occupational socialisation, only vocational training nicely blended ... 2 1989 ISSN 0141-9889 ...... And then 2 years of post-graduate work in the hospital. You've.
Cecilia Benoit The professional socialisation of midwives: Balancing art and science
Abstract Mastery of esoteric knowledge is one of the central features assigned by sociologists to fully professionalised service occupations, together with an orientation towards public service. There are, nevertheless, different views about the best way in which this education and socialisation can be provided for new recruits for practitioner roles. Some maintain that the university provides an ideal training ground. Critics of this view, however, call for a rejection of 'university diploma mills' and a retum to the type of apprenticeship socialisation common during the premodern era. This paper tests the usefulness of these perspectives in understanding the occupational socialisation of Newfoundland and Labrador midwives. Three major styles of training - traditional apprenticeship, vocational schooling and university education - can be discerned. In comparison to both apprenticeship and academic styles of occupational socialisation, only vocational training nicely blended the art and science of midwifery to produce competent and committed professionals.
Introduction
Possession and utilisation of esoteric knowledge is one of the central features assigned by classical sociologists to fully professionalised service occupations. These early writers believed that the privileged social and economic status of the professions resulted from their mastery of a body of esoteric theoretical and practical knowledge, and their longterm dedication to clients. The professions, they claimed, possess a genuine orientation towards public service, in contrast to the exclusive concem of business with profit and self-interest (Spencer 1896; Comte [1851-4] 1968). According to classical writers, it is this unique combination of competence and commitment that make the professions vital to society and therefore Sociology of Health & Illness Vol. 11 No. 2 1989 ISSN 0141-9889
The professional socialisation of midwives 161 deserving of special occupational status (Durkheim [1890-1900] 1957; Tawney [1921] 1937). Modem sociologists, while agreeing on the centrality of esoteric professional knowledge, have adopted different approaches concerning the training of people for practitioner roles. Some writers have focused upon the mastery of 'affective neutrality' (Parsons 1951), placing particular emphasis upon the acquisition of scientific and technical expertise by neophytes in university professional schools. The transition from formal training to the world of service work is seen as relatively unproblematic. Other sociologists (Merton 1957), while recognising the significance of scientific knowledge and technical expertise, have stressed the importance of sympathetic understanding of the life situations of clients. Unless imbued with a spirit of dedication to altruistic service dudng the initial training period, they have argued, students will be oriented toward narrowly specialised, managerial and research career lines rather than towards practitioner roles (Light 1986; Ebert 1986). Such a perspective, in their view, can be best instilled in students through a liberal arts education in 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, maintain that university programmes for service occupations, which stress passing examinations and 'making the grade' (Becker et al 1968), contribute to cynicism among students. In this view, students are likely to achieve professional competence and commitment to clients only through practical activity in the postgraduation period. Some writers call for a rejection of 'university diploma mills' (Illich 1971), and a return to the type of apprenticeship socialisation common during the premodern era, when the lay population still had a major input in the preparation of practitioners for service (Boehme 1984; Haug and Saussman 1969). Many Marxists have adopted a similar line of reasoning, maintaining that the 'university-factory system' (Bowles and Gintis 1976) transmits alienated knowledge to students, leaving them 'deskilled' (Aronowitz 1973; Oppenheimer 1973; Braverman 1974). Professionals become 'mental labourers' ((Derber 1982; Wright 1980) whose alleged expert knowledge is a mere ideological construct. Recently feminists too have embraced this radical perspective on occupational socialisation, maintaining that service occupations, in particular those with a large female cohort (midwifery, nursing, sodal work, teaching), have become 'scientised' and 'male dominated' (Rothman 1982; Eakins 1986). The result, they argue, has been a serious loss of occupational status as today's female service workers are turned into narrowly-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 apprenticeship training for service occupations. This controversy surrounding occupational socialisation is not only of
162 Cecilia Benoit theoretical interest. Practitioners in established and emerging occupations in many Western countdes are discussing the best way to socialise new recruits for professional roles. Midwifery is no exception. In Europe as well as in Canada and the United States a debate is now under way concerning the importance of 'lay' and 'scientific' knowledge. Although university programmes in midwifery are most common in the U.S., France has also institutionalised academic education for midwives. By contrast, the British style of vocational schooling is still intact. But the British system of training midwives for service roles is now under review by midwifery educators, and it is likely that midwives there, too, will soon be educated in the university. The recent trend to academise midwifery training is being subjected to vocal criticism by those who call instead for a style of traditional apprenticeship enabling students to learn the 'art' of midwifery. This paper considers the usefulness of these perspectives in understanding the occupational socialisation of midwives in Newfoundland and Labrador. In my study, three major styles of training - traditional apprenticeship, vocational schooling and university education - can be discerned. In comparison to both apprenticeship and academic styles of occupational socialisation, only vocational training nicely blended the art and science of midwifery to produce competent and committed graduates who approximated the ideal type of professional service worker. The vocationally-trained midwife was able to employ her specialised knowledge in daily practice to a degree not enjoyed by either her lay predecessor or academic descendent. It is in this sense that the vocationally-trained midwife 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 autonomous space for the midwife to create, transmit and apply her knowledge.
Data and methods
This paper is drawn from a broader research project which explores in detail the organisation of midwifery in Newfoundland and Labrador in historical perspective. The province was chosen because it provided an unique opportunity to study the development of midwifery from organisation in clients' homes to large-scale sites of practice. Such longitudinal research cannot be done in more highly populated and industrialised areas of the West because occupational competition between midwifery and other health professions, especially medicine, is more intense and the bureaucratisation of service work more advanced. The sample population included midwives fi^om all types of organisational settings: clients' homes, nursing stations, health centres, cottage hospitals, regional hospitals, referral hospitals, health board offices and the university nursing school. Fifteen retired yet still alert granny and early cottage
The professional socialisation of midwives 163 hospital midwives were initially interviewed. These interviews provided a valuable historical backdrop to the study. Since the former Midwives' Roll was defunct, random sampling was not possible. Instead, the snowball technique was used to create an informal midwives' register, beginning with academic midwives located at the university nursing school. This resulted in a list of approximately 70 midwives presently employed in the province. Eventually 41 tape-recorded interviews were conducted with a representative sample from this group. The questionnaire was semistructured and purposively open-ended, allowing for unanticipated data to emerge (Glaser and Strauss 1%7). Personal background information was sought, in addition to descriptive data on the major organisational features of midwifery in the province. The bulk of the interviews were carried out in 1985, subsequently transcribed and searched for common themes. It became apparent that, in comparison to the other structural variables tested for, including social class, gender, ethnicity and geographic location, midwives' differential position in the maternity care system significantly affected their autonomy at work, possession and utilisation of esoteric knowlege and coUegiality and, ultimately, their achievement of professional status. Work context thus became the core variable. The interview data were interpreted accordingly, and available secondary historical data were used to substantiate the results of the case study. This paper presents the findings on Newfoundland and Labrador midwives' occupational socialisation only. The three major styles of occupational socialisation - the traditional apprenticeship system, vocational training and academic education - are presented in historical sequence.
1. The apprenticeship system
In traditional Newfoundland and Labrador, as in most premodern societies, attending women in childbirth was mainly the province of older married 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 attendants can adequately care for pregnant women, providing sustained personalised care throughout the lying-in period. Females, in their view, are by nature warm and expressive, while males tend to be innately cool and instrumental. Women are endowed with the special gift of sympathetic understanding, making them ideal midwives. In the words of one such granny: It don't seem nice for a man to go in and watch everything, the afterbirth coming and all like that. It don't seem really nice to me. It's all right for a woman, 'cause a woman understands it all. In my time, they left it up to women and we would handle it ourselves.
164 Cecilia Benoit Female status was merely one condition for recruitment as midwife. As in the case of traditional healers elsewhere (Fabrega and Silver, 1970), Newfoundland and Labrador lay midwives were usually not young. Most of them began independent practice only around the age of forty, often working well into their octogenarian years. The midwife, it was believed, aanunulated a stock of 'wisdom knowledge' (Znaniecki 196S) with increasing age - hence the term 'wise woman' in several European languages or 'granny woman', as she was affectionately known in Newfoundland and Labrador. The sage-femme or granny midwife was ideally an older, mature woman, 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 their families. This observation parallels the finding of high community status enjoyed by black U.S. granny midwives (Mongean et al 1961; Auerbach 1968). Although Newfoundland and Labrador midwives occasionally viewed their counterparts in neighbouring communities as 'ignorant' or 'incompetent', none was ever accused of witchcraft or of being in league with the devil - a common event for midwives practicing in medieval Europe (Donnison 1977). These various aspects of the granny woman's knowledge were shared by most women in the community, just like the skills of keeping up the home, caring for children and kin, and familiarity with healing practices. The granny, however, also possessed a unique knowledge, which, by way of informal apprenticeship, was passed on by a seasoned teacher of the midwifery craft. It was this specialised body of knowledge, then, which distinguished the granny from other local women without apprenticeship training for the role of community midwife. Although some grannies maintained, as has been reported about Zinacantec Shamans (Fabrega and Silver 1970:474), that they were recruited before birth and thus 'destined' to become midwives, they were typically recruited to midwifery by a family member. Much less frequently a young woman from the community might express a calling for this work and apprentice herself to an ageing midwife who was not her kin. Or, after the untimely death of a granny, an older woman from the area might be encouraged to fill the gap by the travelling minister or the district doctor. Women attempting to enter midwifery in this alternative way were sometimes chosen only after demonstrating a keen interest in caring for others. Both forms of recruitment could operate together, as in the case of this granny woman: I always enjoyed public life and community work. At an early age I started visiting the sick and aged. My life ambition was to be a nurse and midwife after I learned some things about obstetrics from my mother, who has also been a midwife. [Later] I delivered several babies in emergencies. 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 hard scrapes and he said, 'well, you do your best for me and I'll do my best for you.' So that's how it all started. While there was neither a formal educational prerequisite nor a designated 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-in period. In addition, the trainee learned how to sterilise rudimentary instruments in a pan of boiling water at the back of the stove, and to take care of the newborn, e.g., by tying the umbilical cord with a small piece of linen and protecting it with the 'dried flour' she had been instructed to brown in the oven. Eventually, the novice was permitted to visit the woman in labour independently, spending long nights at the woman's bedside until the birth was imminent, at which time the granny took control. The apprentice watched her teacher in action, noting how she encouraged the labouring woman to 'work with the pain' while they held hands and waited for 'nature to do its work'. She also heard the granny tell the woman 'not to scream too much but to bear down', that with lots of 'oil and patience' and prayers to the Mother of Perpetual Help to guide them, everything would retum to normal. She observed her teacher in difficult obstetrical cases - twin deliveries, breech and vertex presentations, footlings, mild pre-edampsia - and learned about the serious complications which required that she call for available medical help. During such training sessions the apprentice also picked up paediatric skills, for example rubbing premature infants with oil, wrapping them in flannelette, and, when not at their mother's breast, laying them in a warm bed surrounded by hot bricks until normal weight had been reached. Finally, the trainee learned to care for the woman and her family dudng the postpartum 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), this odginal style of training practitioners also transmitted cultural values. Af^rentices were familiadsed with traditional dtuals and rules of midwifery practice, such as how to discard the afterbirth properly by wrapping it in an old sheet and throwing it in the hot stove, how to console family members in the event of injury or death of a newborn or mother, and how to baptise and prepare the deceased for burial. In addition, birth attendance in clients' homes placed the young trainee in a situation where she had to come face-to-face with the economic and social problems of her future clients. She watched how her teacher moulded her practices in accordance with the needs of the pregnant woman which, as one granny woman explains, were sometimes desperate indeed:
166 Cecilia Benoit I expected clean sheets and towels. Over there in the merchant families everything would be perfect. But in some places you'd go, there would not even be anything to eat and only one sheet on the bed and that would be it. I'd born the baby and then take the sheet, wash it and put it back on the bed again, and I'd use my own sheet to catch the baby. Once she mastered the necessary practical skills and sympathetic understanding, the apprentice was permitted to carry out pre- and postnatal visits and respond to night calls on her own, as well as fill in for her teacher when busy with another client. Finally the apprentice herself became a practitioner in her own right, an informally certified lay midwife capable of guiding new apprentices through the lengthy schooling process. One granny woman, whose grandmother and mother were also local midwives, describes her own career, which spanned five decades: I used to go with my grandmother and . . . just watched. I was there when a woman used to be sick. Grandmother used to bring the stuff and sterilise it. I had four children before I really started. I delivered my first baby for my sister when she took sick before her time. I had everything right alongside, everything ready for the time the midwife come, just waiting for her. But the baby come and I took the string and I tied the little stomach and tied the other part. Now the midwife come and she said: '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, one to the other. One time I was three weeks never stopped. Oh yes, I enjoyed it while I was at it. I was getting my old age pension when I gave it up. The apprenticeship system, in theory, produced mature, wise and experienced granny women committed to working in their home communities. This method of occupational socialisation was, however, beset by serious problems. Grannies were frequently overworked, without additional time to oversee the training of apprentices (Benoit, 1989). This limitation of granny practice is also common to modern lay midwifery (Wietz and Sullivan 1985). The lack of teachers was compounded by a chronic shortage of dedicated students. Some local women consequently leamed to perform midwifery tasks by necessity rather than because of an inner calling. There simply 'was no one else to tend to sick women'. While some who entered midwifery in this way subsequently developed genuine commitment, many felt trapped in a work role bringing little personal reward. One contemporary midwife describes the situation of her mother: I can remember as a kid someone pounding on the door in the middle of the night and dad saying that mom had gone to deliver a baby and would be back in two days. There was another older lady [but] she was probably in her seventies by that time. My mom was the only person available and she felt a certain responsibility. She couldn't bear the
The professional socialisation of midwives 167 thought of somebody having to deliver on their own, and this would have happened, you know. Or somebody who had no experience would have been present - in cases where the baby was corded and if the cord had been 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 never got into it. It was very much a matter that there was nobody else available. Now - she's onlyfifty-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 provides wisdom knowledge, also lacked a formal mechanism to eliminate incompetence, especially among ageing granny women whose technical skills and hygienic practices were no longer up to par.^ Some pregnant women were the victims of the unsound birth rituals of senile grannies who stubbornly adhered to their community role. One granny midwife recalls how she lost her infant son in this way: I had trouble with the midwife 'cause she didn't help me. He had his little arm like that, and she didn't know how to get him. WeU, I come out of it but he didn't. See, she was getting old then. I sooner have had someone else 'cause she couldn't handle things right. Many granny midwives possessed a remarkable understanding of the socio-economic and cultural circumstances of their clientele, in addition to practical skills in dealing with normal pregnancy and childbirth. But their isolated rural existence deprived them of access to obstetrical knowledge transmitted through formal educational programmes as well as to the lifesaving technologies and medical back-up services of hospitals. Most grannies were content to simply continue with the traditional apprenticeship system. Yet, like many modem lay midwives (Weitz and Sullivan 1985:40) some grannies longed to improve their knowledge, to leam new ways of reducing frequent pregnancies and preventing deaths, instead of merely appealing 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 the time come for their baby or if they get fever or anything, I'd know what to do. I wanted to get away to learn. In brief, the grannies, committed and competent matemity workers only in a limited sense, remained tied to a preprofessional status. Some were skilled and dedicated practitioners, other were incompetent, and many had become 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 backup and birth technology, they were powerless to ensure safe obstetrical care in case of abnormalities. They could not guarantee their clients expert care, a
168 Cecilia Benoit basic prerequisite of professionalism. In an effort to improve the knowledge base of the grannies, a new type of training - vocational training - emerged in the early modem period. 2. Vocational training
The apprenticeship system remained intact until the second decade of the twentieth century, when state-financed pronatalist changes were introduced in Newfoundland and Labrador. Government concern for child welfare and public health in the post-World War I period prompted legislation requiring the registration of every birth. Limited pubhc funds were made available for philanthropic groups to establish milk depots, health clinics and maternity hospitals.^ In addition, funds were alloted to employ foreign doctors and vocationally-trained midwives, mainly from Britain and the Boston area of the United States. The latter served as district midwives in rural areas and among the urban poor, as administrators of matemity wards, and as instructors (together with visiting physicians) in the newly established 'Midwives' Course' offered to interested practicing grannies and young local recruits at one of the two matemity hospitals in the capital city. This new style was remarkably different from the earlier apprenticeship system. Methods of recmitment underwent substantial change, for the first time opening up a career line for younger, unmarried women. Although all grannies were encouraged to upgrade their lay credentials, there was an increasing tendency to recmit literate single women who, unlike the grannies, were not 'set in their ways' and thus more willing to accept the new scientific aspects of midwifery training taught at the hospital school. One vocationally-trained midwife, now retired, explains why she was chosen by her community: When I was bom here there wasn't any midwife trained then. We always had 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 getting too old to do any work. I always liked helping people but I never done any midwifery before I trained. I was always a trained midwife. Father Thomas asked me to go to the school in St. John's. They wanted to get someone young, not an old person. An awful lot of old grannies who went into the school, who were doing this work for years, were so set in their ways that they wasn't going to do anything the teachers talked about.' By situating vocational schooling in the maternity hospital, vocational students gained access to a continuous flow of pregnant women on the ward. This had not been so in the apprenticeship system based on one-to-
The professional socialisation of midwives 169 one interaction between the granny midwife and her home birth client. The vocational novice was presented with the unique opportunity to observe many labours and deliveries within a short time period and in a controlled environment. This helped her to adopt a rational and matter-of-fact perspective (Weber 1978:998) on the reproductive process which the lay apprentice had viewed as under the domain of God and Nature and as sanctioned by the pregnant woman's family and the local community. In grasping this new perspective on the female reproductive cycle, the vocational student learned when safe medical intervention in the labour process was possible and desirable, both to ease childbirth pain and to safeguard the life of infants and mothers. The novice was instructed to discard ancient notions that women's suffering during childbirth was due to Eve's Curse, and to learn the logical causes of the abnormality of a pregnant woman's labour. In brief, during vocational training students learned to predict abnormality and to alert the doctor if necessary. Thorough obstetric training was hardly possible during the short three months of the vocational programme originally offered at the maternity hospital. Formal education was limited, since the student midwife was expected to 'leam while doing'. In exchange for a meagre stipend which covered her room and board, the trainee had to squeeze formal lectures and study periods into her few hours of free time from a gruelling work shift. Gradually these rudimentary conditions of the vocational programme improved, however. Formal lectures were extended to six months, in addition to clinical experience with pregnant women at all stages of their reproductive cycle. A balance was struck between the transmission of theoretical knowledge and its application. In this sense, the vocational student gained some access to what classical sociologists (Durkheim [18901900] 1957) referred to as 'esoteric knowledge'. One of its early graduates decribes the vocational programme: I was 32.1 packed up my bags and went to St. John's. They had a boarding house for us near the school. I went in thefirstday, I was told 'come on, there is a case on.' So we had to take a mask and go into the case room. Oh, I felt like coming home! It was so foreign to me; I thought it was just terrible. But when I saw the baby's head, it gave me a different 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 Tuesday and Thursday. Women used to come for their check-ups and the doctor used to teach us how to find the baby, where the baby was lying, how to find the heart beats and all this. The nurse-midwives would just tell us how to check the person for examination, but he would do all the lecturing. After it was over, I got a license. I was a licensed practicing midwife. Vocational training did not merely require acquisition of formal knowledge and of new obstetrical techniques. In anticipation of her future role
170 Cecilia Benoit of practitioner, the student-in-training, like her granny forerunner, was also expected to familiarise herself with the social and cultural background of her clientele. Vocational instructors, most of whom had practiced in rural communities and small town hospitals, drew upon their own midwifery expedence in order to instill in students a dedication to serving poor, uneducated, native and rural clients in the same manner as urban clients and those of higher socio-economic standing. As one vocationallytrained midwife explains: When we were in training, [our teachers] would tell us stories about their expedences around the place and what to expect when we got home, how things were when you went to different houses, that in some places people had everything you wanted but in other places you just had to improvise with different things, which was true. Some houses had everything and others nothing at all. It testifies to the success of the vocational programme in this regard, that most midwifery students did in fact eventually practice as maternity attendants, many returning to their home community or an adjacent one, providing an important service to the outport population. These trained midwives with their midwifery bags in tow and a Midwives' Manual to consult in cases of emergency^ gradually replaced the aging granny women trained by way of apprenticeship. The new vocational education was able to overcome one of the major drawbacks of the apprenticeship system by institutionalising fonhal mechanisms to eliminate incompetence. The vocational midwife was a government-certified practitioner, required to register all births with the Central Midwives' Board, to record the particulars of each labour and delivery and, in addition, to keep in close contact with the distdct midwife. The distdct midwife was vested with the power to discipline community midwives and to eliminate their name from the Midwives' Roll if, for example, they knowingly refused to attend a distressed client or acted in a wrongful manner during a delivery. Vocational training, then, was accompanied by established procedures that permitted the removal of incompetent and uncommitted practitioners, thereby providing relatively consistent expert care to clients. Nevertheless, as long as home birth remained the norm, many older grannies, with or without vocational training, continued to practice in the old ways and remained sceptical about the benefits of the new midwifery taught in the distant urban environment. One granny who underwent both types of schooling maintains that 'the midwifery course didn't teach me anything I didn't already know'. There is more than a germ of truth in this statement since even vocational graduates, without a career option apart from home birth attendance, had to place much of their esotedc knowledge on hold. Just like their granny forerunners, they had no easy access to doctors and medical technology nor a way to escape the
The professional socialisation of midwives 171 restrictions placed upon their work activities by home birth clients and the local community. But gradually a small work site, the cottage hospital,^ gained a prominent role in matemity care, allowing the vocationally-trained midwife substantial freedom from client and community control and the opportunity to use her specialised knowledge and technical skills to a far greater degree. The result was continuity between vocational schooling and cottage hospital work, between knowledge transmitted during formal training and postgraduate socialisation. The centralisation of matemity care services in the past few decades has resulted in the virtual elimination of this small work site, however, giving way to large-scale bureaucratic hospitals characterised by hightechnology and medical dominance (Freidson 1970) of maternity care. It comes as no surprise that these events have been accompanied by substantial change in midwifery education as well. In the past few decades, the early modem style of vocational schooling has been increasingly replaced by 'matemity nursing'. The Midwives' Course instituted in the mid-1920s has become defunct, and in the past two decades candidates have been trained as doctors' obstetrical assistants, receiving only a few months of additional maternity course work on a regional or referral hospital matemity ward but no community practice. The obstetric nurse is officially regarded in the teaching hospitals as just as qualified as vocationally-trained midwives, and is awarded a comparable salary. One of the outcomes has been a growing public dissatisfaction with matemity care services.' The centralisation of health services has not only resulted in the erosion of vocational schooling for midwives and eliminated a relatively autonomous site of midwifery practice but has, it seems, also lowered the quality of matemity services for certain groups of clients. Rather than attempt to recreate vocational schooling and regenerate the dying cottage hospital system, the university, under pressure from government and health administrators, in the mid-1970s established an academic midwifery programme.
3. The university programme
The academisation of Newfoundland and Labrador midwifery** is closely intertwined with the centralisation of matemity care services. The provincial and federal governments united in the 1960s and early 1970s to implement a series of 'rapid modernisation' projects, including the inauguration of an extensive centralisation programme known as the resettlement scheme. This was, in fact, a programme of frequently forced urbanisation involving the relocation of entire communities, presumably in order to make available to inhabitants outside the capital city the major amenities of modern living. Not surprisingly, the bulk of the population
172 Cecilia Benoit resettled in artificially created growth centres had to contend with difficult social, economic and psychological adjustments (Matthews, 1976). Although it should not be overlooked that many of the relocated communities also expedenced substantial life-style improvements, in the case of maternity care the results were mixed. On the one hand, pregnant women gained access to medical specialists and advanced reproductive technology in the emerging regional and referral hospitals. This gain, however, was accompanied by a loss of continuity of care, which was especially problematic for rural clients who travel up to 150 miles for hospital delivery. Regional and referral hospitals have, in fact, virtually eliminated the role of the professional midwife. Medical dominance of maternity care and the technological orientation of these large hospitals has reduced the midwife's role to a hand-maiden/technocrat. (A similar development has also occurred in nursing [Freidson, 1970:20-2].) Staff obstetricians, along with GPs in pdvate practice and medical students in training, deliver most babies in a high-tech environment. In contrast to the cottage hospital where maternity clients traditionally found themselves on a general ward, the regional and referral hospitals have separated maternity care into major specialised components - prenatal, labour, delivery and postpartum. There is, in addition, also a nursery room which physically separates mother and newborn, who are forced to interact according to a bureaucratic timetable rather than their own biological cycles. In part because of the availabity of such modern facilities, midwives are given no special recognition for their expertise. These complex hospitals have thus seriously deskilled the midwife. The centralisation of childbirth in regional and referral hospitals has been unable to meet the pre- and postnatal needs of pregnant women in isolated rural areas, however. At present there is a number of nursing stations in isolated areas and health centres in mral communities, both providing primary care. Midwives at the nursing stations and health centres provide emergency care and non-specialised services, in addition to serving as primary points of contact for pregnant women. The nursing station or health centre may also function as an 'unofficial' labour and delivery unit, although this practice is not condoned by central health authodties in larger hospitals. The result, not surprisingly, has been very low delivery rates in isolated work sites. Midwives there have become, like their regional and referral hospital counterparts, 'deskilled', unable to practice as genuine professionals. This situation has resulted in a decline in pregnant women's confidence in both the local nursing station and health centre midwives, who can no longer guarantee them continuity of care during normal childbirth. This was the organisational structure of midwifery practice encountered by academic educators when in the late 1970s they attempted to introduce new ways of socialising midwives. They soon confronted formidable
The professional socialisation of midwives 173 barriers. Even before the programme could get off the ground, in fact, midwifery educators faced the difficult problem of finding field placements for students. With the erosion of the cottage hospitals, an important institution of clinical training for the neophyte midwife had been eliminated. The new alternative clinical sites - regional and referral hospitals - were in heavy demand from students in other health occupations, in particular medicine and nursing. This situation was worsened by a sharp decline in the birth rate (five or more children per family was common until the later 1960s). Family physicians and obstetricians, having replaced cottage hospital midwives as primary birth attendants, were increasingly unwilling to step aside and allow midwifery students to deliver 'their' maternity clients. In the face of such intense competition for clinical training, academic educators eventually deemphasised practical ward experience and delivery skills, instead evaluating midwifery students' success by shortanswer papers, a final examination and their written performance on a major community project designed to test ability to carry out scholarly research. Other problems emerged. Recruitment from among the local population has remained low. The stringent formal entrance requirements and the programme's heavy stress on 'academics', have discouraged many potential candidates from applying. One midwifery educator highlights the difficulty: How to get local people to come? Some of the universities have special programs to orient them into the educational system. But if they want to be professionals, then they have to be able to say: 'I'm no different than any other midwife.' In brief, university entrance requirements, with the importance they place upon high school records and mastery of a standardised liberal arts curriculum, and their dismissal of knowledge of the socio-cultural backgrounds of clients, has discouraged students who, even if strongly interested in midwifery, may fail to meet these academic standards. Clinical experience and recruitment have not been the only stumbling blocks. Students attracted to the midwifery speciality often maintain that its 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 a student who failed the course: I've done this university course and my marks aren't high enough to get my midwifery certificate. But where do the marks come from? It's all academics. When I got my marks back I called my instructor and she told me that in my community project I had not followed the proper format for the references in the back. I said: 'What has that got to do with midwifery'? First I'm told that I failed my exams because I didn't write down 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. What I've learned this year was a lot, lot more than anything that was put on those exams . . . I don't see how they can teach midwifery in a university setting. I think it's outrageous. Practising vocationally-trained midwives, many of whom worked in the cottage hospitals, also criticise the programme's academic emphasis with its divorce between midwifery theory and practice, and its production of graduates without either holistic knowledge of the reproduction process or even 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 hospital for the midwifery and you do the whole kaboodle together. You get your theory and everything rolled into one, and it sinks in better. But [at the university] it's separate. The theory is thrown at them! You want a lot of hands-on in normals and abnormals in order to see what you read about in textbooks. [The University students] can deliver. But they've missed out on a lot. You need to train on all the wards: antenatal, postnatal and delivery. And then 2 years of post-graduate work in the hospital. You've got everything you need then. Another vocationally-trained midwife maintains that academic schooling forces recruits to concentrate on 'assessing' clients, while their bedside needs 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 same ward. While we were running around and attending to the patients' needs, they were 'assessing' and thinking about 'mental status'. [Yet] a patient was in there in bed and uncomfortable and in pain. First of all, I would sort that all out and then I would do the psychology. They did it the other way around! Midwifery educators, not surprisingly, take exception to such strong cdticism. They point to positive aspects of a university education, including access to librades, a wide choice of courses in the biological and social sciences, and the excitement of studying alongside students from other academic disciplines. All this provides the graduate with effective communication and counselling skills. The university programme is successful in other respects as well. It produces midwives for managedal positions, in addition to researchers and academic teachers. And academic schooling enhances midwives' political position vis-a-vis other health professionals, including doctors. One midwifery educator argues that academic education 'gives you more of a political awareness. I can talk to physicians on most things that they talk about because I have a university degree too'. But can academic socialisation successfully train professional midwives
The professional socialisation of midwives 175 competent in the art and science of midwifery? Are graduates keen on providing altruistic service to clients? The fact remains that few graduates embark upon maternity work. One reason is their low level of practical skill. Even midwifery educators admit that a chasm remains between the expertise of the vocational midwife and her university counterpart. Some suggest that if student nurses only later specialised in midwifery at the MA level, this major lack in competence and commitment to maternity practice could perhaps be overcome. But most vocationally-trained midwives believe otherwise. As an older one who worked for two decades in a cottage hospital states: Really, I have nothing against BNs or any [university] degree. I'm all for it. But I really feel that we have lost our perspective. Theoretically, [university midwives] have the learning, the education. They seem to have all the answers. But when it comes to dealing with the patient in a situation, they don't have the practical experience. They are excellent girls but 'removed' from the patient. They have their formal education, their BNs and now they're getting their Masters. Okay, we need administrators. But the standard of care has gone down since I started work in 1952. This is what is lacking. It remains uncertain whether the reformation of academic midwifery education in the direction of greater credentialing will solve the dilemma now confronting midwifery educators. Recruits who possess commitment to maternity work yet are not 'university material' will continue to be barred. But this is only part of the problem. What is also needed is an attractive clinical site - such as the cottage hospitals in their heyday where neophytes can apply midwifery theory. Even then graduates would still be unable to utilise their esoteric knowledge during the postsocialisation period since isolated and large-scale sites of practice remain the norm. Only a major restructuring of matemity care delivery in favour of small health organisations, where practitioners can blend the art and science of midwifery, while maintaining some autonomy in the face of both community and bureaucratic forms of encroachment, could lead to a situation in which the academic training of contemporary midwives might result in their achievement of professional standing.
Discussion and conclusion
My data indicate that a central feature assigned by sociologists to the professions - possession and utilisation of esoteric knowledge - is closely linked to occupational work settings. The occupational socialisation of Newfoundland and Labrador midwives can be classified in terms of three analytical categories in this regard: preprofessionals, technocrats and professionals.
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' maternity service and practiced a healing art based on informal knowledge derived from practical training, from watching other village midwives, and from personal experience. This common-sense approach was achieved by active participation in the community, and was governed by guidelines set down by tradition rather than by science (Boehme, 1984). While it gained them a certain local charisma as wise women, it failed to gain them a reputation for esoteric knowledge. Although effective in caring for normal maternity cases, the grannies' limited skills, virtual absence of tools and lack of easy access to medical services in case of abnormality left them incompetent and uncommitted in many respects. Contemporary academically-educated midwives come closest to being comprehended by the concept of 'deprofessionalisation'. They are under the continuous supervision of medical specialists and hospital bureaucrats during their clinical training and in their work, resulting in a narrowing of their occupational role. Such findings fail to support the perspective adopted by sociologists linking university education to successful professional socialisation of service workers. In comparison to both apprenticeship and academic styles of occupational socialisation, vocational schooling produced midwives who score high on professional status. Like their modem academic counterparts, vocationallytrained midwives were educated in the science of midwifery. Yet they were uniquely advantaged in that they also received schooling in the art of their occupation, gained from extensive practical experience in the cottage hospital. The cottage hospital allowed vocational neophytes to relate midwifery theory to practice during clinical training. Moreover, the cottage hospital allowed its vocationally-trained midwives to keep all their midwifery skills, including expertise in conducting deliveries, honed. Since these midwives practiced at a time when the birth rate was high and the occupational competition low, they had access to a large pool of pregnant women. The nicely balanced situation of the cottage hospital graduate adequate client supply without overload - created an atmosphere conducive to frequent and sympathetic interaction with clients. She could draw upon her personal acquaintance with clients, carry them through the entire reproductive cycle, and often attend their subsequent pregnancies and those of relatives as well. In sum, vocationally-trained midwives were genuine professionals, operating with a substantial degree of freedom from community and bureaucratic control. It would, of course, be shortsighted to exaggerate the general conclusions that can be drawn from these preliminary findings. My particular case study may be an anomaly, perhaps the result of unique socio-cultural features of Newfoundland and Labrador society. In order to test whether this account is generalisable, research on other midwifery groups, as well
The professional socialisation of midwives 177 as on other emergent service occupations - especially the so-called 'semiprofessions' (nursing, sodal work, teaching, physiotherapy) - is needed. Such contextualised investigations might also substantiate the major theories of occupational socialisation sketched at the beginning of this paper. Finally, such grounded research could be of practical use to service occupations such as midwifery when designing programmes to socialise new recruits into professional roles. Department of Sociology Memorial University of Newfoundland St. John's, Newfoundland Canada
Acknowledgements
This research would not have been possible without the cooperation of Newfoundland and Labrador midwives. The author also thanks Oswald Hall for initial inspiration and Judith Adier and Velher Meja for their criticism and encouragement. The project was supported in part by grants from the Social Service and Humanities Research Council of Canada and from the Institute for Social and Economic Research at Memorial University of Newfoundland.
Notes 1 Blue milk indicates a lack of colostrum which gives breast milk its white colour and forms its essential nutritional value. 2 Such shortcomings were not unique to the Newfoundland and Labrador midwifery apprenticeship system. See, for example, Laget [1980] for a description of similar problematic midwifery practices in 17th and 18th century France. 3 Similar developments occurred elsewhere in North America and Europe at earlier periods. See, for example, Rosenberg 1979. 4 This new recruitment pattem was typical of vocational programmes for midwives found 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, the proper use of laxatives, enemas, and silver nitrate drops for infants' eyes to prevent blindness by gonorrheal infection, as well as the ways to recognise the vital signs of impending abnormality, such as prolonged labour over eighteen hours; breech, transverse and cross presentations; haemorrhaging or fever of the pregnant woman and puerperal eclampsia. 6 The Newfoundland and Labrador cottage hospital system dates back to the early 1930s. It parallels similar nation-wide hospitalisation systems elsewhere originally established for the 'common people', espedally those of less privileged
178 Cecilia Benoit classes and ethnic groups outside major cities [Glaser 1970]. The Cottage Hospital System comprised eighteen strategically located cottage hospitals in the major towns, and served the matemity and primary care needs of the small communities in the wider catchment area as well. The cottage hospitals gradually emerged as 15-30 bed institutions, with a relatively small yet balanced staff of medical, nursing and midwifery personnel, in addition to a skeleton maintenance crew. 7 Studies of client dissatisfaction carded out by local women's groups during this period clearly indicated that many pregnant women regretted the loss of the cottage hospital midwives who did not rush their clients through the birth process with the aid of impersonal technology, only in order to desert them shortly after delivery. 8 As mentioned above, the transformation of midwives into university graduates is a very recent phenomenon confined mainly to North America, with France being a notable exception on the other side of the Atlantic. French midwifery students now train for three years, graduating with university rather than merely state qualifications, as is still the case in most other European countdes. Similar developments are now being discussed among Bdtish midwifery educators. Of course, academisation of occupational socialisation is hardly unique to midwifery. On the contrary, the schooling of neophytes in universities has been the typical strategy of most occupations attempting to upgrade their occupation to an 'intellectual discipline' [Hughes 1971]. This had been the route also of the traditional 'gentlemen professions' of medicine, law and the ministry [Carr-Saunders 1933], as well as of 19th century medical and paramedical craftworkers - toothpuUers [dentists], apothecades [pharmacists], horsedoctors [veterinadans] and engineers [Ackerknecht and Fischer-Homberger 1977].
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