The Mother-Procreator and the Independent Midwife:
This article is being published anonymously. It was written by one of the students in my Fall 2018 History of Midwifery class at Vassar College.
Over the past twenty years, Polish mothers have been seeking a way to reclaim agency in the birthing process in a highly medicalized, authoritarian system of obstetrical care. While midwifes are prevalent in the Polish healthcare system, they occupy contradictory roles of both subservience and independence. In their daily work, they are afforded independence: with the ability to deliver babies and prescribe medicine without a doctor. However, working in the hospital setting under the ultimate authority of the doctor, the Polish midwife has an identical status to nurses. Midwives and nurses operate under the authority of the Polish doctor in a healthcare system in which women had to fight for the right to give birth in dignified settings and to make their own decisions about childbirth. Until recently, Polish midwives acted as an extension of the paternalistic technocratic birth system.
Accounts of modern Polish midwifery can be traced back to the occupation of Western Poland by Nazi Germany during World War II. The Germans, in attempting to promote their racial hierarchies using state healthcare apparatuses, resettled German midwives and passed laws attempting to promote German motherhood. These laws included criminalizing abortion for German women, but not for Polish women, and providing benefits for German mothers, but excluding Polish mothers from the program.
Additionally, the National Socialist government attempted to criminalize Polish midwives by passing occupational bans and accusing the midwives of being poorly qualified and not following hygiene requirements. The Germans attempted a biopolitical project based on a racist philosophy that elevated Germans over all others, using control over women’s bodies and their reproductive abilities as the mechanism through which to implement it. Midwives, as birth practitioners who were charged with following the standards set by the regime, were essential to the project.
The role of Catholic teachings in Polish culture is also important in understanding the current state of midwifery and the system of childbirth. Emphasizing the role of the church in public and private life, conservative governments endeavored to promote an image of a “mother-procreator” and “woman-homemaker” in accordance with their ideological beliefs in patriarchal gender roles and the nuclear family. These governments equated the survival of the Polish national identity with traditional gender roles and the subservient placement of the mother in the family structure.
This ideological project coincided with healthcare policies which made childbirth more dangerous, including banning abortion, religious based abstinence teachings, and privatizing some medical services. These policies both enforced a standard cultural view of women as instruments of reproduction for the state and endangered the birthing mother. This view of motherhood works in tandem with the authoritarian model of health and childbirth in which mothers have very little agency in the childbirth process. As instruments of the state, the efficient production of children is paramount, while the preferences of the mother are irrelevant.
The current role of the midwife in childbirth in Poland can be seen as early as 1978, when midwives were the primary childbirth attendants, yet still under the authority of Polish obstetricians. In a report published by the UCLA School of Public Health in 1978, midwives were credited as the main attendant in 80–90 percent of all births in Poland, as doctors would delegate routine cases to them. The same report emphasized the difference in roles between rural and urban midwives, as rural midwives would perform prenatal care for women while midwives in the city were only allowed to assist physicians while they performed these services. While midwives were the primary providers of birthing care, they were still expected to defer to the ultimate authority of the doctor.
However, both rural and urban midwives were allowed measures of freedom, as they performed births by themselves. Additionally, midwives were responsible for home visits in order to provide post-partum care for up to six weeks after birth, and often gave their patients advice in regards to family planning. While midwives were still expected to defer to doctors in the hierarchy of Polish medical personnel due to their lower status, they were still independent in many aspects of their daily duties.
While midwives in Poland were afforded agency, mothers and other birthing persons in the childbirth process were subject to a battery of predetermined and often unneeded medical procedures. During an observational placement at a hospital in South Poland, a British midwifery student describes the routine procedures that were forced upon laboring women who entered the hospital, including enemas for every woman regardless of their labor status and the vast majority of women receiving episiotomies. She notes that
“I was shocked to discover that all women in labour (regardless of how established the labour was) underwent a routine enema. This was carried out in a separate room, without asking for the woman’s consent. In fact, not many things I saw involved a choice for the women. It felt to me as though they were stripped of their individuality and power to make decisions on their arrival. They placed themselves in the hands of professionals who decided on their behalf what was best for them”.
These women were introduced into the mechanistic model of childbirth in the Polish hospital, with little regard for how they would prefer to experience childbirth. The goal of the childbirth experience was not to give women a rewarding experience that would allow them to bond with their family and new child, but instead to quickly and routinely deliver babies. Little thought is given to the needs of the mother, as mothers were expected to either give birth alone in the delivery room or pay a hefty fee in order to give birth with a partner. Instead, the complete integration of the process of childbirth into the medical system has placed doctors as the ultimate authority in the birthing process.
The medicalization of childbirth has continued since 1978, despite movements attempting reform. Writing for the Association for the Improvement in Maternity Services, Anna Otffinowska positions the doctor at the top of the birthing hierarchy in Poland, claiming that the reason that 99 percent of births take place in a hospital setting is the opposition of doctors on the grounds that homebirth is an irresponsible whim that endangers the safety of the child. Despite movements like the Give Birth Like a Human Being campaign that attempted to promote patients’ rights in childbirth, Otffinowska claims that many women attempt to hire personal midwives to ensure that they receive attentive and personalized treatment.
Additionally, Otffinowska claims that midwives have lost some of their independence from the 1970s, when the UCLA School of Public Health report was published, and have been subsumed into the medical field under the authority of doctors. Writing as a member of the Childbirth with Dignity Foundation, Otffinowska promotes the independence of midwives and the movement away from the technocratic birthing system, as she believes this will center the needs and wishes of the patient in the childbirth process.
Rather than accepting the ideological position promoted by the state, Otffinowska argues that women should not be viewed simply as incubators for future children. Rather, she recognizes the humanity of the women giving birth and their feelings about the birthing process. To do so would require personalized and attentive medical care, rather than a standardized program of birth that requires invasive and unnecessary medical care for every woman.
The process of medicalization of childbirth in Poland has transformed midwifery from an independent profession to one that has been integrated into the hospital setting. Midwifery is viewed as a subfield within the nursing field. In academic studies of professional burnout amongst hospice nurses, midwives are used as a control group for comparison. Here, midwives and nurses were deemed similar enough in terms of practice and social standing to be an accurate point of comparison for scientific research. Additionally, legislators and public health officials group nurses and midwives together when writing new regulations. In 2016, certain nurses and midwives with Bachelor’s degree in nursing and midwifery were given the power to prescribe medicine.
Additionally, when changing the path for nursing and midwifery training, increasing the time spent in a Bachelor’s program to 3 years and a Master’s program to 2 years, midwives are grouped with nurses as a specialized branch of nursing and midwifery education is integrated with medical education. By placing midwives as a subgroup of nurses in the medical hierarchy, midwives are prescribed a role deemed less knowledgeable than that held by medical practitioners and one to whom doctors delegate tasks. The incorporation of midwives into the nursing profession and the medical field stands in great contrast to the limited independence that midwives enjoyed in the 1970s.
However, midwives in Poland in recent years have been regaining some of the autonomy that they used to enjoy in their practice before the profession underwent medicalization. As previous mentioned, educated midwives were given the ability to prescribe certain medicines and refer diagnostic tests. Midwives in a Warsaw hospital describe themselves as very independent in their duties and centering the patient as the most important person in the birthing process. However, midwives are still embedded within the hospital, with the exception of post partum home visits, and they still report back to the doctor as their supervisor within the hospital structure. Midwives may have gained independence in their routine tasks, but they still operate within the hospital setting and follow the technocratic philosophy of birth.
Women in Poland who seek treatment from a midwife in the birth process can get a high level of care and safety. Care is accessible to all due to Poland’s National Health Fund, which provides coverage to even uninsured women for pregnancy, childbirth, and postpartum care. After 21 weeks of pregnancy, women do not have to pay out of pocket for treatment from a midwife. This has resulted in some of the lowest infant and maternal mortality rates in the world. In 2014, the infant mortality rate was 4 in 1000 live births, and the maternal mortality rate was only 3 deaths per 100,000 births.
Due to its comprehensive coverage, the Polish healthcare system has adequately protected the safety of both mothers and children in the birthing process. This is important to consider in the context of its conservative government and previous policies. Poland has drawn comparisons to Texas culturally, and proposals have been suggested to bring the Polish model of midwifery to the state. However, it is unclear whether the implementation of the model of care would improve maternal health statistics, as Texas lacks the comprehensive health insurance coverage that Poland offers its citizens.
Despite their former status as an independent profession, midwives in Poland have been fully incorporated into the hospital setting under the purview of doctors. While this has often meant the subordination of midwives as lesser practitioners, they have regained some of their independence.
However, this resurgance in midwifery has not always resulted in a positive birthing experience for Polish women, as many report nightmarish conditions and a prevalence of unnecessary medical procedures. This is the result of conservative governments that promote the image of the ideal mother as a tool for birth rather than an active part of the birth process. This trend has been reversing in recent years, as infant and maternal mortality rates have fallen and midwives have become a more independent part of the birthing process.