Midwifery in France
Midwifery in France has undergone significant transformations since it first emerged as a profession in the early sixteenth century. The political, social, and religious shifts throughout France’s history are echoed in the ongoing transformation of the positionality of the midwife. Given the long and complex history of French midwifery, I will outline the most significant points in its development — moving from its emergence as an occupation in the 1500s, to the tensions accompanying the emergence of the (male) medical profession in early modern France, to the development of contemporary childbirth practices — before delving into midwifery, pregnancy, and childbirth in present-day France.
In its earliest officially recognized form, midwifery was an ecclesiastically circumscribed practice. This sets France apart from other Western European nations, in which midwifery for the most part emerged separate from — or in opposition to — the Church. French midwives were essentially extensions of the Church bureaucracy, and were expected to uphold the teachings of the Church, as well as act as expert witnesses in cases of infanticide, contested virginity, abortion, and sterility.
The close connection between midwifery and the Church both served to legitimize midwifery as a profession, and at the same time to circumscribe midwives’ practices. Their licensing and regulation ensured them proper payment and to an extent ensured their success; however, the Church limited the number of women whose pregnancies and births a midwife was allowed to oversee per year, and arguably strained the midwife’s relationship with the women that she served, due to her proximity to authority.
Scholars and historians have an extensive knowledge of pregnancy and childbirth practices and the general outlooks and concerns surrounding them in early modern France, as a result of the high volume of obstetrical treatises written by surgeons, physicians, and midwives at this time. In Childbirth and the Display of Authority in Early Modern Europe, particularly the chapter “French Treatises 1550–1730,” Lianne McTavish outlines the common practices of physicians and midwives in France during this period. The treatises that McTavish analyzes range in specialization from books containing a few case studies of births, to in-depth works on caesarean sections. She notes that women authors of treatises typically stressed the importance of midwives in antenatal care and labor, while men tended to argue for restricting the roles of midwives.
A rising conflict between female-midwife-controlled and male-medical-professional-controlled birthing practices emerged during this time, which is evident in the numerous pamphlets attacking male practitioners in the early modern period. This aligns with the male takeover of gynecology and obstetrics which was simultaneously occurring across Western Europe, as outlined by Barbara Ehrenreich and Deirdre English in Witches, Midwives, and Nurses: A History of Women Healers.
During this period, McTavish argues, obstetrical treatises were primarily produced not for the expansion of public knowledge, but in order to improve the reputation of the author, which marks a definitive shift from birthing-person-centered lay midwifery. Prior to the flood of medical texts that emerged at this time, lay midwives, who learned midwifery via apprenticeships, were the most common birthing assistants. Through an analysis of a range of early modern French obstetrical treatises, McTavish reveals the gendered tensions that marked the shift to male-controlled gynecology and obstetrics.
Childbirth practices in France shifted markedly in the twentieth century, and particularly the latter half. As occurred throughout much of Western Europe and in the United States, birth shifted almost entirely to the hospital and became a medicalized process. In 1945 in France, 50 percent of births took place at home; today, one percent of births occur at home, and half of these accidentally take place there. Childbirth has become increasingly technologized over the past several decades; however, unlike in the United States, midwives have maintained a central role in France.
Today, professional midwives — comparable to nurse-midwives in the United States — are involved in most births. Midwives receive four years of training prior to entering the profession. Pregnancy and childbirth are highly interdisciplinary in France, however, and most people giving birth are assisted by a range of specialists throughout, including obstetricians, gynecologists, physicians, pediatricians, psychologists, and anesthetists, in addition to midwives. In most cases, the person giving birth will first go to a general care physician, who will then help them choose a gynecologist. The gynecologist will oversee the pregnancy, and will often help the person to choose a hospital and midwife.
J.K. Emons and M.I.J. Luiten outline the role of midwives before, during, and after childbirth in France in “Midwifery in Europe: An inventory in fifteen EU-member states,” as well as introduce common critiques of the current state of midwifery. According to Emons and Luiten, the responsibilities of midwives include antenatal care, antenatal classes, echography (when necessary), medical supervision of “normal” births, postnatal medical supervision of mother and child, and parental education.
While the practice of midwifery has expanded over the past few decades to include more technological skills, this has been accompanied by a loss of independence, as midwives have become integrated into hospitals and now operate alongside a team of medical professionals. The vast majority of French midwives are what we would consider to be nurse-midwives: 85 percent of midwives work in hospitals; of the remaining 15 percent, only a small number deliver babies — many independent midwives primarily provide antenatal and postnatal care. Although childbirth in France involves far less intervention than hospital births in the United States and many other “western” nations, the National Union for Midwives considers the general view of pregnancy and birth in France to be too technical and pathologized. This view is not necessarily shared by the majority of midwives, however.
Typically in France the first antenatal exam occurs sometime before the end of the third month of pregnancy. In addition to appointments with a gynecologist throughout the pregnancy, many people work with a midwife, who helps with birthing exercises and education surrounding childbirth. Separate “maternity hospitals” are common throughout France. Although most births take place in a hospital or maternity hospital, the “cascade of interventions” that frequently accompanies hospital birth in the United States is far less common in France. This is reflected in France’s 20.8 percent caesarean section rate — for comparison, 32.5 percent of births in the United States are caesarean sections, while the caesarean rate in the Netherlands rests at 15.6 percent, and Turkey, on the high end of the scale, delivers 50.4 percent of babies via caesarean section.
That is not to say that natural birth is the norm in France: inducing labor and administering epidurals are extremely common practices. Additionally, midwives typically use medical instruments, and can administer certain medications and labor tests (Emons and Luiten 46). Despite the technicalized aspects of hospital births, however, midwives still maintain a significant degree of agency in the process. In the year 2000, 70 to 75 percent of births took place under the primary responsibility of a midwife, and the birthing model has remained fairly consistent throughout the twenty-first century.
It is generally thought that midwives should oversee “normal” births, while doctors should only intervene if complications occur — although there is no standardized definition of what constitutes a “normal” birth. In spite of the high involvement of midwives in most births, Emons and Luiten note that some midwives have expressed concerns regarding the pressure to work according to the protocols of doctors.
After giving birth, the typical hospital stay is three days. Healthcare legislation in France grants full coverage for a variety of postnatal examinations and services for both the birthing person and the infant, as I will elaborate on below. There is an increasing awareness of postpartum depression in France, and midwives play a major role in this: Dr. Susanne Braig, medical director of Gynecology, Obstetrics, and Pediatrics at Annecy Hospital in Haute Savoie, states, “‘Midwives are probably best situated to spot cases of postpartum depression because of their close proximity to mothers following childbirth.’” Dr. Braig adds that prenatal care providers are also striving to provide more education surrounding postpartum depression.
Due to the state of French healthcare, France is considered one of the best countries in which to give birth. Giving birth in a public hospital is typically entirely covered by insurance; however, midwife-attended home births are widely considered to be riskier, and are not necessarily covered. During pregnancy, insurance covers the full costs of a variety of prenatal tests and appointments, including nine examinations with a gynecologist. After giving birth, each person is guaranteed three free home visits from a midwife, who attends to both the birthing person and the baby.
Plantier argues in “7 Ways French Women Do Childbirth & Breast-Feeding Differently” that one of the most important roles of the midwife following birth is to provide emotional support and to relate to the birthing person on an interpersonal level as well as a professional level. The state also covers ten appointments with a midwife specifically with the purpose of re-strengthening the perineum and pelvic floor.
Employers are required by law to allow up to sixteen weeks of maternity leave, and in fact, people who have just given birth are required to take at least eight weeks of leave, which can include the weeks leading up to the birth. Maternity leave is longer if the person has already given birth two or more times, or if they are having twins or triplets. Paternity leave is typically eleven consecutive days.
Despite the comparatively advanced healthcare policies surrounding pregnancy and childbirth, parents receive little support from the state following their child’s early infancy: childcare is typically incredibly expensive — although there is state-sponsored childcare, it is widely considered insufficient — and many women are forced to stop working in order to stay home with the child themselves. Additionally, as previously mentioned, paternity leave only lasts eleven days, meaning that oftentimes people who have just given birth are forced to take care of a newborn child on their own while still recovering from labor.
Despite the critiques of France’s hospital-based birthing model, the country has impressively low rates of maternal and infant mortality: 8/100,000 and 3.2/1,000, respectively (compare to the United States, which has a 14/100,000 maternal mortality rate and 5.9/1,000 infant mortality rate). Midwives participate in 99.5 percent of births in France, and commonly assist in every step of pregnancy, labor, and early infancy. The uninsured cost of midwife-assisted home births, however, make it nearly impossible for low-income birthing people in France to control the nature and location of their birth. While French birthing practices are evidently an imperfect model, nations such as the United States, in which midwives do not play a role in the majority of births, would benefit from incorporating aspects of France’s healthcare, prenatal care, birthing practices, and postnatal care into its approach.
