic and rationalityof homebirthmothers' concerns,
Hambleteffectively pleads for the protectionof the state regardingwomen's legal right to choose homebirth.By counteringmedical challenges that suggest the
negligence or insensibilityof homebirthmotherstowardthe welfare of theirchildren,Hambletattemptsto legitimatenot only homebirth,but also the responsible
decision-makingstrategiesof homebirthmothers. Hamblet characterizeshomebirthersas respectableAmerican mothers, precisely because of their pragmatic
decisions aroundchildbirthand the health of their children,particularlyafter experiencingdangerousand disrespectfultreatmentin the hospital. Just like all respectableAmericanmothers,homebirthmotherswant what they deem the safest
for themselves and theirbabies.

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Hambletwas not alone in her dissatisfactionwith medical officials' portrayal

of homebirthmothersin the legislature.Althoughotheradvocatesdid not respond
formally within the GeneralAssembly, many wrote letters to lawmakers,newspapers, and even the opposing physicians themselves. Midwifery advocates also
respondedprivatelyto the charges leveled against them, both on listservs and in
conversationswith otheradvocates.Whatfollows is a selection of these responses
from my interviewswith midwiferyadvocates.
"I See It VeryClearly as Rape Now": HomebirthMothers versus Medical and
State Officials
Nearly all of the participantsin my study expressed a sense of disempowermentby boththe stateandthe healthcare system as homebirthingmothers.Indeed,
as discussed above, theirchoice of homebirthis contestedpublicly in the Virginia
legislature.Many midwifery supportersexplainedthat their role as mothers,and
certainlyas homebirthers,seemed insignificantin this domain;many felt too insignificant, too fringe, too extreme,too ignorant, radical, stupid, naive, and not
sophisticatedenough to demandrights throughpolitical actions as citizens. The
following narrativesillustratehow midwiferyadvocates'feelings of disempowerment, anger,and frustrationsurroundingmedical and state discourse also present
challenges to societal standardsaroundmedicalizedmotherhood.
Throughoutmy fieldworkandinterviews,I heardagainandagainfromhomebirth mothers that they felt disregardedby both doctors and legislators. For example, Paula Queen uses the metaphorof being raped-both throughmedicalized childbirthin the hospital and throughthe big hand of governmentregulating
her childbirthoptions-to indicate the collusion of state and medical ideologies
of childbirthagainsthomebirthingwomen.
Well,to havea child,you haveto playit theirway andI see it veryclearlyas
rapenow.I'vebeenthroughit I knowandthatreallymakesyoua certainperson,
and it also makes me questionmyself thatI was so blindedthatI thought-, that

I was raped,okay?AndI can'tevenmournit. I couldmournit by myself,but

there'snotthatmanypeoplethatunderstand
it. It'snotlikeI cango reportit to let
youknowyou'restandingupforyourself.It'sreallya layingdownof one'sself
andthat'sit. It'sperversionto a veryhighsense.If you eraseit, thenyou have
theotherfeelingof thebabythatmakesit all worthit. So, I'm sorry,I see it as a
crunchof thebig handof government
comingdownanddoingthatandwomen
not even knowing it. That's the whole thing... they really are missing a partof
them. You can see it, it's not there. [personalinterview,Paula Queen, April 17,
2002]

Most importantto Queenis thatwomenarenot even recognizingthatboth the

medical system and the big handof governmenthave takentheirpoweraway from
them. She links the disavowalof the mother'schildbirthexperienceas rape to the
positive outcomeof havinga babythatmakesit all worthit (see also Jordan1997).
She attributesthis disjunctureto the state itself, not only the medical system that
she feels rapedher duringhospital-basedchildbirth.In essence, Queen feels that
women are being doubly rapedby being forced to "choose"hospital birth-both
by the politics of doctorsin the hospitalandby her governmentthatdenies her the
rightto legally choose a midwife to attendher homebirth.

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Midwifery advocates also contrasted themselves with lobbyists and state officials by highlighting their status as mothers and demanding their rights as women,
mothers, and citizens. In response to my questions about her motivations for political activity around midwifery, Fern Jackson told me an extended narrative about
being disempowered by health care workers during her first birth in the hospital
and her ensuing efforts to hire a homebirth midwife for her second birth. This
process motivated Jackson to become politically active and to examine her role as
a reasonable citizen.
I thinkprettyhighly of myself as being very well educated,very concernedabout
my childrenand their health and well-being, very well informed,the idea that I
could go and do all thatresearchand make my decision, okay,this is whatis best
for me and for my family,umm, andthen to have the statetell me, "No, you can't
make that decision because you can't hire a midwife for homebirth.""Wethink
thathomebirthis too dangerous,"which has been theirstatedobjection.... It's so
anti-American,it's anti-everythingthis countrystandsfor and I umm, am pretty
committedto the kind of ideals that the countrystands for.... And I don't think
I can point to a specific place where it [the Constitution]says it, but it certainly
implies in there that reasonablecitizens should be able to do their own research
and maketheirown decisions aboutsomethinglike who they wantto hire, where
they want to give birthto theirbaby.And the state has no business in standingin
the way of that. That's not why states were founded or constructedto basically,
ya know,to protectthe monopoly on healthcareby the medicalsystem. [personal
interview,FernJackson,September13, 2002]
Jackson argues that she, as a reasonable citizen who is well educated and well
informed, should be able to choose where and with whom she gives birth. Further,
she challenges medical claims that the choice of homebirth is un-American: I
am pretty committed to the kind of ideals that the country stands for. Rather, she
contests that it is anti-American, it's anti-everything this country stands for for the
state to restrict citizens' access to the health care practitioners of their choice and
protect the monopoly of health care by the medical system.
Likewise, Evie Diaz expressed her frustration that citizens, in contrast to paid
lobbyists, were dissuaded from participating in the legislative process. The narrative below followed questions I asked regarding Diaz's attitude toward political
activity. Her initial response was brief: "Um, let me see how to say this, um, that
our freedoms are for sale to the highest bidder?" In turn, I asked: "How do you
see that impacting what is being done politically [for midwifery]?"
We would have to sit throughso many other issues and we were the only citizens down there. Everyone else-, were lobbyists who-, hired guns to go get
something for their, um, um, industrythat was paying them to be there. And
we were a bunchamoms with an occasional dad.... And h-how insignificantwe
were viewed. I mean, it has been, well it's, it's, it's obstetricsall over./We were/
so disrespected.They really did not want to see us and then somebody would
pull a boob out or a baby would cry (laughing)or you know and they'rejust like
"Oh, God?!" I mean, [Linda Darner]posted [to a listserv] that you know "this
is called confrontationalpo-, um lobbying"or whateverthatfor the governor's
office andI'm like (smackstongueon the roof of hermouthin a chiding manner),
I'm thinkingwe've been prettyconfrontationalfrom the beginningjust cause we
showed up. They have not known what to do with us. We were told we had bad
manners.[personalinterview,Evie Diaz, February3, 2001]

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Diaz initially sets up we'broadlyas midwifery advocates, and more specifically as citizens. By downplayingthe political importanceof citizens as a buncha
momswith an occasional dad againstlobbyists,everyoneelse, andhiredguns who
are paid to go get somethingfor their industrythat was paying them to be there,
Diaz highlightsthe importanceof advocatesas volunteers.
It comes as no surprisethat it is (mainly) women who are participatingas
volunteers,in contrastto (mainly) male legislatorsand lobbyists who are paid to
attendthese hearings.The implicitvaluationof wage workin Diaz's narrative,and
also in largersocietaldiscoursesaroundwomen'scitizenship(Hyatt2001; KesslerHarris2001), forces anthropologiststo considerhow women's statusas mothers,
homebirthers,and grassrootsvolunteerscontributeto and restricttheir claims to
rightsas citizens. As SusanHyatt(2001) indicates,the recentpublic celebrationof
"volunteering"and the "spiritof service"for the United States-see, for example,
State of the Union addresses by Bill Clinton and George W. Bush aroundthe
turn of the 21st century-suggests a new kind of political subject. Volunteers
underthis political rhetoricdo not shareboth rights within and responsibilitiesto
the state as the citizen does. Rather,they function only in obligation and service
to the state-effectively removing the state's obligation to protect the freedoms
and social, political, and economic rights of these individuals(Hyatt 2001:205).
Womenhavebeen theprimaryvolunteersunderthis new model of politicalsubjects
(Hyatt2001:208).
Echoingthe concernsof otheradvocatesthatmedicallobbyistsandlegislators
saw midwiferyadvocatesas motherswith bad manners,Diaz uses adjectives,such
as insignificant,disrespected,andconfrontationalto describemidwiferyadvocates
in contrastto hired, paid medical lobbyists in the GeneralAssembly. Michael P.
Brown (1997) suggests that activists often identify themselves in contrastto state
officials: "In the citizens that we imagine, the voters, grassrootsvolunteers,and
clients are recipientsof urbanservices, while the bureaucratsare paid employees,
professionals, and experts inside of, and embodying, the state" (1997:85). Diaz
firstidentifiestheyas lobbyists and then theybecome an amalgamationof medical
lobbyists and legislators when she suggests they really did not want to see us.
And then somebodywouldpull a boob out or a baby would cry (laughing) or you
knowand they'rejust like 'Oh, God?!' Diaz alludes to both medical lobbyists and
state officials in this instanceby suggesting theirjoint discomfortwith an openly
nursingmother,and more specifically when she likens her experienceswithin the
legislature to the disrespect she and other women have faced during childbirth
experiences in the hospital, it's obstetrics all over. IWewerel SO disrespected.
Diaz's equationof these groups is hardly surprising,as she and other midwifery
supportershave witnessed legislatorsside with the powerfulmedical lobby again
andagainin pastyears.12At the same time, the dichotomizationof mothersagainst
state and medical interests in childbirthposes challenges to advocates as they
attemptto work within the legislative system to legalize homebirth.
"MyFriendly Policeman": ComplicatingMidwiferySupporters'Views of State
and Medical Communities
In addition to advocates' apt considerationof the links between medicine
and the state, and the monolithic, bureaucraticpower structure,which appeared

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unbendingto their desires for legal homebirthwith midwives, many midwifery

supportersalso observe cracksand contradictionswithin this structure.For example, the chief patronof pro-midwiferylegislation, Delegate Phil Hamilton, was
quite skeptical of homebirtherswhen midwifery advocates first approachedhim
about pro-midwiferylegislation. TerriJacobs explained: "[Hamilton]is the one
who carriedthe study and who carriedthe bills. And at firsthe seemed to be very
disinterested,he was just doing it. But he turnedinto the most interestedpersonin
the issue. I can't believe thathe's takenthe standthathe has"(personalinterview,
August 7,2001). Many supportersspoke aboutthe importanceof sharingpersonal
narrativeswith legislatorsat public hearingsand in letters.Supportivelawmakers,
such as Hamilton,also publicly creditedthe passion of these narrativesas the reason they came to supportmidwiferylegislation(HWICommitteemeeting,January
24, 2002).
Outsideof the GeneralAssembly,midwiferysupportersalso recognizedboth
stateandmedicalofficialswho influencedtheirinstitutionalsystem in theirsupport
of undergroundmidwives. Even as midwives and their supportersspoke of being
harassed by "the state,"they also indicated sympatheticindividuals within that
structure,suchas individualpolice officers-one midwife even describedanofficer
as "my friendly policeman"-and health departmentofficials who allowed the
statuteof limitationsto runout on investigationsto warn,butnot actuallyprosecute,
midwives.
Ultimately,homebirthersand midwifery advocates saw themselves as both
respectablemothersandupstandingcitizens, alongsidethose sympatheticlawmakers and police officers who agree thatmidwiferyshould not be a crime. However,
they also recognize themselves as a minority within lawmakers'constituencies,
where female voters are largely satisfied with hospital-birthchildbirth;as Ellen
Hambletso aptly put it, "everyonejust assumedthat... families who chose home
birthwere, well, a little kooky"(Hamblet2000).
Conclusion
I have shown how official medical discourse aroundmidwifery argues that
women arenot competentto make the choice to have a homebirthbecause they do
not participatein good Americanmotheringpractices,particularlyby eschewing
the mainstreamchoice to deliver their children in a hospital-where, as both
advocatesandscholarshaveargued,they arealso devaluedandinfantalized(DavisFloyd 1992; Hyatt 1999; Kahn 1995; Martin 1987). This argumentenables both
physicians and state officials to arrogateto themselves authoritativeknowledge
aroundchildbirth,as well as the responsibilityfor the protectionand regulation
of mothers and babies, thus protecting a monopoly by the mainstreammedical
industry.Further,this strategy challenges homebirthmothers' respectabilityas
Americanmothersand links them with other "pathological"motherswho are at
variancewith dominantmedicaland stateideologies aroundappropriatechildbirth
and motheringpractices.
In response, midwifery advocates have begun to reclaim the notion of respectablemotherhoodandjustify theirchoice to homebirthas a partof theirgood
motheringpractice. Like medical officials, midwifery advocates understandthe
collusion of medical and state controls over women; they identify the state and

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medical community as men wielding power against a group of disempowered

homebirthmothers.They also recognize medical and state officials as a group of
paid professionals,in contrastto themselves as volunteersand citizens.
Takentogether,the dissatisfactionanddisempowermentthatmanyadvocates
feel from both medical and state authoritiesevidence an understandingof the
stateand the medical communityin coalition-in oppositionto a groupof women
vying for their right to make particularchildbirthchoices. However, midwifery
advocatesalso see certaincontradictionsin thishegemonicmedicalandstatepower
structure,most notably, the state investigatorsand legislators who have become
sympatheticto theircause. Joiningthese other"good citizens"within the ranksof
the bureaucraticstructureof the state,midwiferyadvocatescontinuetheirattempts
to convince lawmakersof their commitment to both "respectablemotherhood"
and "respectablecitizenship."Ultimately,it is in relationto the state and medical
oppositionthatmidwiferysupportersdefinetheirpoliticalmobilizationas mothers
and citizens.
Epilogue
In 2003, Virginialegislators struckdown the 1977 statutethat had made it
illegal to accept compensationfor midwifery services without a license (granted
only to CNMs). Notably, the decision was made relativelyquietly, with little opposition from medical officials, and withoutthe public debatesthat characterized
legislative hearingsregardingpreviousmidwiferybills. The reasons for this shift
have been open to speculationamong midwiferysupporters,but stateandmedical
officials have subsequentlymade it clear that rescinding the 1977 law does not
protectmidwives againstchargesof practicingmedicine withouta license or practicing nurse-midwiferywithouta license. Midwives and homebirtherscontinueto
shareconcernsover the legal safety of DEMs, especially becausemedicalofficials
have fought diligently against subsequentbills to license CPMs and legislators
rejectedbills aimed at licensurein 2003 and 2004.
Since the legislative change in 2003, DEMs have become more politically
visible and have been the primaryspeakersadvocatingfor their licensure at legislative hearings. A bill to license DEMs as CPMs made it through Virginia's
House of Representativesin 2004, but was rejectedby the Senate Committeeon
Educationand Health after a physician's testimony asserting,familiarly,that licensing midwives "wouldnot be in the best interestsof the women andchildrenof
Virginia"(RobertMcBride, Senate Committeeon Educationand Healthhearing,
February24, 2004). One senatoralso told a personal story before the vote. She
explainedthather friendhad desireda home deliveryin 1969, buthad hadto come
to the hospitalbecause both women were in laborat the same time andplannedto
havethe same obstetricianin attendance.13The senator'sfriendhadcomplications,
but was treatedsuccessfully in the hospital. Afterward,the physiciancreditedthe
coincidence of the senator's labor, which requiredthe other woman to come to
the hospital, with saving the homebirth-boundwoman's life. The senatorclosed
the story by relaying the physician's decision never to attendanotherhomebirth.
By the senator'saccount,her prudentchildbirthchoices saved the life of her unknowingfriend,as well as any otherhomebirtherswho mighthave followed in her
footsteps with this physician. She characterizedher vote againstthe bill to license
CPMs as an extension of her efforts to protectVirginiawomen from such choices.

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It is clear that despite the increased participation of midwives in the legislative debates over their practice in Virginia, anecdotes implying that women who choose
homebirth are uninformed, or must be reckless, remain convincing arguments in
efforts to restrict the practice of midwives.
Despite these continued setbacks, as this article goes to press, legislation to
license CPMs has just passed through both the Virginia House and Senate and
awaits the governor's signature, to go into effect in July 2005. Midwives and
advocates are ecstatic and see the passage of this legislation as evidence that their
hard work lobbying legislators over the past eight years has been worthwhile. As
Virginia midwives now face the daunting task of negotiating regulations with the
Board of Medicine and as homebirthers struggle for access to midwives in other
states, the interrogation of claims to respectable American motherhood remain
essential to the analysis of health care policy debates, as well as the implementation
of laws promising enhanced reproductive rights.
NOTES
Acknowledgments. I am gratefulfor the comments and suggestions of three anonymous reviewers, as well as the constructivefeedback on drafts of this article from Bill
Leap, Brett Williams, Susan VirginiaMead, Heidi Schultz, Tricia Silver, Mindy Michels,
Denis Provencher,Stephen Craven,Brenda Murphy,and Teo Owen. Sadly, I am unable
to individuallythank many of the midwives and homebirthmothers who inspired me to
engage in this researchbecause of the tenuouslegal situationfor midwifery in Virginia-I
am deeply indebted to each of you for sharing your personal and political struggles.
Research for this study was also supportedby two grants from the College of Arts and
Sciences at AmericanUniversity.
1. Although the term medical discourse has been used almost exclusively to refer
to dialogue in the practitioner-patientinteraction(Kuipers 1989:109), scholars have also
begun to look at how medical discourse is constructedand resisted in discussions among
health care recipients (Hamilton 1998; Leap 1991) and within health care policy debates
andpolitical activity(Gal 1997;Ginsburg1987;Lay 2000a). Forthe purposesof this article,
I use this expandeddefinitionof medical discourse to refer not only to the doctor-patient
relationshipor the interactionsamong medical staff within and without the hospital but
also to the ways in which medical officials talk about health care practicesto state policy
makers.
2. Direct-entrymidwifery is a term that originatedin Europeto describe midwives
who entereddirectlyinto the profession,often throughapprenticeship,as opposed to those
who enteredthroughnursingschools (Davis-Floyd 1998). The legal statusof DEMs varies
from state to state and the recent increase in state investigationsof DEMs on a national
scale has led to debate over the interpretationof existing laws-in some states DEMs are
clearly regulatedand licensed, in others DEMs are prohibitedby law, and in still others
DEMs are unregulatedand their legal statusis vague. For the most currentinformationon
the legal statusof DEMs in each stateanda review of the legal challenges DEMs face under
differentstatelaws, see the following websites:http://www.fromcallingtocourtroom.net
and
http://www.mana.org.
3. My ethnographicresearchhas focused on grassrootsorganizingfor midwifery in
Virginia.I have not conductedinterviewswith opponentsof legislation to improveaccess
to midwives, because collective politicization against midwifery comes almost entirely
from professionalmedical organizations.Unlike the independentgrassrootsorganizingby
groupssuch as pro-life and pro-choiceactivists,thereis currentlyno articulatedgrassroots
movementagainst midwiferyin the United States.

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4. Recent researchon childbirthandauthoritativeknowledgehas highlightedthe constructionof alternativemodels of authoritativeknowledge(Davis-Floydand Sargent1997),

particularlythroughthe practiceof midwifery (Davis-Floydand Davis 1997; Davis-Floyd,
Pigg, and Cosminsky 2001). In the second half of this article, I consider how homebirth
mothersare also constructingalternativeauthoritativeknowledgesaboutrespectablemotherhood, in the context of state and medical discourses against both midwifery and themselves.
5. The CPM is a professionalcredentialconferredby the North AmericanRegistry
of Midwives (NARM), a national certifying body for DEMs. It is a competency-based
certification:as Robbie Davis-Floyd explains, "whereyou gained your knowledge, skills,
andexperienceis not the issue-that you have themis whatcounts"(1998). Nevertheless,a
CPM must "completea clinical componentthatis at least one year in length andequivalent
to 1,350 contact hours under the supervision of one or more approvedpreceptors"and
mustpass a writtenandclinical examination(NorthAmericanRegistryof Midwives 2003).
Additionally,recertificationis requiredevery threeyears.
6. CNMs, who practiceprimarilyin hospitalsandmustbe supervisedby a physicianin
Virginia,aremixed in theirsupportof autonomouslypracticingDEMs. In 1999, the Virginia
chapterof theAmericanCollege of CertifiedNurseMidwives(ACNM)supportedlegislation
to legalize DEMs. As a resultof pressurefrom physicians'organizations,however,ACNM
rescindedtheirpublic supportin subsequentyears. A handfulof CNMs, particularlythose
who havepracticedin out-of-hospitalsettings,continueto supportDEMs in theirlegislative
efforts (for additionaldiscussion, see Craven2003:18 and CravenIn press).
7. In fact, during the 2000 HWI Committee hearing, proponentsof the legislation
to license CPMs spoke first. At the beginning of the proponents'testimony only 4 of the
22 delegates were in the hearing room. Fourteenothers trickled in as the presentations
proceeded,but less thanhalf heardany testimonyfrom the bill's proponents.In subsequent
years, proponentsopted to give theirtestimonyafterthe oppositionto ensurethatdelegates
were at least present.
8. All transcriptionsaremine, with the assistanceof Asan Askin, Anna Inazu,Robbie
Kaplan,JanetGallay, and Emily Tumpsonon selected interviewsand hearings.I identify
speakersby name when quoting public discourse, but all references to interviews I conducted with midwives and midwifery advocatesare referencedwith pseudonymsfor their
protection.I use the following transcriptionconventions:
[brackets]indicatetext insertedfor clarity
/backslashes/ indicate unclear portions of recording;transcriptionis based on field
notes
(text) within parenthesesindicatethe actions of the speaker,such as (laughing)
... indicates a pause by the speaker
.... indicates the omission of text by the author

text- indicatesa word thatwas abruptlycut off by the speaker

italics in the body of the articleindicateexcerptsfrom transcribedtestimonyor interviews
9. Two of the three female physicians who spoke in opposition to bills in 2000,
2001, and 2002 mentioned their status as mothers, while none of the six male speakers
acknowledgedany connectionsto fatherhood.
10. A starkracial divide continues to exist between the outcomes of homebirthsfor
white women and African American women in the United States. Eugene Declerq, Lisa
Paine,andMichaelWinter's(1995) studyof U.S. homebirths,as they were reportedon birth
certificatesbetween 1989 and 1992, found that the majorityof homebirthsin the United
States occurredamong white women who tended to have betterbirthoutcomes thanthose
of otherwhite Americanwomen. Homebirthsamong AfricanAmericanwomen, however,
resultedin poorerbirthoutcomes than those of other African Americanwomen (Declerq,
Paine,andWinter1995:480).As PamelaKlassensummarizes,women of color in the United

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States still struggleharderfor good quality,accessible healthcare than most of their Euro
Americancounterparts(2001:20; see also Fraser1998; Whiteford1996; Williams 1996).
11. In 2002, midwiferysupportersstrategizedwith supportivedelegatesandlobbyists
to introducethree bills to regulate DEMs. Their strategy was to show flexibility around
requirements,allowingthe stateto choose which optionwas most viable withinthe existing
health care system and ultimately pass only one (for additionalinformation,see Craven
2003:21).
12. The medical lobby is powerful in a varietyof ways in Virginia(echoing national
trends):most specifically,many physicians are socially involved with lawmakersand the
health care industryis one of the most substantialfinancial contributorsto lawmakers'
campaigns.Accordingto the VirginiaPublic Access Project,the "healthcare industry"was
the largestcandidatedonorindustryin Virginiain 2000, the second largestin 2001, andthe
thirdlargestin 2002 (2003; personalcommunication,David M. Poole, executivedirectorof
VPAP,September4, 2003). There was no recordof campaigncontributionsby midwifery
advocacy groupsduringthis time.
13. A handfulof obstetriciansattendedhomebirthsin Virginiainto the late 1900s. In
this case, the senatordescribedthe pro-homebirthobstetricianas very avant-garde.
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