The Professional Demarcation of Obstetric Medicine
and Traditional Midwifery

Cyd Ropp, PhD

Department of Speech Communication
California Polytechnic State University, San Luis Obispo

Introduction:

Obstetrics and midwifery comprise two distinct systems of health care. Although both health care systems share the same task of assisting women during childbirth and the same goal of bringing forth new life, the patterns of thinking, language, and behavior that define obstetrics and traditional midwifery are markedly different from one another and, as such, constitute distinct cultures of care. As distinct cultures, obstetrics and midwifery represent different systems of symbolic meaning which necessarily give rise to different social institutions and patterns of interpersonal interactions. In order to make explicit the distinct cultures represented by the obstetric approach and traditional midwifery, this paper seeks to describe the characteristics of the two systems, including the variations in foundational beliefs that give rise to the divergent behaviors that distinguish these two approaches to childbirth.

Theoretical Approach:

The analytical schema used to distinguish between these two professions is primarily based upon the work of the esteemed philosopher and literary critic, Kenneth Burke. In A Grammar of Motives, Burke presents an analytical framework for sorting out human relations and motivations which he calls the dramatistic pentad. This dramatistic pentad is a particularly apt tool for illustrating the differences between obstetrics and midwifery, for Burke proposed the system not only as a means of analyzing descriptions of human behavior, but as a means of recognizing how each set of terms serves to demarcate one group from another.

Burke's descriptive system employs five dramatic elements common to all human relations: scene, agent, agency, act, and purpose. Any human endeavor may be identified by where it occurs [scene], who does it [agent], the means by which it gets done [agency], what it is that happens [act], and why it occurs [purpose]. These five elements are related to one another as "principles of consistency" that bind pentads together in certain "ratios" (Motives, 9). Burke's principle of consistency states that any particular description of "scene" carries within it the implications of how the other elements will be defined. A hospital scene, for example, implicates the physician as the agent in charge, consistent with the scene:agent ratio, whereas the homebirth scene implicates the birthparents as primary agent, since they are people in charge of their home. The pentad also asks for identification of what Burke called the "god-term": the particular concept that serves as the ultimate motivational ground for human action under any particular dramatistic schema. In the case at hand, the god-term underlying the medical approach to birth may be identified as science. Midwifery does not share obstetric's identification with science; for midwifery, the god-term is nature.

Before mapping the two professions according to Burke's dramatistic pentad, let us review the commonly recognized differences between the obstetric and midwifery models of birth.

Obstetric Model, Midwifery Model: A Brief Overview

Extensive research has proven that obstetricians and midwives attend different symbolic events and these disparate symbolisms elicit disparate observations about the "reality" of the birth event--what Burke referred to as the "terministic screen" through which obstetricians and midwives interpret the world. For example, physicians tend to see childbirth as a high-risk activity that may erupt into a medical emergency at any moment--it is through this screen that obstetricians view the process of labor and delivery. Deviations from expected norms are viewed with suspicion as symptomatic of bio-mechanical malfunction, and interventions are deployed to rectify the condition. This practice of holding patients to predetermined time standards ensures that physicians only deal with standardized norms; deviations from the norm are simply not allowed, which serves to further reinforce the customarily-accepted norms of the medical model. By this reasoning, labor that progresses more rapidly or slowly than average comes to be regarded, under the medical model, as abnormal and therefore pathological. Midwives, on the other hand, view childbirth through an entirely different terministic screen. Since midwives conceive of childbirth as a natural, normal activity that women are uniquely equipped to accomplish, a woman's labor and delivery is viewed with more patience and optimism; deviations from normative standards are not considered alarming in and of themselves, but expressions of healthy individuality.

Obstetrics is a branch of biomedicine and, as such, stresses medicine's role as an applied science--especially biology and biochemistry. Obstetricians, in common with other physicians who practice biomedicine, consider themselves to be applied scientists. Traditional midwifery, on the other hand, does not claim to be a branch of medicine for, under the midwifery model, pregnancy is not considered a medical condition. Midwives consider childbirth to be a natural, normal activity, not a medical event. Midwifery is not, therefore, a subset of obstetrics, for midwifery claims to be neither medical nor scientific. Childbirth only becomes a medical event when a disease or emergent complication arises, and at that point in time the birth model changes from the non-medical midwifery model to the now more appropriate obstetric model of birth.

Obstetrics employs a rhetoric of science thoroughly steeped in the modern, rational worldview, reflecting "a relatively simple, stable, highly ordered place, describable in and reducible to absolute formulas that hold across contexts" (Lucaites and Condit 11). The Cartesian separation of mind and body inherent in the conventional medical model encourages the physician to view the laboring patient in mechanistic terms, and technological interventions become acceptable tools of the mechanics of birth. Under the medical model, the laboring woman is rendered passive, both in personal agency and in actual physicality, while agency, in the form of control, responsibility, and activity, is transferred to the obstetrician and medical staff.

Midwifery, by contrast, represents a traditional, pre-modern orientation best described as an ethic of care that some feminist scholars have identified as more typical of female socialization. Nona Lyons, for example, contrasts a more typically masculine orientation to caring as one that invokes impartial rules, standards, and principles that maintain "fairness," with a more typically feminine approach of promoting the welfare of others on their own terms rather than through application of impartial universal standards of care (1983).

The impartiality of the scientific method as applied to the realm of medicine has lately come under attack by a number of feminist scholars who charge the medical model with a patriarchal bias that denies female ways of knowing any legitimate authority in the health care process (Bortin et al.; Warren; Davis-Floyd and Davis; Fisher). These critics place as much or more stock in intuition, experience, emotions, and bodily sensations to inform the birthing process as they do in more "masculine" forms of authoritative knowledge. In the seminal work, Birth As an American Rite of Passage, anthropologist Robbie Davis-Floyd coined the term "technocratic model of birth" to refer to obstetric medicine's reliance upon technology. Davis-Floyd points out that when the Cartesian model of the mechanical human body is imposed upon the process of birth, technology displaces the physical and emotional intimacy and female-centered sexuality which are part and parcel of the holistic model of birth. Adherents of the midwifery model reject this technocratic model by fully embracing female sexuality and non-scientific ways of knowing during the birthing process.

Since traditional midwifery makes no attempt to demarcate itself as a medical or scientific profession, midwifes are free to employ a conversable rhetoric that speaks to the laboring woman's emotional, social, and spiritual needs in addition to her physical needs. Under the midwifery model, childbirth is not reduced to a mechanistic event focused entirely upon timing the contractions of the uterus, measuring the dilation of the cervix, and monitoring the heart tones of the fetus; rather, birth is viewed holistically, requiring the laboring woman's whole-hearted and full-bodied participation. The laboring woman's agency is encouraged and supported throughout the course of pregnancy and labor as the midwife attends to her needs on her terms. The physical arrangements for labor and delivery are entirely the client's choice, and not arranged for the convenience of the midwife and her helpers. The woman's choice of birthing at home in her own familiar environment, surrounded by her choice of family and friends; eating, drinking, moving about at will--all these choices reflect the laboring woman's expression of personal agency and responsibility and the midwife's lack of investment in the value of professional power and control.

Obstetricians wield what is known as authoritative knowledge, that is, they are the ones who have the authority to declare what is going on and what should be done about it, or, as anthropologist Brigitte Jordan puts it, the "knowledge that within a community is considered legitimate, consequential, official, worthy of discussion, and appropriate for justifying particular actions" (58). This is because, in the high-technology arena of modern medicine, only physicians and their trained assistants possess the knowledge to read and interpret the machines.

The art of traditional midwifery, on the other hand, stems from a pre-modern, pre-Cartesian worldview that privileges practical reasoning and intuitive knowledge over scientific methodology and technology-based authoritative knowledge. A 1994 study by Davis-Floyd contrasted the technocratic rituals of American hospital birth—those obstetric procedures that conceptually separate mother from child, mind from body, and labor from delivery—with the holistic ideology of mind-body and parent-child integration. This holistic approach to childbirth is integral to the midwifery model and influences the practical management of midwife-assisted births. Midwives, for example, rely upon intuition as a salient source of authoritative knowledge during the birthing process (Davis-Floyd and Davis). This intuition is predicated upon a sense of "connection" among the midwife, the mother, and the child, as well as among their bodies and spirits, that arises from a non-Cartesian epistemological orientation of holism.

Other key differences between the obstetric model and midwifery model, as summarized by Kathleen Doherty Turkel in her article, "Midwifery and the Medical Model," include:

Medical Model: Midwifery Model:

technological reliance natural observation

hierarchical patient control woman-centered control

pathological model of birth birth as healthy activity

mother/child separation mother/child unity

In addition to the differences noted above, physicians are university-trained, while most direct-entry midwives, by contrast, receive their training through a combination of home study and apprenticeship to an experienced midwife. Also, hospital-based births usually rely upon analgesics and anesthesia for pain management, whereas midwife-assisted births rely upon a variety of pain management techniques that include comforting words, the use of therapeutic touch, physical mobility and position changes, and warm baths and showers. Finally, continuity of care is an integral facet of midwife case management, with a midwife typically providing her clients with personally administered prenatal, perinatal, and postnatal care.

Prudential Reasoning, Rationalism, and the Irrational:

In addition to the commonly recognized distinctions between the two models of childbirth, my research indicates that the midwifery model encourages the use of prudential reasoning, while the medical model encourages reliance on rationalism. By rationalism, I refer to the employment of formal logical proofs, rules of objective evidence, and normative standards of care. The midwifery model relies far less upon formalistic standards and in many instances seems to violate rationalism. For example, midwifery's reliance upon subjective intuition as a source of knowledge, as well as the midwife's holistic integration of mind/body and mother/fetus, violates rationalist principles of objectivity. Midwives use non-rational means to discern the demands of an exigency. Using intuition, emotion, and body-knowledge to discern information, as well as acting-without-thinking--or its opposite: patiently-watching-and-waiting--are examples of non-rational modalities at work.

To advocates of the medical model, the irrational aspects of the midwifery model seems to amount to an "anything goes" model of care, entirely without standards. But midwives who employ prudential reasoning as their primary critical thinking process would disagree that "anything goes" in midwifery management; rather, they argue that prudential reasoning allows the freedom to provide the most appropriate care by responding to the particular case rather than sometimes inappropriate mandatory protocols. The midwifery standard could thus be defined as an ability, in each particular case, to realize the available means for ensuring the welfare of mother and baby.

One of the challenges encountered when discussing prudential reasoning is that prudence is so closely tied to concrete experience and action in response to a particular case that it is impossible to reduce it to a neat set of abstract principles, for this philosophical reduction would constitute an essential violation of prudence. As philosopher Eugene Garver puts it, prudence, unlike science, deals with things whose fundamental principles are variable, therefore prudence resists generalization.

Prudential reasoning represents the ability to range freely between rationality and irrationality in the pursuit of the best course of action to resolve the exigency at hand. The midwifery model tends to develop and encourage irrational modalities of experience in pursuit of this goal, while the medical model tends to discount them. Rather than positing rationality and irrationality as the two positions represented by obstetrics and traditional midwifery, it is more accurate to posit rules and normative standards on the one hand, and emerging exigencies and their timely resolution on the other. Prudential reasoning involves shuttling back and forth between these positions in pursuit of the best response to the particular case. A prudent person, therefore, lets the emerging exigency drive the application of appropriate rational norms. The prudent person knows, usually by benefit of experience, if/when/and to what extent rationality applies to the situation. An exclusively rational person, on the other hand, upholds normative standards and formalistic rules as the highest standard of care, and will apply those standards irrespective the suitability of their application to the particularities of the exigency.

Demarcating the Professions of Obstetrics and Midwifery

According to Burke's Dramatistic Pentad:

The practical utility of mapping the obstetric and midwifery models according to Burke's dramatistic pentad goes beyond merely identifying the demarcation of these two competing professions. Across the nation, in venues ranging from legislative bodies to licensing review boards to the criminal trials of midwives, an understanding of the true boundaries of these two professions is essential for the just administration of public policy.

Consider, for example, a midwife brought up on charges of practicing medicine without a license or child endangerment. If the midwife's behaviors can be shown to be in keeping with the cultural paradigm of the midwifery model, as understood with the help of this pentadic schema, then her actions should not be considered criminal aberrations. But if the midwife's behaviors can be shown to be a violation of the midwifery model of care, then her actions can rightly be prosecuted as, for example, either criminal negligence (very poor midwifery) or practicing medicine without a license (unauthorized use of the medical model). In states where the legislature has determined midwifery to be a valid health care practice, understanding the demarcation between medicine and midwifery should alleviate unnecessary prosecutions of midwives who properly administer the midwifery model of care. When a midwife stands accused of licensing violations, understanding these distinctive schemas should make it possible to determine which of the defendant's actions are in keeping with the midwifery model of care and therefore exempt from prosecution, which behaviors are actually medical interventions under the obstetric model of care and therefore a violation of medical licensing, and which behaviors are simply negligent under anyone's model of care and indictable as, for instance, child endangerment.

In order to make clear the distinctions between the obstetric model and the midwifery model, Burke's dramatistic pentad will now be mapped onto the commonly recognized components of each system of care. We will begin with mapping the obstetric model of care and then proceed to the midwifery model.

The Obstetric Model Pentad. God-term: science:

Medical Scene: The scene for a medicalized birth is the hospital delivery room, or, in extreme circumstances, the hospital emergency room or obstetric operating theater. The props that adorn this scene are technological; the lighting is bright; the atmosphere is noisy and hectic. In this scene, the birthmother is the central prop, for she is the object upon which the physician operates. The mother may be further objectified through the use of drugs that render her unable to physically participate in the birth. The unborn baby is the desired object the agents in this drama strive to acquire. The larger ideological ground of the scene is the mechanistic, rationalistic, scientific worldview.

Medical Agent: According to Burke's scene: agent ratio, by virtue of the fact that the scene is the hospital, the physician is the primary agent of the scene, since the hospital is the stage upon which he acts. The obstetrician is the star of this show; all of the ritualistic events surrounding hospital labor lead up to his arrival on the scene and in his absence the birth cannot proceed. The obstetric nurses function as co-agents supporting the needs of the physician. The agent status of physicians is largely based upon the deference accorded doctors as exclusive sources of authoritative knowledge in issues considered to be medical.

Medical Agency: Rationalism, as a key constituent of the medical god-term science, is the critical-thinking engine that drives medical agency (god-term: agency ratio). The means by which the birth is achieved is through technological intervention. This intervention is directed by the attending medical personnel (agency: agent ratio). The technology may be mechanical (scalpels, forceps, vacuum extractors, syringes, mechanized infusion pumps, IV drips), electronic (EFMs, ultrasound, blood gas readouts), or medicinal (Pitocin, anesthetics, narcotics). When the birthfather is present, his job is that of a tool for managing the birthmother, in order to encourage her cooperation with the medical management of the birth.

Medical Act: The act is the delivery of the child from the mother by the obstetrician (agent: act ratio). The mother, in this scene, does not actively birth the baby; the child is taken from her by the primary agent, the physician, who immediately severs the umbilical cord. The physician then hands the newborn directly to the co-agent, the obstetric nurse, who dries and wraps the baby at a separate work station.

Medical Purpose: The purpose of the hospital birthing scene is the safe delivery of the child and the comfort and safety of the mother (scene: purpose ratio). Successful accomplishment of these two primary goals serves an important secondary purpose of avoiding hospital lawsuits; a "perfect birth" is the ultimate goal. The obstetric model on the whole is based on the presumption that any risk to a mother or baby is too great. The goal of the obstetric model is to reduce risk to as close to zero as possible--hence, the high frequency of interventions designed to prevent "what-if" scenarios. Efficiency is also a primary goal for, at any given time, laboring women may outnumber care providers.

Even in their absence, the above classifications apply, and any deviation from this schema constitutes a grave emergency in and of itself. For example, giving birth outside the confines of the hospital is considered an emergency condition fraught with peril. If a physician were to encounter a woman laboring at the "wrong" scene--at home, for example--emergency transport to the nearest hospital is top priority (scene: purpose ratio). In the absence of an attending physician, those present are considered helpless in the face of the impending birth (agent: agency ratio). Even if a doctor is present, if the proper means of technological agency is missing--e.g., a power outage that idles the machines--the physician's ability to assure a safe delivery for mother and child is considered severely impaired (agent: agency ratio).

The Midwifery Model Pentad. God-term: nature:

Midwifery Scene: The traditional scene is in the birthmother's home, surrounded by family, friends, neighbors. The birth may occur anywhere in the home, but most typically in the bedroom or living room. The larger ideological ground is nature and natural womanly processes.

Midwifery Agent: Since the scene is the birthmother's home, Burke's scene: agent ratio indicates the birth parents will be the primary agents of the scene. The midwife or visiting physician is only a "guest" in the home, there to bring about whatever it is those parents wish to bring about. The birthmother is the star of the show; it is through her actions that the birth will take place. The fetus is also considered a primary agent in this model, and his or her movement through and beyond the birth canal is sometimes referred to as the "hero's journey." The birthfather's presence reinforces the "natural" ideological ground of the bonded family unit. The midwife functions as the birthmother's co-agent and is motivated by the mother's and baby's needs rather than imposing her own agenda upon them (agent: agency ratio).

Difficult decisions, such as whether or not to transfer to the hospital during the course of a long labor, are arrived at through conversation with the birthmother. In this sense, the midwife acts in much the same manner as a therapist who aids the client's self-discovery by encouraging and reflecting her discourse. The rhetorical exchange between the laboring woman and the midwife represents a more complicated decision-making process than the simple assumption that, as the primary agent in the situation, the birthing mother's word is law. The midwife does not automatically heed the mother's request, but tests the woman's resolve through discourse. A birthmother who really wants to transfer to the hospital, for example, will bring that about through her actions as well as her words, and no amount of coaxing or placating will dissuade her. This birthmother would insist that she means what she says and will not rest until her desire is heeded.

Midwifery Agency: The birthmother labors naturally and by her efforts the baby is pushed down the birth canal. In this model, in addition to being the birthmother's co-agent, the midwife serves as a tool used by the mother as primary agent (agent: agency ratio). Technological instruments are minimal (blood pressure cuff, DeLee suction trap, oxygen bottle and mask, Doppler device), while natural remedies are found in abundance (herbs, homeopathics, medicinal foods, hot baths, massage, body fluids, essential oils) (god-term: agency ratio). Patience is a key attribute. Bodily awareness and intuition are abundantly employed as salient sources of knowledge. Prudential reasoning determines when, if, and how the midwife responds to the unfolding exigencies of birth.

There are no hard and fast normative standards under the traditional midwifery model. A midwife intuitively responds to the unique exigencies of the particular case, occasionally deviating from textbook recommendations through a process of non-rational thought. This ability is developed through experience and practice, and often results in unexpected but efficacious responses. The standard of midwifery's prudential reasoning is the ability to successfully respond to exigencies on a case-by-case basis.

A midwife will not intervene prophylactically in the natural course of events because of a theoretical possibility that something may be amiss. She will patiently wait to make sure intervention is necessary. The difference between the approaches of these two models to risk reflects each model's stance in relation to manmade agency versus natural agency. Patience is not as much of a virtue under the medical model as it is under the midwifery model, because nature is not expected to resolve crises in a positive way. If there is a medical crisis, it cannot resolve unless a doctor intervenes to resolve it. Midwives take an entirely different approach that relies upon the observation and facilitation of natural processes. A midwife's patience can easily be confused with ignorance or negligence when looked at through the medical model's terministic screen. Under the medical model, intervention is the standard response because the physician's authoritative agency manifests itself through action. A midwife's agency, on the other hand, is more difficult to identify because of its alignment with the natural course of events.

Midwifery Act: The baby is not taken from the birthmother as in the hospital model, but is birthed by the mother's active agency. Due to the birthmother's status as primary agent of this pentad, the birth proceeds at her pace and according to her individual physiology rather than predetermined time limits and mandated standards of care (agency: act ratio). The infant is either placed immediately upon the mother's breast, or is allowed to continue its own heroic journey from her crotch up to her breast. In addition to supporting the mother's labor, the father ritualistically cuts the umbilical cord after it stops pulsating.

Midwifery Purpose: The purpose of the homebirth setting is to respond to emerging exigencies in the most natural way possible, with the expectation that a natural birth is a good birth (god-term: purpose ratio). For the mother as well as the child, this natural birth implies a reduction in extraneous emotional stressors such as unknown agents in the scene and unfamiliar surroundings, in keeping with Burke's scene: purpose ratio. The homebirth is considered by its participants to be a physical demonstration and embodiment of the spiritual quality of familial love.

As was the case with the alternate, obstetric model's pentad, any violation of the schema outlined above constitutes a violation of the midwifery model. Because of the relationship ratio between the scene, agent, and agency, it is considered extremely difficult to have a truly "natural" birth in a hospital setting. For example, certified nurse midwives who practice in a hospital setting necessarily adopt a more medicalized approach to midwife-assisted birth that stands in tension with both the midwifery practiced by traditional, homebirth midwives, and the obstetrics practiced by physicians.

In cases where the woman's health status constitutes a dangerous medical condition, the "natural" god-term of the midwifery model would not be the most appropriate schema to apply, as it violates the god-term: scene ratio. If the woman's diseased condition precludes a "natural" birth, then the medical model is the most appropriate to apply. In such cases, it is important to define risk in a manner fair to the midwifery model of birth for, as it has already been noted, the obstetric model of birth views virtually all births as potentially high-risk. According to the requirements for proving a charge of child endangerment, for example, a medical expert only needs to imply that worst case scenarios may occur, for the law asks the jury to determine whether the child was placed into "circumstances that could cause great bodily injury or death." This is not a difficult conclusion to elicit from a physician, for the entire obstetric model of birth is predicated upon the assumption that vaginal birth is fraught with hazards that can escalate within moments to a full-blown emergency.

Critics of the midwifery model of health care appear to identify so strongly with the medical model paradigm that they cannot recognize the validity of midwifery's alternative pentadic schema. The midwifery scene, the home, is often criticized because it is not the medical scene, the hospital. A midwife under review may be criticized for not exercising authority as the agent in charge, but this would be a violation of the midwifery agent: agency ratio; it is only under the medical model where the agent is the professional on the scene--the physician. A midwife on trial may be criticized for using non-technological agency in keeping with the midwifery model, such as when she uses her own body as an instrument to gauge an infant's heart rhythms. Or, she may be criticized for allowing a birth to proceed at a slower pace than the medical model's act element would allow, even though allowing a birth to proceed at its own pace is fully in keeping with the act under the midwifery model.

These types of criticisms can only be levied against a midwife when the critic is so firmly entrenched in the dominant medical schema that the critic either does not recognize, because of the terministic screen phenomenon, or recognizes but completely rejects the alternative paradigm and so holds the individual midwife personally accountable for all deviations from the dominant model. On the other hand, while the pentadic mapping of the midwifery model provides a kind of ideological "shelter" for the practices of traditional midwifery, it provides an equally strong mandate for the obstetric model when medical conditions rule out the "natural" course.

In Conclusion:

We have seen that while the professions of obstetrics and traditional midwifery may share the common boundary of assisting women during childbirth, the differences in the social institutions and patterns of interpersonal interactions, as well as the protocol of behaviors that constitute what each health care system defines as appropriate, are predicated upon different mental processes. The mental processes that shape these two distinctive cultures consist of different sets of values as well as reliance upon different modes of critical thinking.

Burke's dramatistic pentad offers a useful tool that not only clearly maps the distinctions between the two systems, it is also a useful means of determining which behavioral manifestations are appropriate by employing the necessary ratios among the various pentadic elements. This application of Burke's pentad is directly and immediately applicable to the ongoing debate over the practice of traditional midwifery. For example, obstetric medicine's god-term "science" not only explains but mandates technological agency, whereas midwifery's god-term "nature" discourages technological agency due to the god-term: agency ratio. Likewise, the scene: agent ratio of the midwifery model places the parturient women as the primary agent of her homebirth scene, whereas the scene: agent ratio of the obstetric model designates the physician as primary agent of the hospital scene.

Because of the strong relationships implicated among pentadic ratios, it is difficult to maintain the integrity of a given system when these ratios are violated. If the strong ratio relationships within a given pentadic schema are fully understood, then singling out any element within a schema for criticism is tantamount to rejecting the entire schema. This has practical implications for the just administration of law. For example, informed consent on the part of the birthmother should be sufficient to prove the mother knew herself to be the agent on the scene and the midwife should not be prosecuted for "negligently" facilitating the birthmother's wishes, because the agent of the midwifery model is the mother, not the midwife. For the same reason, State Medical Boards would be ill-advised to attempt the establishment of universal standardized protocols for all licensed midwives, for that would necessitate a rejection of the prudential reasoning agency of the midwifery model. Obstetric medicine's reliance upon rationalism falls under medical agency, which mandates that certain formulaic protocols and standards of care be employed in answer to particular exigencies. Midwifery's reliance upon prudential reasoning under midwifery agency allows for more inventive solutions to birthing exigencies that would be not be considered reasonable under obstetric's rule-based system. When the State holds a midwife to the "reasonable person" standard during trial, that reasonable person standard is generally assumed to be rationalism. Yet, for the midwifery model of care, that reasonable person standard is not rationalism, but prudence. It is incorrect to assume that there are no standards in the absence of rationalism; the applicable standard is prudence.

If a midwife's behaviors can be shown to be in keeping with the cultural paradigm of the midwifery model, as understood with the help of this pentadic schema, then her actions should not be considered criminal aberrations. But, if a midwife's behaviors can be shown to be a violation of the midwifery model of care, then her actions can rightly be prosecuted as either criminal negligence (very poor midwifery) or practicing medicine without a license (unauthorized use of the medical model). Since midwifery has been determined by the state to be a valid alternative cultural health care practice, understanding the demarcation between medicine and midwifery should alleviate unnecessary prosecutions of midwives who properly administer the midwifery model of care. Once these distinctive schemas are fully understood, it becomes possible to tell which of a midwife's actions are fully in keeping with the midwifery model of care and therefore exempt from prosecution, which behaviors are actually medical interventions under the obstetric model of care and therefore a violation of medical licensing, and which behaviors are simply negligent under anyone's model of care.

Works Cited:

Arney, W. R. Power and the Profession of Obstetrics. Chicago: Chicago UP, 1982.

Borton, Sylvia et al. "A Feminist Perspective on the Study of Home Birth." Journal of Nurse-Midwifery 39 (1994): 142-149.

Burke, Kenneth. A Grammar of Motives. Berkeley: University of California Press, 1945.

Davis-Floyd, Robbie. Birth as an American Rite of Passage. Berkely: U of California P, 1992.

Davis-Floyd, Robbie E. "The Technocratic Body: American Childbirth as Cultural Expression." Social Science Medicine (England), 38 (1994): 1125-40.

Davis-Floyd, Robbie and Elizabeth Davis. "Intuition as Authoritative Knowledge in Midwifery and Homebirth." Medical Anthropology Quarterly 10(2) (1996): 237-269.

Fisher, Sue. In the Patient's Best Interest: Women and the Politics of Medical Decisions. New Bruswick: Rutgers UP, 1986.

Garver, Eugene. Aristotle's Rhetoric: An Art of Character. Chicago: Chicago UP, 1994.

Goer, Henci. Obstetric Myths Versus Research Realities. Westport: Bergin, 1995.

Jordan, Brigitte. Birth In Four Cultures. Prospect Heights: Waveland, 1993.

Lay, Mary M. The Rhetoric of Midwifery: Gender, Knowledge, and Power. New Brunswick: Rutgers UP, 2000.

Lucaites, John L. and Celeste M. Condit. Introduction. Contemporary Rhetorical Theory: A Reader. Ed. John L. Lucaites, Celeste M. Condit, and Sally Caudill. New York: Guilford, 1999. 1-18.

Lyons, Nona Plessner. "Two Perspectives: On Self, Relationships, and Morality." Harvard Educational Review, 53 (1983): 125-145.

Turkel, Kathleen Douherty. "Midwifery and the Medical Model." Women's Studies in Transition: The Pursuit of Interdisciplinarity. Eds: Kate Conway-Turner et al. Newark: U of Delaware P, 1998. 218-235.

Warren, Virginia L. "Feminist Directions in Medical Ethics." Feminist Perspectives in Medical Ethics. Eds. Helen Bequaert Holmes and Laura M. Purdy. Bloomington: Indiana UP, 1992. 32-45.

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