Language of Science and Language of Love: The Legitimation of Independent Midwifery Practice in Russia. Summary
Since the 1990s Russian reproductive healthcare has undergone a series of transformations. Liberalization and commercialization of this sphere have led to the development of new types of childbirth services. The introduction of a “natural” approach to labor and the spread of independent midwifery practices are some of the most significant changes and challenges to post-Soviet maternity care provision.
According to the institutional rules of Russian healthcare, midwives may not play a substantial role in helping women give birth. They can only act as doctors’ assistants and do not have the right to run independent practices or to attend deliveries at home. “Natural” childbirth activists are trying to alter this situation: to advance less medicalized forms of maternity care and to establish midwifery in Russia as an autonomous profession.
The history of the midwifery (and homebirth) movement in the country can be traced to the late 1980s, when dissident scholar Igor’ Charkovskii, supported by a small group of followers, staged water births in Moscow (Belousova 2002:51). Since the mid-2000s the movement has been steadily transforming itself from an underground dissident initiative into a business. Childbirth has become a field of competition between obstetricians and midwives as representatives of a “weak” profession, who make competing claims for competence in issues of human reproduction and for control over female reproductive experiences.
In order to establish their own professional jurisdiction (Abbott 1988; Freidson 1994) midwives need to redefine the birth experience and the types of assistance needed at births. This paper considers the discourses employed by Russian independent midwives in their struggle for professional autonomy.
Research Data and Methods
Russian midwives can be conventionally divided into two main groups. The first one consists of midwives who work in state maternity hospitals. Their work is considered legitimate from the authorities’ point of view. However, they act mostly as doctors’ assistants and lack control over the conditions and content of their work. The second group is made up of independent midwives who attend homebirths or, in some cases, “natural” births at hospitals. Their work is not recognized and licensed by the state, but they exercise autonomy in their practice and play a key role in the movement to professionalize Russian midwifery. My paper focuses on the professional ideology of this second group.
This group is rather unorganized and diverse. Its members do not share a common educational background (although many independent midwives have some medical education) or assumptions about “natural” childbirth. For this reason, I study public representations of one of the communities of Russian independent midwives which grew around the first (and only) Russian journal of “natural” childbirth. This community was chosen because it is the most visible group of independent midwifery activists at both the national and international level.
My data was collected through participant observation at three international midwifery conferences that took place in Moscow in 2010, 2011, and 2013 and were organized by the journal. These conferences were devoted to discussion of “natural” childbirth issues and the legalization of midwifery. Alongside this data I use other public materials produced by the community under consideration. These materials include issues of the journal (2009–2012, 16 issues), materials from the journal’s official website, and materials from the journal’s official blog.
Legitimation of Independent Midwifery
I single out four core discourses that are used by Russian midwifery activists in justifying their claims for professional autonomy: medical discourse, liberal discourse, spiritual discourse, and gender discourse. The first two discourses are generally employed by midwives for external legitimation of their practice with respect to doctors, representatives of the international midwifery movement, state bureaucrats, and so on. The last two discourses are used for the internal legitimation of independent midwifery practice. The object of this legitimation seems mainly to be the shared identity of Russian independent midwives.
Like their colleagues from other countries (Foley and Faircloth 2003), Russian independent midwives do not deny the importance of medical knowledge. They respect the authority of modern medicine and widely use obstetrical concepts and arguments to justify their own practices. Yet midwives claim that contemporary reproductive healthcare has become too invasive, that it pathologizes childbirth and is insensitive to patients’ needs. Midwives represent their own approach as “the right medicine,” which adheres to the ideals of “natural” (i.e., “normal”) delivery and woman-friendly care.
Midwives define themselves as specialists in “normal” deliveries, and obstetricians as experts in pathological cases. Consequently, they attempt to shift the boundaries of “normality” in childbirth and to show that those births that are considered pathological by conventional medical standards (breach births, vaginal births after cesarean section) can be classified as normal and treated by a midwife alone.
Independent midwifery appears as an alternative to the hegemonic obstetrical control of delivery. And as medical models of birth vary between different countries, so do modes of midwifery practice (Viisainen 2001:1110). In Soviet and post-Soviet contexts, the medicalization of childbirth followed a path different from that of Western Europe and the United States. In Russia, objection to medicalization is determined not so much by the excessive power of medical professionals as it is by extensive state intervention in reproductive experiences, which is realized largely through an overgrown and inefficient healthcare bureaucracy. As a result, Russian independent midwives build their struggle for professional autonomy not on a critique of medical science and doctors as its representatives but on a critique of healthcare institutions unfriendly or even hostile toward clients. Midwives portray state maternity hospitals as “factories” and “assembly lines” that deprive parents of genuine privacy and intimacy during their childbirth experiences. This unattractive image is contrasted with the emotionally involved and caring attitude towards birthing couples expressed by independent midwives.
An understanding of childbirth as a human rights issue is a touchstone of independent midwifery. Midwives consider the right to choose one’s place of delivery, birth assistant, and birth scenario to be a key component of women’s reproductive rights. They argue that contemporary Russian healthcare does not offer any alternative to hospital births attended by a doctor. The institutionalization of midwifery practice should lead to the introduction of alternatives and thus contribute to women’s right to make informed choices concerning their birth experiences.
The institutions of Russian healthcare were designed with the assumption of extensive state control over the reproductive experiences of citizens. The constitutive principles of this system presume that birth should be treated as a public event with the state as a paternal agent responsible for providing care to mothers and children (Belousova 2002:50). Russian independent midwifery developed as a reaction to this situation. The liberal rhetoric that is embedded in its ideology is conditioned, first of all, by the activists’ desire to privatize the childbirth experience and the experience of parenthood.
This point of view is evident from the way in which home birthing parents are represented by independent midwifery activists. Official media usually characterize such parents as ignorant, credulous, and irresponsible—as people who can be easily deceived by cunning swindlers (i.e., independent midwives). Midwives, on the other hand, describe their clients as responsible individuals who are unwilling to delegate their parental responsibilities to the state and its medical institutions. These couples are competent in the sphere of reproduction; they care for their own reproductive health and have sufficient knowledge to assess the benefits and risks of different approaches to childbirth (including different alternative childbirth techniques). From this perspective, those parents who follow the conventional path of hospitalized birth seem ignorant and imprudent.
It also should be noted that the very idea of professional autonomy is perceived by supporters of independent midwifery through the lens of liberal ideology. Being aware of the illegal character of independent midwifery practice in Russia, they regard the official licensing of this occupation to be a crucial step toward turning it into an established profession.
Russian independent midwives view delivery as a sacred event, closer to a prayer than to a medical operation. Medical institutions are criticized for fragmenting this sacred feminine experience and for breaking the connection between the physiological and spiritual aspects of childbirth. Midwives argue that they can help women access a truly authentic and connected experience of childbirth. They define three aspects of a connected birth: (1) connection of the bodily and spiritual components of childbirth; (2) connection of female reproductive experiences, wherein conception, pregnancy, labor, and breastfeeding are seen as subsequent stages of a continuous process; (3) the definition of pregnancy and childbirth not as exceptional or pathological states but as an integral part of the everyday life of a family.
This understanding of birth as a spiritual experience determines the importance of religion in the ideology of independent midwifery. This is especially true for Orthodox midwives (who usually call themselves povitukha). For these midwives, the performance of religious rituals before and during delivery is not just asking for divine intervention but also accentuating their belonging in a national cultural tradition.
Midwifery is defined by many activists as a divine calling. In a context where Russian independent midwives do not have legal certificates that would justify their right to provide help to birthing women, they seek support for their professional claims from a transcendental authority.
Some changes that have occurred in post-Soviet independent midwifery regarding religion are worth mentioning. In the mid-1990s Orthodox midwives were insisting that women should confess and receive communion and a priest’s blessing prior to delivery. They also refused to attend the births of unbaptized women. Nowadays, when independent midwifery is transforming itself from a marginal practice into a business, a more client-friendly approach has been adopted with religious rules and rites enacted according to the parents’ preferences.
Gender discourse is one of the most pronounced discourses in the ideology of Russian independent midwives. Midwives criticize official medicine for its pathologization of childbirth and try to rethink this experience as normal and pleasant, connected with the empowerment of the birthing woman and with the revelation of her genuine femininity.
Through redefining one of the key female bodily conditions midwives establish a new understanding of womanhood. According to their ideology, woman is a strong and independent subject, possessing authentic knowledge about her own experiences, who does not need to be controlled by a medical institution.
It should be highlighted that, unlike the American and European midwifery movements, Russian midwifery adepts emphasize the spiritual rather than political aspects of the female reproductive experiences (Belooussova 2002:12–13). The emphasis here is not on overcoming medical dominance but on the revival of “essential” femininity through the practice of nonmedicalized birth.
“Natural” birth in this sense serves as a normative model of birth. In order to develop the “right” femininity a woman should go through the “right” childbirth process. The right femininity in this perspective is associated with compassion, kindness, care for home and relatives, and generally fits the frame of gender traditionalism. Midwives acknowledge that many contemporary women lead a different way of life. Because of their work, these women are embedded in a public “masculine” world and, consequently, develop “masculine” qualities—assertiveness, rationality, autonomy. A “soft” and “natural” way of giving birth is suggested to help these women reclaim their true female natures.
It is important to note that the struggle of midwives for professional autonomy is legitimated by the mobilization of a traditional gender identity. Midwives characterize themselves as women who help other women at birth and stand for family values. They enter political sphere first and foremost as mothers and from this standpoint claim their professional rights.
In a Western context midwifery is frequently (however, not always rightfully) associated with feminism. In my concluding remarks I ask whether Russian independent midwifery can be considered a feminist project. I define two main points that limit the feminist potential of Russian independent midwifery:
1) While trying to “rehabilitate” femininity, midwives do not contravene a rigid, “traditionalist” dichotomy of male and female. They may even strengthen conventional views of gender relations by essentializing motherhood. Instead of autonomy, rationality, and universal competence (modern “male” values), midwives prioritize interconnectedness, intuitive bodily knowledge, and care (“female” values). However, even in turning the gender hierarchy upside down, midwives do not question its constitutive principle—the opposition of “male” and “female” as production and reproduction. “Genuine” femininity, although positively assessed, remains associated with the physiological capacity to give birth to a child. And the empowerment of women is associated with the ability to give birth in a particular way—the soft and gentle, midwife-assisted “natural” birth.
2) The ideology and practices of independent midwifery contribute to the (re)production of inequality between different groups of women. First, the frame of independent midwifery produces its own polarizing essentialist norms of “good” (“natural”) and “bad” (“medicalized”) delivery. This approach presumes that those women who do not want or are unable to follow the “natural” childbirth norm are stigmatized and their experience devalued. Second, the benefits that women receive from independent midwifery practice are socially stratified. Midwives market their services mostly to those parents who are already sufficiently informed about reproductive health. Such parents are able to make informed choices concerning the place of birth and birth attendant. They do not just follow expert advice, but are ready to listen to their own bodily signals and to take responsibility for their birth experiences. Individuals without the educational resources to compare different approaches to childbirth (or even to be aware of the idea of natural childbirth) can hardly become the clients of independent midwives. Additional difficulties are caused by the illegal character of independent midwifery in Russia. Parents need access to social networks to find a practicing midwife; they also need material resources to organize delivery.
- Abbott, Andrew. 1988. The System of Professions: An Essay on the Division of Expert Labor. Chicago: University of Chicago Press.
- Belooussova, Ekaterina. 2002. “The ‘Natural Childbirth’ Movement in Russia: Self-Representation Strategies.” Anthropology of East Europe Review 20(1):11–18.
- Belousova, Ekaterina. 2002. “The Preservation of National Childbirth Traditions in the Russian Homebirth Community.” Journal of the Slavic and East European Folklore Association 7(2):50–77.
- Foley, Lara and Christopher Faircloth. 2003. “Medicine as Discursive Resource: Legitimation in the Work Narratives of Midwives.” Sociology of Health and Illness 25(2):165–184.
- Freidson, Eliot. 1994. Professionalism Reborn: Theory, Prophecy and Policy. Cambridge: Polity Press.
- Viisainen, Kirsi. 2001. “Negotiating Control and Meaning: Home Birth as a Self-Constructed Choice in Finland.” Social Science and Medicine 52:1109–1121.