When is a midwife not a midwife?

by DAVID BERLIN
for the Globe & Mail

Obstructed Labour: Race and Gender in the Re-Emergence of Midwifery
By Sheryl Nestel
UBC Press, 220 pages, $29.95

For the past quarter of a century, Sheryl Nestel, who teaches sociology at the Ontario Institute for Studies in Education at the University of Toronto, has been a prenatal educator and a leader in the movement to de-medicalize and humanize childbearing. She has lectured and published papers fiercely critical of physicians, who have, in her view, monopolized the birthing experience, sanitized it and, in many cases, opted for caesarean sections for no better reason than to ensure that the doctor can get to the golf course on time.

While Nestel has argued against the temptation to fetishize natural childbirth, she has always maintained that women must be granted the right to choose between the hospital and the home environment. Like many of her peers, Nestel has railed against the government agencies that have, since the mid-1970s, forced midwives to skulk about in dark corridors like the abortionists of old.
But in this daring and insightful book, Nestel has made an about-face. Rather than sustain her attack on the medical establishment -- which, despite the fact that midwifery is now legal in Ontario, is still working hard to co-opt midwives into mainstream medicine -- she has turned her powerful analytical talents and considerable investigative skills against the Ontario Association of Midwifery (OAM), an institution with which she shares many values and beliefs. As a result of her efforts, the OAM ends up at the centre of a scandal so embarrassing that it is hard to imagine how its board of directors can do anything but resign.

As I read through this extraordinarily well-written book, the question that kept cropping up was: Why is Nestel doing this? Why has she chosen to betray her peers and expose their shortcomings in a way that could harm the entire midwifery community? Would she not have done better to have let well enough alone, focus her considerable energies on any one of a dozen Canadian institutions that have proved impermeable to change? What principle justified this radical about-face?
The quick answer is that Nestel found the OAM guilty of systemic racism. She first began to suspect that something was deeply wrong in 1989, while attending the annual general meeting of midwifery's professional body. "I was terribly upset by the pervasiveness of 'colour blindness' at the meeting" she writes. In the way she employs the term, "colour blindness" refers not so much to impartiality as to treating people of all colours and races as though they were white, holding white persons' values and having white people's concerns.

In 1995, Nestel headed the Interdisciplinary Childbirth Educators Training Program, which had, that summer, received nearly triple the usual number of applications. Even more unusual was that half of the students were immigrant women. Most were trained midwives from outside Canada, who were seeking to be integrated into Ontario's newly legalized midwifery profession. Week after week, Nestel listened to these women and was taken by the depth of their knowledge and their commitment to humanized maternity practices.

"Their integration into the midwifery profession would be relatively smooth, I predicted. But as time passed on I realized that I was wrong. I was dismayed to see how, with only one exception, all these women retreated from their dream to practice midwifery in Ontario."

Disappointed, Nestel launched investigations that turned up disconcerting facts: Of the 72 midwives who were registered in Ontario in 1996, only one was a woman of colour. Later that year, a BA program was established in the province that raised the count to 96 registered midwives. Of those, only three were new immigrants. Two years later, there were 126 registered midwives in Ontario but only 12 women of colour. The first Canadian legislation establishing midwifery as a state-regulated and state-funded health profession was passed into law in December, 1993. About half of the hundreds of midwives who registered to have their prior training recognized were "racialized minorities." But of the group whose training was finally grandfathered, only 12 per cent were non-whites.

In an attempt to understand what these numbers meant, Nestel conducted a series of interviews, 48 of them included in this book. Many were difficult and uncomfortable. Immigrant women worried about airing their complaints. But slowly, Nestel began detecting a pattern of bullying strategies: calls not returned, impossibly difficult-to-attain transcripts submitted to the OAM and then lost. Nestel heard about a whole variety of white-only support systems, and talked to black women about their often-desperate attempts to conform to a standard that forced them to blanch their names on application forms or dress like the "Avon lady" for interviews.

But even as evidence of systemic racism mounted, Nestel remained unsure that she wanted to prosecute the case. "I struggled greatly with my own betrayal of the midwifery project," she writes. "I needed constant reassurance that my claims were not exaggerated, and that what I was describing was indeed racism and not some other phenomenon."

It even occurs to her that OAM's discrimination was just a temporary measure, a way of avoiding a confrontation with the medical establishment's common misconceptions about Third World midwifery practices. Then she learned that the OAM's power elite has no intention of correcting the problem. On the contrary. Rather than deal with the issues, the OAM set up "equity committees" whose chief task was to deflect criticism and prevent complaints from inflating beyond control.

Nestel tried to get OAM's top executives to tell their side of the story. She was stonewalled. Key players refused repeated requests for interviews. When she finally received an interview with one top executive, it turned out to be a waste of time. None of her questions were addressed. "The OAM executive couldn't even get her mind around the reason why I was asking these kinds of questions. 'Why don't you do some quantitative research,' she advised me in a manner that could only be interpreted as patronizing."

Early doubts were replaced by frustrations. Finally, Nestel concluded that the OAM's power elite was simply in denial. At the uppermost rungs, executives hid within an impenetrable internal discourse that functioned like body armour. Nestel recalled that just this sort of insularity had characterized the early history of the feminist movement. At its inception, the movement formed a single united front. Its leaders treated all women as essentially the same: They were sisters bound together against a common oppressor, the male.

There was tremendous power in this kind of collectivity. But there was also tremendous self-deception. In the 1970s, a group of black women went public in a document that came to be known as the Combahee River Collective Statement. In this manifesto, black women declared that they felt very little kinship with white middle-class women who formed the bulk of the feminist movement. "Although we are feminists and lesbians," the Combahee signatories wrote, "we feel solidarity with progressive black men and do not advocate the fractionalization that white women who are separatists demand." Worldwide feminism rocked and splintered as a result of the Combahee statement.

But the OAM executives acted as though Combahee had never happened. Cloaking themselves in the mantel of universalism, they were reliving the early history of feminism as though the women's movement had learned nothing from its past.

In Nestel's view, this indifference amounted to more than just a violation of standards of fairness and equality: It was a violation of a paramount principle, that equality can never simply be assumed (as the American federalists believed), but can only be accomplished by the very hard work it takes to recognize the real differences between one human being and another. When she finally grasped that the OAM was violating this deepest principle, Nestel was convinced that there was no choice but to go forward with her indictments.

"Women who belong to dominant classes must take responsibility for, and ultimately alter, practices that recreate hierarchies, even when these hierarchies seem to be necessary for feminist emancipatory projects," Nestel writes. "It is essential that racially dominant people hear the stories of segregated people which, when [dominant people] are implicated in them, become inaudible."

But the women to whom Nestel addresses herself have long ago grown deaf.

David Berlin's two daughters both prefer home birth, a preference that scares him almost more than the idea of becoming a grandfather scares him.

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