Palestinian Midwifery: Now and Then
Since the beginning of the 20th century, sovereignty over the land of Palestine has been negotiated and renegotiated by a handful of international actors. With each transfer of power, new state apparatuses have been constructed to monitor and control populations residing within the borders of this relatively small territory. These biopolitical mechanisms have persistently manifested through obstruction of Palestinians’ ability to give birth as they desire, with particular regard to spatialized restrictions.
Under the British Mandate, legislative control over midwifery established a two-tiered system that marginalized traditional practitioners as exclusively rural and encouraged Palestinian women to give birth in hospitals. Today, an elaborate system of checkpoints and borders prevents many Palestinians from accessing the very health centers they’ve come to rely on. In facing these literal barriers to care, returning to a midwifery-based model shows promise for improving birthing experiences among Palestinians.
The Ottoman empire ruled over the land of Palestine for four centuries. For most of their governance, no formal regulations were in place regarding the practice of midwifery. By the end of the Ottomans’ reign, at least three types of midwives coexisted in the area. Two of these varieties were trained in Europe and attended Jewish births. The first set were local to the area, leaving for European diplomas, and then returning to Palestine to care for their communities. The second type, feldschers, were a variety of medic-midwives originating from Eastern Europe and immigrating to the land as early Zionists.
When licensing regulations were put in place in 1861, they only applied to these “modern midwives.” Left unregulated was a third type of midwife, deemed to be too traditional for regulation: the daya (plural: dayat). Dayat oversaw births among Palestinian Arabs, acting as gynecologists, obstetricians, and pediatricians in addition to being highly respected as community leaders. As one British superintendent of midwifery would later observe,
“The Dayah or untrained midwife was a friend of the family; she delivered and named the child, attended all ceremonies and arranged its wedding, and her word was law,” (quoted in Katvana 165).
In 1917, the British usurped control of the area, and the following year saw major changes for midwifery. Nurse-midwives were introduced as a fourth type of midwife in 1918 by the Jewish American organization now known as Hadassah. Furthermore, 1918 saw the passage of the Public Health Ordinance, one of the first pieces of British legislation in Palestine. Similar to the Ottoman legislation that preceded it, this law required midwives to receive diplomas and licenses but did not apply to dayat, who were not seen as a legitimate part of the healthcare industry. The Midwives Ordinance of 1929 finally addressed the status of dayat directly, however state recognition would ultimately prove more detrimental than beneficial.
It’s important to consider the purported goals of the ordinance to make sense of its intended and unintended effects. The first explicit aim of the law was to reduce infant mortality in general and particularly among Palestinian Arabs. In an era of increasing state control, these measures of good health were seen as markers of good governance that were essential to justify British occupation. Furthermore, Palestinian Arabs needed special attention since their infant mortality rates have been persistently higher than Jews in same area due to an inequitable distribution of access to western financial and educational resources. The second supposed goal of the ordinance was to protect professional jurisdiction of midwives and other medical personnel.
It did so by requiring all practitioners of midwifery to either receive a license, becoming a “licensed midwife”, or at least to register with the government as a “registered daya”. The ordinance also outlines which duties midwives can perform and which must be referred, and where each type of midwife is permitted to practice. In reality, the law effectively restricted the roles of all midwives while introducing an additional level of hierarchy within the profession.
The law “forbade all midwives from treating abnormal cases, practicing gynecology or any other branch of medicine, and possessing unauthorized drugs,” (Brownson 33).
This was the case even when an area did not have a sufficient supply of physicians to meet demands, calling into question the law’s intention to actually improve infant and maternal health. Furthermore, dayat were only permitted to practice in locations deemed to have an insufficient supply of midwives, usually rural areas with little business. Dayat were also perceived as dirty and ignorant by British authorities, resulting in disproportionate surveillance and censure. For example, their government issued bags were frequently checked and if tools were found missing, they could receive fines. Conversely, midwives could practice anywhere once licensed, which required only a six-month course, with no need for a diploma or nursing degree. And yet, these courses required paying a fee and being literate, which resulted in de facto exclusion of many Palestinian Arabs.
Furthermore, the state refused to retrain older dayat as midwives, preferring young Arab women in their 20s. In this way, the usual dichotomy between nurse midwives and certified professional midwives is collapsed into one category of “licensed midwives” defined in contrast to “registered dayat” that received no state sponsored training at all. Here the very language used by the ordinance shows the racialized divide between those seen as western, modern, and educated versus those who are eastern, traditional, and ignorant.
This over-limiting legislation put major financial pressure on dayat. Not only where their services and market share restricted, they also had to pay registration fees or invest unpaid time in trying to become licensed. Furthermore, many birthing parents would see a dayat for prenatal care, but ultimately give birth in a hospital, so no money would go to the daya. And there were concerted campaigns to convince Palestinian parents that hospital birth and western childcare practices were superior. For example, home births were cast as dirty and instead women were encouraged to attended infant wellness centers for care and education. This education sought to debunk traditional healing methods seen as superstitious and replace them with Westernized parenting practices. Financial prizes were even offered for “better babies”.
Taken together, the evidence reveals a strong underlying motivation of the legislation to reduce dayat to an interim solution that would inevitably be phased out when hospitals took their place of hegemony in childbirth. All of these drastic interventions did work to reduce infant mortality in Palestine under the British mandate, however they did little to close the gap between Arabs and Jews. This is likely because of continued disparities in the number of medical professionals per capita in each population.
Recently, the decline in infant mortality among Palestinians has been stalled since the end of the second Intifada in 2006. This period of increased violence between the Israeli military and occupied Palestinians has resulted in drastic securitization of the area that greatly restricts Palestinians’ movements. With 528 checkpoints across the nation and only 37 hospitals in the West Bank, it is exceedingly difficult to get access to quality pregnancy care, with one fifth of Palestinian women foregoing prenatal care. Furthermore, it is estimated that home births have increased by 8% as a result, since 10% of women would have to spend 2–4 hours on the road to access a medical facility. The problem is exemplified by the 68 births that have occurred at checkpoints, resulting in 35 miscarriages and 5 maternal deaths. In 2009, these alarming findings prompted a report from the UN Human Rights Council on the issue.
A handful of international organizations are working to rectify these issues. Midwives for Peace is one group that seeks to unite Palestinian and Israeli midwives across borders and political differences to make progress on shared goals. This starts by getting midwives from different backgrounds in the same room to exchange stories and information. They’ve also been distributing safe delivery kits as a form of harm reduction, since so many births are occurring outside of medical centers. By decentralizing reproduction technologies, they’re putting power back into the hands of traditional birthing attendants. Since 2012, there’s also been a more formal attempt by the Palestinian Authority to apply a Norwegian midwifery model of satellite birthing centers attached to more established hospitals. This plan was piloted with funds from Norway and is now being scaled up by the WHO. It not only trains midwives and establishes clinics, but also ensures cars are provided for midwives that want them . In this way, mobile dayat can begin to overcome the forces that have sought to restrict them for over a century.
This extended history of midwifery in Palestine shows a persistent pattern of Western intervention. The provision of external financial and technological resources certainly has the potential to reduce infant mortality but can just as easily invoke colonial legacies. In attempting to aid Palestinian parents and their children, it is essential to empower and uplift traditional healers rather than usurping their authority. Not only is this more ethical, it may also prove more effective.
