The professional socialisation of midwives: Balancing art and science

Cecilia Benoit

The professional socialisation of midwives:Balancing art and science

Abstract Mastery of esoteric knowledge is one of the central featuresassigned by sociologists to fully professionalised serviceoccupations, together with an orientation towards publicservice. There are, nevertheless, different views about the bestway in which this education and socialisation can be providedfor new recruits for practitioner roles. Some maintain that theuniversity provides an ideal training ground. Critics of this view,however, call for a rejection of 'university diploma mills' and aretum to the type of apprenticeship socialisation commonduring the premodern era. This paper tests the usefulness ofthese perspectives in understanding the occupationalsocialisation of Newfoundland and Labrador midwives. Threemajor styles of training - traditional apprenticeship, vocationalschooling and university education - can be discerned. Incomparison to both apprenticeship and academic styles ofoccupational socialisation, only vocational training nicelyblended the art and science of midwifery to produce competentand committed professionals.

Introduction

Possession and utilisation of esoteric knowledge is one of the centralfeatures assigned by classical sociologists to fully professionalised serviceoccupations. These early writers believed that the privileged social andeconomic status of the professions resulted from their mastery of abody of esoteric theoretical and practical knowledge, and their longtermdedication to clients. The professions, they claimed, possess a genuineorientation towards public service, in contrast to the exclusive concem ofbusiness with profit and self-interest (Spencer 1896; Comte [1851-4] 1968).According to classical writers, it is this unique combination of competenceand commitment that make the professions vital to society and therefore

Sociology of Health & Illness Vol. 11 No. 2 1989 ISSN 0141-9889

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deserving of special occupational status (Durkheim [1890-1900] 1957;Tawney [1921] 1937).

Modem sociologists, while agreeing on the centrality of esotericprofessional knowledge, have adopted different approaches concerning thetraining of people for practitioner roles. Some writers have focused uponthe mastery of 'affective neutrality' (Parsons 1951), placing particularemphasis upon the acquisition of scientific and technical expertise byneophytes in university professional schools. The transition from formaltraining to the world of service work is seen as relatively unproblematic.Other sociologists (Merton 1957), while recognising the significance ofscientific knowledge and technical expertise, have stressed the importanceof sympathetic understanding of the life situations of clients. Unlessimbued with a spirit of dedication to altruistic service dudng the initialtraining period, they have argued, students will be oriented towardnarrowly specialised, managerial and research career lines rather thantowards practitioner roles (Light 1986; Ebert 1986). Such a perspective, intheir view, can be best instilled in students through a liberal arts educationin conjunction with specialised training.

Not all sociologists share such a positive view of academic education,however. Some writers (Becker et al 1%1), by contrast, maintainthat university programmes for service occupations, which stress passingexaminations and 'making the grade' (Becker et al 1968), contribute tocynicism among students. In this view, students are likely to achieveprofessional competence and commitment to clients only through practicalactivity in the postgraduation period. Some writers call for a rejection of'university diploma mills' (Illich 1971), and a return to the type ofapprenticeship socialisation common during the premodern era, when thelay population still had a major input in the preparation of practitioners forservice (Boehme 1984; Haug and Saussman 1969). Many Marxists haveadopted a similar line of reasoning, maintaining that the 'university-factorysystem' (Bowles and Gintis 1976) transmits alienated knowledge tostudents, leaving them 'deskilled' (Aronowitz 1973; Oppenheimer 1973;Braverman 1974). Professionals become 'mental labourers' ((Derber 1982;Wright 1980) whose alleged expert knowledge is a mere ideologicalconstruct. Recently feminists too have embraced this radical perspectiveon occupational socialisation, maintaining that service occupations, inparticular those with a large female cohort (midwifery, nursing, sodalwork, teaching), have become 'scientised' and 'male dominated' (Rothman1982; Eakins 1986). The result, they argue, has been a serious loss ofoccupational status as today's female service workers are turned intonarrowly-trained technical experts and 'handmaidens' of male 'experts'practicing professional dominance (Freidson 1970:20). Not surprisingly,these feminist writers call for a reinstatement of traditional apprenticeshiptraining for service occupations.

This controversy surrounding occupational socialisation is not only of

162 Cecilia Benoit

theoretical interest. Practitioners in established and emerging occupationsin many Western countdes are discussing the best way to socialise newrecruits for professional roles. Midwifery is no exception. In Europe aswell as in Canada and the United States a debate is now under wayconcerning the importance of 'lay' and 'scientific' knowledge. Althoughuniversity programmes in midwifery are most common in the U.S., Francehas also institutionalised academic education for midwives. By contrast,the British style of vocational schooling is still intact. But the British systemof training midwives for service roles is now under review by midwiferyeducators, and it is likely that midwives there, too, will soon be educated inthe university. The recent trend to academise midwifery training is beingsubjected to vocal criticism by those who call instead for a style oftraditional apprenticeship enabling students to learn the 'art' of midwifery.

This paper considers the usefulness of these perspectives in under-standing the occupational socialisation of midwives in Newfoundland andLabrador. In my study, three major styles of training - traditionalapprenticeship, vocational schooling and university education - can bediscerned. In comparison to both apprenticeship and academic styles ofoccupational socialisation, only vocational training nicely blended the artand science of midwifery to produce competent and committed graduateswho approximated the ideal type of professional service worker. Thevocationally-trained midwife was able to employ her specialised knowledgein daily practice to a degree not enjoyed by either her lay predecessor oracademic descendent. It is in this sense that the vocationally-trainedmidwife can be said to have possessed 'professional power' (Freidson, 1986):her esoteric knowledge was grounded in a major institution of professionalism- the cottage hospital - which made available a relatively autonomousspace for the midwife to create, transmit and apply her knowledge.

Data and methods

This paper is drawn from a broader research project which explores indetail the organisation of midwifery in Newfoundland and Labrador inhistorical perspective. The province was chosen because it providedan unique opportunity to study the development of midwifery fromorganisation in clients' homes to large-scale sites of practice. Suchlongitudinal research cannot be done in more highly populated andindustrialised areas of the West because occupational competition betweenmidwifery and other health professions, especially medicine, is moreintense and the bureaucratisation of service work more advanced.

The sample population included midwives fi om all types of organisationalsettings: clients' homes, nursing stations, health centres, cottage hospitals,regional hospitals, referral hospitals, health board offices and the universitynursing school. Fifteen retired yet still alert granny and early cottage


hospital midwives were initially interviewed. These interviews provided avaluable historical backdrop to the study. Since the former Midwives' Rollwas defunct, random sampling was not possible. Instead, the snowballtechnique was used to create an informal midwives' register, beginningwith academic midwives located at the university nursing school. Thisresulted in a list of approximately 70 midwives presently employed in theprovince. Eventually 41 tape-recorded interviews were conducted with arepresentative sample from this group. The questionnaire was semi-structured and purposively open-ended, allowing for unanticipated data toemerge (Glaser and Strauss 1%7). Personal background information wassought, in addition to descriptive data on the major organisational featuresof midwifery in the province. The bulk of the interviews were carried out in1985, subsequently transcribed and searched for common themes. Itbecame apparent that, in comparison to the other structural variablestested for, including social class, gender, ethnicity and geographic location,midwives' differential position in the maternity care system significantlyaffected their autonomy at work, possession and utilisation of esotericknowlege and coUegiality and, ultimately, their achievement of professionalstatus. Work context thus became the core variable. The interview datawere interpreted accordingly, and available secondary historical data wereused to substantiate the results of the case study.

This paper presents the findings on Newfoundland and Labradormidwives' occupational socialisation only. The three major styles ofoccupational socialisation - the traditional apprenticeship system, vocationaltraining and academic education - are presented in historical sequence.

1. The apprenticeship system

In traditional Newfoundland and Labrador, as in most premodernsocieties, attending women in childbirth was mainly the province of oldermarried or widowed women who themselves had bome many children(Donegan 1978; Wertz and Wertz 1977; Donnison 1977).

The traditional lay midwives were convinced that only female attendantscan adequately care for pregnant women, providing sustained personalisedcare throughout the lying-in period. Females, in their view, are bynature warm and expressive, while males tend to be innately cool andinstrumental. Women are endowed with the special gift of sympatheticunderstanding, making them ideal midwives. In the words of one suchgranny:

It don't seem nice for a man to go in and watch everything, the afterbirthcoming and all like that. It don't seem really nice to me. It's all right for awoman, 'cause a woman understands it all. In my time, they left it up towomen and we would handle it ourselves.

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Female status was merely one condition for recruitment as midwife. Asin the case of traditional healers elsewhere (Fabrega and Silver, 1970),Newfoundland and Labrador lay midwives were usually not young. Mostof them began independent practice only around the age of forty, oftenworking well into their octogenarian years. The midwife, it was believed,aanunulated a stock of 'wisdom knowledge' (Znaniecki 196S) with increasingage - hence the term 'wise woman' in several European languages or'granny woman', as she was affectionately known in Newfoundland andLabrador. The sage-femme or granny midwife was ideally an older, maturewoman, though perhaps illiterate, who was seen as the 'salt of the earth'.She was revered as a kind of charismatic leader (Weber 1978:1111),especially after long years of altruistic service to pregnant women and theirfamilies. This observation parallels the finding of high community statusenjoyed by black U.S. granny midwives (Mongean et al 1961; Auerbach1968). Although Newfoundland and Labrador midwives occasionallyviewed their counterparts in neighbouring communities as 'ignorant' or'incompetent', none was ever accused of witchcraft or of being in leaguewith the devil - a common event for midwives practicing in medievalEurope (Donnison 1977).

These various aspects of the granny woman's knowledge were shared bymost women in the community, just like the skills of keeping up the home,caring for children and kin, and familiarity with healing practices. Thegranny, however, also possessed a unique knowledge, which, by way ofinformal apprenticeship, was passed on by a seasoned teacher of themidwifery craft. It was this specialised body of knowledge, then, whichdistinguished the granny from other local women without apprenticeshiptraining for the role of community midwife.

Although some grannies maintained, as has been reported aboutZinacantec Shamans (Fabrega and Silver 1970:474), that they wererecruited before birth and thus 'destined' to become midwives, they weretypically recruited to midwifery by a family member. Much less frequentlya young woman from the community might express a calling for this workand apprentice herself to an ageing midwife who was not her kin. Or, afterthe untimely death of a granny, an older woman from the area might beencouraged to fill the gap by the travelling minister or the district doctor.Women attempting to enter midwifery in this alternative way weresometimes chosen only after demonstrating a keen interest in caring forothers. Both forms of recruitment could operate together, as in the case ofthis granny woman:

I always enjoyed public life and community work. At an early age Istarted visiting the sick and aged. My life ambition was to be a nurse andmidwife after I learned some things about obstetrics from my mother,who has also been a midwife. [Later] I delivered several babies inemergencies. Then the travelling doctor asked if I would help him out.

TTie professional socialisation of midwives 165

I told him that he would have to help me out if I got into any hardscrapes and he said, 'well, you do your best for me and I'll do my best foryou.' So that's how it all started.

While there was neither a formal educational prerequisite nor adesignated age at which a local girl could begin her actual apprenticeship,schooling typically commenced long before she saw her first delivery.Initially she was expected to learn such less attractive tasks as washing,cleaning, and cooking meals for the family during the ten day lying-inperiod. In addition, the trainee learned how to sterilise rudimentaryinstruments in a pan of boiling water at the back of the stove, and to takecare of the newborn, e.g., by tying the umbilical cord with a small piece oflinen and protecting it with the 'dried flour' she had been instructed tobrown in the oven. Eventually, the novice was permitted to visit thewoman in labour independently, spending long nights at the woman'sbedside until the birth was imminent, at which time the granny tookcontrol. The apprentice watched her teacher in action, noting how sheencouraged the labouring woman to 'work with the pain' while they heldhands and waited for 'nature to do its work'. She also heard the granny tellthe woman 'not to scream too much but to bear down', that with lots of 'oiland patience' and prayers to the Mother of Perpetual Help to guide them,everything would retum to normal. She observed her teacher in difficultobstetrical cases - twin deliveries, breech and vertex presentations,footlings, mild pre-edampsia - and learned about the serious complicationswhich required that she call for available medical help. During suchtraining sessions the apprentice also picked up paediatric skills, forexample rubbing premature infants with oil, wrapping them in flannelette,and, when not at their mother's breast, laying them in a warm bedsurrounded by hot bricks until normal weight had been reached. Finally,the trainee learned to care for the woman and her family dudng thepostpartum pedod, advising the new mother on breastfeeding her infant -except if her milk was 'blue'.'

But the apprenticeship system did not merely transmit practical skills.As has been found among Latin Amedcan curanderos (Fabrega 1971), thisodginal style of training practitioners also transmitted cultural values.Af^rentices were familiadsed with traditional dtuals and rules of midwiferypractice, such as how to discard the afterbirth properly by wrapping it in anold sheet and throwing it in the hot stove, how to console family membersin the event of injury or death of a newborn or mother, and how to baptiseand prepare the deceased for burial. In addition, birth attendance inclients' homes placed the young trainee in a situation where she had tocome face-to-face with the economic and social problems of her futureclients. She watched how her teacher moulded her practices in accordancewith the needs of the pregnant woman which, as one granny womanexplains, were sometimes desperate indeed:

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I expected clean sheets and towels. Over there in the merchant familieseverything would be perfect. But in some places you'd go, there wouldnot even be anything to eat and only one sheet on the bed and that wouldbe it. I'd born the baby and then take the sheet, wash it and put it backon the bed again, and I'd use my own sheet to catch the baby.

Once she mastered the necessary practical skills and sympatheticunderstanding, the apprentice was permitted to carry out pre- and post-natal visits and respond to night calls on her own, as well as fill in for herteacher when busy with another client. Finally the apprentice herselfbecame a practitioner in her own right, an informally certified lay midwifecapable of guiding new apprentices through the lengthy schooling process.One granny woman, whose grandmother and mother were also localmidwives, describes her own career, which spanned five decades:

I used to go with my grandmother and . . . just watched. I was therewhen a woman used to be sick. Grandmother used to bring the stuff andsterilise it. I had four children before I really started. I delivered my firstbaby for my sister when she took sick before her time. I had everythingright alongside, everything ready for the time the midwife come, justwaiting for her. But the baby come and I took the string and I tied thelittle stomach and tied the other part. Now the midwife come and shesaid: 'My dear, you done it better than I can', 'cause she was getting old.And then, from that, they used to come after me. One to the other, oneto the other. One time I was three weeks never stopped. Oh yes, Ienjoyed it while I was at it. I was getting my old age pension when I gaveit up.

The apprenticeship system, in theory, produced mature, wise andexperienced granny women committed to working in their home communi-ties. This method of occupational socialisation was, however, beset byserious problems. Grannies were frequently overworked, without additionaltime to oversee the training of apprentices (Benoit, 1989). This limitationof granny practice is also common to modern lay midwifery (Wietz andSullivan 1985). The lack of teachers was compounded by a chronicshortage of dedicated students. Some local women consequently leamed toperform midwifery tasks by necessity rather than because of an innercalling. There simply 'was no one else to tend to sick women'. While somewho entered midwifery in this way subsequently developed genuinecommitment, many felt trapped in a work role bringing little personalreward. One contemporary midwife describes the situation of her mother:

I can remember as a kid someone pounding on the door in the middle ofthe night and dad saying that mom had gone to deliver a baby and wouldbe back in two days. There was another older lady [but] she wasprobably in her seventies by that time. My mom was the only personavailable and she felt a certain responsibility. She couldn't bear the


thought of somebody having to deliver on their own, and this would havehappened, you know. Or somebody who had no experience would havebeen present - in cases where the baby was corded and if the cord hadbeen cut before the baby was delivered, then the baby would have died. . . But I think if she had had a choice she probably would have nevergot into it. It was very much a matter that there was nobody elseavailable. Now - she's only fifty-seven - she says she has 'lost her nerve',and can't bear the thought of doing those things, that even [the sight of]blood just really bothers her.

The apprenticeship system, with its assumption that old age provideswisdom knowledge, also lacked a formal mechanism to eliminate incom-petence, especially among ageing granny women whose technical skills andhygienic practices were no longer up to par.^ Some pregnant women werethe victims of the unsound birth rituals of senile grannies who stubbornlyadhered to their community role. One granny midwife recalls how she losther infant son in this way:

I had trouble with the midwife 'cause she didn't help me. He had hislittle arm like that, and she didn't know how to get him. WeU, I come outof it but he didn't. See, she was getting old then. I sooner have hadsomeone else 'cause she couldn't handle things right.

Many granny midwives possessed a remarkable understanding of thesocio-economic and cultural circumstances of their clientele, in addition topractical skills in dealing with normal pregnancy and childbirth. But theirisolated rural existence deprived them of access to obstetrical knowledgetransmitted through formal educational programmes as well as to the life-saving technologies and medical back-up services of hospitals. Mostgrannies were content to simply continue with the traditional apprenticeshipsystem. Yet, like many modem lay midwives (Weitz and Sullivan 1985:40)some grannies longed to improve their knowledge, to leam new ways ofreducing frequent pregnancies and preventing deaths, instead of merelyappealing to the mercy of the Lord. As one granny put it:

I wanted to know the whole works, to know if they get sick before thetime come for their baby or if they get fever or anything, I'd know whatto do. I wanted to get away to learn.

In brief, the grannies, committed and competent matemity workers onlyin a limited sense, remained tied to a preprofessional status. Some wereskilled and dedicated practitioners, other were incompetent, and many hadbecome midwives without ever experiencing midwifery as a special calling.Furthennore, since the grannies lacked scientific knowledge of anatomy,biology, neurology and chemistry and had little access to medical backupand birth technology, they were powerless to ensure safe obstetrical care incase of abnormalities. They could not guarantee their clients expert care, a

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basic prerequisite of professionalism. In an effort to improve the knowledgebase of the grannies, a new type of training - vocational training - emergedin the early modem period.

2. Vocational training

The apprenticeship system remained intact until the second decade of thetwentieth century, when state-financed pronatalist changes were introducedin Newfoundland and Labrador. Government concern for child welfareand public health in the post-World War I period prompted legislationrequiring the registration of every birth. Limited pubhc funds were madeavailable for philanthropic groups to establish milk depots, health clinicsand maternity hospitals.^ In addition, funds were alloted to employ foreigndoctors and vocationally-trained midwives, mainly from Britain and theBoston area of the United States. The latter served as district midwives inrural areas and among the urban poor, as administrators of matemitywards, and as instructors (together with visiting physicians) in the newlyestablished 'Midwives' Course' offered to interested practicing granniesand young local recruits at one of the two matemity hospitals in the capitalcity.

This new style was remarkably different from the earlier apprenticeshipsystem. Methods of recmitment underwent substantial change, for the firsttime opening up a career line for younger, unmarried women. Although allgrannies were encouraged to upgrade their lay credentials, there was anincreasing tendency to recmit literate single women who, unlike thegrannies, were not 'set in their ways' and thus more willing to accept thenew scientific aspects of midwifery training taught at the hospital school.One vocationally-trained midwife, now retired, explains why she waschosen by her community:

When I was bom here there wasn't any midwife trained then. We alwayshad just old women - you know, granny women, as they called them.[When I was young], my grandmother was a good granny midwife.There were two or three others. But when I came out they were gettingtoo old to do any work. I always liked helping people but I never doneany midwifery before I trained. I was always a trained midwife. FatherThomas asked me to go to the school in St. John's. They wanted to getsomeone young, not an old person. An awful lot of old grannies whowent into the school, who were doing this work for years, were so set intheir ways that they wasn't going to do anything the teachers talkedabout.'

By situating vocational schooling in the maternity hospital, vocationalstudents gained access to a continuous flow of pregnant women on theward. This had not been so in the apprenticeship system based on one-to-


one interaction between the granny midwife and her home birth client. Thevocational novice was presented with the unique opportunity to observemany labours and deliveries within a short time period and in a controlledenvironment. This helped her to adopt a rational and matter-of-factperspective (Weber 1978:998) on the reproductive process which the layapprentice had viewed as under the domain of God and Nature and assanctioned by the pregnant woman's family and the local community. Ingrasping this new perspective on the female reproductive cycle, thevocational student learned when safe medical intervention in the labourprocess was possible and desirable, both to ease childbirth pain and tosafeguard the life of infants and mothers. The novice was instructed todiscard ancient notions that women's suffering during childbirth was due toEve's Curse, and to learn the logical causes of the abnormality of apregnant woman's labour. In brief, during vocational training studentslearned to predict abnormality and to alert the doctor if necessary.

Thorough obstetric training was hardly possible during the short threemonths of the vocational programme originally offered at the maternityhospital. Formal education was limited, since the student midwife wasexpected to 'leam while doing'. In exchange for a meagre stipend whichcovered her room and board, the trainee had to squeeze formal lecturesand study periods into her few hours of free time from a gruelling workshift. Gradually these rudimentary conditions of the vocational programmeimproved, however. Formal lectures were extended to six months, inaddition to clinical experience with pregnant women at all stages of theirreproductive cycle. A balance was struck between the transmission oftheoretical knowledge and its application. In this sense, the vocationalstudent gained some access to what classical sociologists (Durkheim [1890-1900] 1957) referred to as 'esoteric knowledge'. One of its early graduatesdecribes the vocational programme:

I was 32.1 packed up my bags and went to St. John's. They had aboarding house for us near the school. I went in the first day, I was told'come on, there is a case on.' So we had to take a mask and go into thecase room. Oh, I felt like coming home! It was so foreign to me; Ithought it was just terrible. But when I saw the baby's head, it gave me adifferent feeling. I wanted to stay there then, to see the end of it.I wanted to see more of i t . . . We had to go down to clinic every Tuesdayand Thursday. Women used to come for their check-ups and the doctorused to teach us how to find the baby, where the baby was lying, how tofind the heart beats and all this. The nurse-midwives would just tell ushow to check the person for examination, but he would do all thelecturing. After it was over, I got a license. I was a licensed practicingmidwife.

Vocational training did not merely require acquisition of formal know-ledge and of new obstetrical techniques. In anticipation of her future role

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of practitioner, the student-in-training, like her granny forerunner, wasalso expected to familiarise herself with the social and cultural backgroundof her clientele. Vocational instructors, most of whom had practiced inrural communities and small town hospitals, drew upon their own mid-wifery expedence in order to instill in students a dedication to servingpoor, uneducated, native and rural clients in the same manner as urbanclients and those of higher socio-economic standing. As one vocationally-trained midwife explains:

When we were in training, [our teachers] would tell us stories about theirexpedences around the place and what to expect when we got home,how things were when you went to different houses, that in some placespeople had everything you wanted but in other places you just had toimprovise with different things, which was true. Some houses had every-thing and others nothing at all.

It testifies to the success of the vocational programme in this regard, thatmost midwifery students did in fact eventually practice as maternityattendants, many returning to their home community or an adjacent one,providing an important service to the outport population. These trainedmidwives with their midwifery bags in tow and a Midwives' Manual toconsult in cases of emergency^ gradually replaced the aging granny womentrained by way of apprenticeship.

The new vocational education was able to overcome one of the majordrawbacks of the apprenticeship system by institutionalising fonhalmechanisms to eliminate incompetence. The vocational midwife was agovernment-certified practitioner, required to register all births with theCentral Midwives' Board, to record the particulars of each labour anddelivery and, in addition, to keep in close contact with the distdct midwife.The distdct midwife was vested with the power to discipline communitymidwives and to eliminate their name from the Midwives' Roll if, forexample, they knowingly refused to attend a distressed client or acted in awrongful manner during a delivery. Vocational training, then, wasaccompanied by established procedures that permitted the removal ofincompetent and uncommitted practitioners, thereby providing relativelyconsistent expert care to clients.

Nevertheless, as long as home birth remained the norm, many oldergrannies, with or without vocational training, continued to practice in theold ways and remained sceptical about the benefits of the new midwiferytaught in the distant urban environment. One granny who underwent bothtypes of schooling maintains that 'the midwifery course didn't teach meanything I didn't already know'. There is more than a germ of truth in thisstatement since even vocational graduates, without a career option apartfrom home birth attendance, had to place much of their esotedcknowledge on hold. Just like their granny forerunners, they had no easyaccess to doctors and medical technology nor a way to escape the


restrictions placed upon their work activities by home birth clients and thelocal community.

But gradually a small work site, the cottage hospital,^ gained aprominent role in matemity care, allowing the vocationally-trainedmidwife substantial freedom from client and community control and theopportunity to use her specialised knowledge and technical skills to a fargreater degree. The result was continuity between vocational schoolingand cottage hospital work, between knowledge transmitted during formaltraining and postgraduate socialisation.

The centralisation of matemity care services in the past few decades hasresulted in the virtual elimination of this small work site, however,giving way to large-scale bureaucratic hospitals characterised by high-technology and medical dominance (Freidson 1970) of maternity care. Itcomes as no surprise that these events have been accompanied bysubstantial change in midwifery education as well. In the past few decades,the early modem style of vocational schooling has been increasinglyreplaced by 'matemity nursing'. The Midwives' Course instituted in themid-1920s has become defunct, and in the past two decades candidateshave been trained as doctors' obstetrical assistants, receiving only a fewmonths of additional maternity course work on a regional or referralhospital matemity ward but no community practice. The obstetric nurse isofficially regarded in the teaching hospitals as just as qualified asvocationally-trained midwives, and is awarded a comparable salary.

One of the outcomes has been a growing public dissatisfaction withmatemity care services.' The centralisation of health services has not onlyresulted in the erosion of vocational schooling for midwives and eliminateda relatively autonomous site of midwifery practice but has, it seems, alsolowered the quality of matemity services for certain groups of clients.

Rather than attempt to recreate vocational schooling and regenerate thedying cottage hospital system, the university, under pressure fromgovernment and health administrators, in the mid-1970s established anacademic midwifery programme.

3. The university programme

The academisation of Newfoundland and Labrador midwifery** is closelyintertwined with the centralisation of matemity care services. Theprovincial and federal governments united in the 1960s and early 1970s toimplement a series of 'rapid modernisation' projects, including theinauguration of an extensive centralisation programme known as theresettlement scheme. This was, in fact, a programme of frequently forcedurbanisation involving the relocation of entire communities, presumably inorder to make available to inhabitants outside the capital city the majoramenities of modern living. Not surprisingly, the bulk of the population

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resettled in artificially created growth centres had to contend withdifficult social, economic and psychological adjustments (Matthews, 1976).Although it should not be overlooked that many of the relocatedcommunities also expedenced substantial life-style improvements, in thecase of maternity care the results were mixed. On the one hand, pregnantwomen gained access to medical specialists and advanced reproductivetechnology in the emerging regional and referral hospitals. This gain,however, was accompanied by a loss of continuity of care, which wasespecially problematic for rural clients who travel up to 150 miles forhospital delivery.

Regional and referral hospitals have, in fact, virtually eliminated the roleof the professional midwife. Medical dominance of maternity care and thetechnological orientation of these large hospitals has reduced the midwife'srole to a hand-maiden/technocrat. (A similar development has also occurredin nursing [Freidson, 1970:20-2].) Staff obstetricians, along with GPs inpdvate practice and medical students in training, deliver most babies in ahigh-tech environment. In contrast to the cottage hospital where maternityclients traditionally found themselves on a general ward, the regional andreferral hospitals have separated maternity care into major specialisedcomponents - prenatal, labour, delivery and postpartum. There is, inaddition, also a nursery room which physically separates mother andnewborn, who are forced to interact according to a bureaucratic timetablerather than their own biological cycles. In part because of the availabity ofsuch modern facilities, midwives are given no special recognition for theirexpertise. These complex hospitals have thus seriously deskilled themidwife.

The centralisation of childbirth in regional and referral hospitals hasbeen unable to meet the pre- and postnatal needs of pregnant women inisolated rural areas, however. At present there is a number of nursingstations in isolated areas and health centres in mral communities, bothproviding primary care. Midwives at the nursing stations and health centresprovide emergency care and non-specialised services, in addition to servingas primary points of contact for pregnant women. The nursing station orhealth centre may also function as an 'unofficial' labour and delivery unit,although this practice is not condoned by central health authodties inlarger hospitals. The result, not surprisingly, has been very low deliveryrates in isolated work sites. Midwives there have become, like theirregional and referral hospital counterparts, 'deskilled', unable to practiceas genuine professionals. This situation has resulted in a decline inpregnant women's confidence in both the local nursing station and healthcentre midwives, who can no longer guarantee them continuity of careduring normal childbirth.

This was the organisational structure of midwifery practice encounteredby academic educators when in the late 1970s they attempted to introducenew ways of socialising midwives. They soon confronted formidable


barriers. Even before the programme could get off the ground, in fact,midwifery educators faced the difficult problem of finding field placementsfor students. With the erosion of the cottage hospitals, an important institu-tion of clinical training for the neophyte midwife had been eliminated. Thenew alternative clinical sites - regional and referral hospitals - were inheavy demand from students in other health occupations, in particularmedicine and nursing. This situation was worsened by a sharp decline inthe birth rate (five or more children per family was common until the later1960s). Family physicians and obstetricians, having replaced cottagehospital midwives as primary birth attendants, were increasingly unwillingto step aside and allow midwifery students to deliver 'their' maternityclients. In the face of such intense competition for clinical training,academic educators eventually deemphasised practical ward experienceand delivery skills, instead evaluating midwifery students' success by short-answer papers, a final examination and their written performance on amajor community project designed to test ability to carry out scholarlyresearch.

Other problems emerged. Recruitment from among the local populationhas remained low. The stringent formal entrance requirements andthe programme's heavy stress on 'academics', have discouraged manypotential candidates from applying. One midwifery educator highlights thedifficulty:

How to get local people to come? Some of the universities have specialprograms to orient them into the educational system. But if they want tobe professionals, then they have to be able to say: 'I'm no different thanany other midwife.'

In brief, university entrance requirements, with the importance theyplace upon high school records and mastery of a standardised liberal artscurriculum, and their dismissal of knowledge of the socio-culturalbackgrounds of clients, has discouraged students who, even if stronglyinterested in midwifery, may fail to meet these academic standards.

Clinical experience and recruitment have not been the only stumblingblocks. Students attracted to the midwifery speciality often maintain thatits emphasis upon 'esoteric scientific theory and process' rather than upon'hands-on midwifery skills' makes it a 'bit of a sham'. In the words of astudent who failed the course:

I've done this university course and my marks aren't high enough to getmy midwifery certificate. But where do the marks come from? It's allacademics. When I got my marks back I called my instructor and she toldme that in my community project I had not followed the proper formatfor the references in the back. I said: 'What has that got to do withmidwifery'? First I'm told that I failed my exams because I didn't writedown the proper brackets, quotation marks and whatever, then I'm told

174 Cecilia Benoit

that I have to repeat the Practical. The two just didn't make sense. WhatI've learned this year was a lot, lot more than anything that was put onthose exams . . . I don't see how they can teach midwifery in a universitysetting. I think it's outrageous.

Practising vocationally-trained midwives, many of whom worked in thecottage hospitals, also criticise the programme's academic emphasis withits divorce between midwifery theory and practice, and its production ofgraduates without either holistic knowledge of the reproduction process oreven the skills crucial to good client care. In the words of one such midwife:

Vocational training is far better because you're in an obstetric hospitalfor the midwifery and you do the whole kaboodle together. You get yourtheory and everything rolled into one, and it sinks in better. But [at theuniversity] it's separate. The theory is thrown at them! You want a lot ofhands-on in normals and abnormals in order to see what you read aboutin textbooks. [The University students] can deliver. But they've missedout on a lot. You need to train on all the wards: antenatal, postnatal anddelivery. And then 2 years of post-graduate work in the hospital. You'vegot everything you need then.

Another vocationally-trained midwife maintains that academic schoolingforces recruits to concentrate on 'assessing' clients, while their bedsideneeds often go unmet:

I'm prejudiced to the [vocational program]. . . While I was in training,the girls from the university would come and be allotted to the sameward. While we were running around and attending to the patients'needs, they were 'assessing' and thinking about 'mental status'. [Yet] apatient was in there in bed and uncomfortable and in pain. First of all, Iwould sort that all out and then I would do the psychology. They did itthe other way around!

Midwifery educators, not surprisingly, take exception to such strongcdticism. They point to positive aspects of a university education, includingaccess to librades, a wide choice of courses in the biological and socialsciences, and the excitement of studying alongside students from otheracademic disciplines. All this provides the graduate with effectivecommunication and counselling skills. The university programme issuccessful in other respects as well. It produces midwives for managedalpositions, in addition to researchers and academic teachers. And academicschooling enhances midwives' political position vis-a-vis other healthprofessionals, including doctors. One midwifery educator argues thatacademic education 'gives you more of a political awareness. I can talk tophysicians on most things that they talk about because I have a universitydegree too'.

But can academic socialisation successfully train professional midwives


competent in the art and science of midwifery? Are graduates keen onproviding altruistic service to clients? The fact remains that few graduatesembark upon maternity work. One reason is their low level of practicalskill. Even midwifery educators admit that a chasm remains between theexpertise of the vocational midwife and her university counterpart. Somesuggest that if student nurses only later specialised in midwifery at the MAlevel, this major lack in competence and commitment to maternity practicecould perhaps be overcome. But most vocationally-trained midwivesbelieve otherwise. As an older one who worked for two decades in acottage hospital states:

Really, I have nothing against BNs or any [university] degree. I'm all forit. But I really feel that we have lost our perspective. Theoretically,[university midwives] have the learning, the education. They seem tohave all the answers. But when it comes to dealing with the patient in asituation, they don't have the practical experience. They are excellentgirls but 'removed' from the patient. They have their formal education,their BNs and now they're getting their Masters. Okay, we needadministrators. But the standard of care has gone down since I startedwork in 1952. This is what is lacking.

It remains uncertain whether the reformation of academic midwiferyeducation in the direction of greater credentialing will solve the dilemmanow confronting midwifery educators. Recruits who possess commitmentto maternity work yet are not 'university material' will continue to bebarred. But this is only part of the problem. What is also needed is anattractive clinical site - such as the cottage hospitals in their heyday -where neophytes can apply midwifery theory. Even then graduates wouldstill be unable to utilise their esoteric knowledge during the post-socialisation period since isolated and large-scale sites of practice remainthe norm. Only a major restructuring of matemity care delivery in favourof small health organisations, where practitioners can blend the art andscience of midwifery, while maintaining some autonomy in the face of bothcommunity and bureaucratic forms of encroachment, could lead to asituation in which the academic training of contemporary midwives mightresult in their achievement of professional standing.

Discussion and conclusion

My data indicate that a central feature assigned by sociologists to theprofessions - possession and utilisation of esoteric knowledge - is closelylinked to occupational work settings. The occupational socialisation ofNewfoundland and Labrador midwives can be classified in terms of threeanalytical categories in this regard: preprofessionals, technocrats andprofessionals.

176 Cecilia Benoit

Contrary to the common view adopted by many critics of maternity care,traditional lay midwives, trained in an informal apprenticeship system,score low on professional status. They performed 'hands-on' maternityservice and practiced a healing art based on informal knowledge derivedfrom practical training, from watching other village midwives, and frompersonal experience. This common-sense approach was achieved by activeparticipation in the community, and was governed by guidelines set downby tradition rather than by science (Boehme, 1984). While it gained them acertain local charisma as wise women, it failed to gain them a reputationfor esoteric knowledge. Although effective in caring for normal maternitycases, the grannies' limited skills, virtual absence of tools and lack of easyaccess to medical services in case of abnormality left them incompetent anduncommitted in many respects.

Contemporary academically-educated midwives come closest to beingcomprehended by the concept of 'deprofessionalisation'. They are underthe continuous supervision of medical specialists and hospital bureaucratsduring their clinical training and in their work, resulting in a narrowing oftheir occupational role. Such findings fail to support the perspectiveadopted by sociologists linking university education to successful professionalsocialisation of service workers.

In comparison to both apprenticeship and academic styles of occupationalsocialisation, vocational schooling produced midwives who score high onprofessional status. Like their modem academic counterparts, vocationally-trained midwives were educated in the science of midwifery. Yet they wereuniquely advantaged in that they also received schooling in the art of theiroccupation, gained from extensive practical experience in the cottagehospital. The cottage hospital allowed vocational neophytes to relatemidwifery theory to practice during clinical training. Moreover, the cottagehospital allowed its vocationally-trained midwives to keep all theirmidwifery skills, including expertise in conducting deliveries, honed. Sincethese midwives practiced at a time when the birth rate was high and theoccupational competition low, they had access to a large pool of pregnantwomen. The nicely balanced situation of the cottage hospital graduate -adequate client supply without overload - created an atmosphereconducive to frequent and sympathetic interaction with clients. She coulddraw upon her personal acquaintance with clients, carry them through theentire reproductive cycle, and often attend their subsequent pregnanciesand those of relatives as well. In sum, vocationally-trained midwives weregenuine professionals, operating with a substantial degree of freedom fromcommunity and bureaucratic control.

It would, of course, be shortsighted to exaggerate the general conclusionsthat can be drawn from these preliminary findings. My particular casestudy may be an anomaly, perhaps the result of unique socio-culturalfeatures of Newfoundland and Labrador society. In order to test whetherthis account is generalisable, research on other midwifery groups, as well


as on other emergent service occupations - especially the so-called 'semi-professions' (nursing, sodal work, teaching, physiotherapy) - is needed.Such contextualised investigations might also substantiate the majortheories of occupational socialisation sketched at the beginning of thispaper. Finally, such grounded research could be of practical use to serviceoccupations such as midwifery when designing programmes to socialisenew recruits into professional roles.

Department of SociologyMemorial University of Newfoundland

St. John's, NewfoundlandCanada

Acknowledgements

This research would not have been possible without the cooperation ofNewfoundland and Labrador midwives. The author also thanks OswaldHall for initial inspiration and Judith Adier and Velher Meja for theircriticism and encouragement. The project was supported in part by grantsfrom the Social Service and Humanities Research Council of Canada andfrom the Institute for Social and Economic Research at MemorialUniversity of Newfoundland.

Notes

1 Blue milk indicates a lack of colostrum which gives breast milk its white colourand forms its essential nutritional value.

2 Such shortcomings were not unique to the Newfoundland and Labradormidwifery apprenticeship system. See, for example, Laget [1980] for adescription of similar problematic midwifery practices in 17th and 18th centuryFrance.

3 Similar developments occurred elsewhere in North America and Europe atearlier periods. See, for example, Rosenberg 1979.

4 This new recruitment pattem was typical of vocational programmes for midwivesfound in other areas of the West at earlier periods. See, for example, Laget[1980; 157-73] on midwifery training in 17th and 18th century France.

5 The manual contains a list of safety rules, including antiseptic techniques, theproper use of laxatives, enemas, and silver nitrate drops for infants' eyes toprevent blindness by gonorrheal infection, as well as the ways to recognise thevital signs of impending abnormality, such as prolonged labour over eighteenhours; breech, transverse and cross presentations; haemorrhaging or fever of thepregnant woman and puerperal eclampsia.

6 The Newfoundland and Labrador cottage hospital system dates back to theearly 1930s. It parallels similar nation-wide hospitalisation systems elsewhereoriginally established for the 'common people', espedally those of less privileged

178 Cecilia Benoit

classes and ethnic groups outside major cities [Glaser 1970]. The CottageHospital System comprised eighteen strategically located cottage hospitals in themajor towns, and served the matemity and primary care needs of the smallcommunities in the wider catchment area as well. The cottage hospitals graduallyemerged as 15-30 bed institutions, with a relatively small yet balanced staff ofmedical, nursing and midwifery personnel, in addition to a skeleton maintenancecrew.

7 Studies of client dissatisfaction carded out by local women's groups during thisperiod clearly indicated that many pregnant women regretted the loss of thecottage hospital midwives who did not rush their clients through the birth processwith the aid of impersonal technology, only in order to desert them shortly afterdelivery.

8 As mentioned above, the transformation of midwives into university graduates isa very recent phenomenon confined mainly to North America, with France beinga notable exception on the other side of the Atlantic. French midwifery studentsnow train for three years, graduating with university rather than merely statequalifications, as is still the case in most other European countdes. Similardevelopments are now being discussed among Bdtish midwifery educators. Ofcourse, academisation of occupational socialisation is hardly unique to midwifery.On the contrary, the schooling of neophytes in universities has been the typicalstrategy of most occupations attempting to upgrade their occupation to an'intellectual discipline' [Hughes 1971]. This had been the route also ofthe traditional 'gentlemen professions' of medicine, law and the ministry[Carr-Saunders 1933], as well as of 19th century medical and paramedicalcraftworkers - toothpuUers [dentists], apothecades [pharmacists], horsedoctors[veterinadans] and engineers [Ackerknecht and Fischer-Homberger 1977].

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The professional socialisation of midwives: Balancing art and science

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