In Coming Home: How Midwives Changed Birth, Wendy Kline historicises childbirth as a highly contentious issue in twentieth-century United States of America (USA). She focuses on the home birth movement of the 1970s and 1980s, examining how midwives and their clients challenged organised medicine and how it responded. She contributes significantly to the historiography of women’s reproductive health care by focusing on a topic which is generally neglected in historical studies. Coming Home is relevant to present-day USA where maternal and infant health care is ‘in great need of modification with midwives being seen as key in returning birth to a more physiologic state that is woman-centred’.Footnote 1
Coming Home presents midwifery and home birth as resilient ancient practices which managed to survive extinction in modern times. For example, in the City of Chicago, the Chicago Maternity Center (CMC) continued the home birth practice past the mid-twentieth century. La Leche League, an organisation which supported breastfeeding among white middle-class women also promoted home birth. Doctor Joseph DeLee viewed home birth as a temporary measure to train medical students with an aim to facilitate complete hospitalisation of childbirth in future. Some of his students, however, embraced home birth and perpetuated it as a viable and more fulfiling alternative childbirth practice for their clients. In the 1970s and 1980s, they were among the major home birth proponents in the nation. The medicalised nature of CMC’s home births reveals the practice as a complex phenomenon and raises the question: what exactly is home birth as opposed to hospital birth?
The book challenges the generally assumed invincibility of modern medicine. Although hospital birth reached an all-time high of almost 100% in 1970, it dissatisfied consumers who felt dehumanised, disempowered and disgusted by it. By the late 1950s, they had already begun seeking alternative experiences, hence, the emergence of the home birth movement in the 1970s. Kline presents the movement as ultimately struggling for women’s empowerment. It was essentially feminist and believed that midwives were more capable of handling childbirth than male physicians. Midwifery allowed women to reclaim their bodies. The movement was part of a broader women’s health movement, influenced by other movements like civil and consumer rights. It faced opposition from those who purported to fight for the unborn child’s right to a safe birth.
Coming Home shows that the revolutionary transformation of childbirth practices in the 1970s and 1980s was achieved because of the open-mindedness and collaborative effort by home birth activists. Although the home birth movement challenged the conventional view of childbirth as a ‘medical event’ (101) and redefined it ‘as a spiritual rite of passage with the potential to empower the mother and strengthen the maternal-infant bond’, it was ‘not vehemently opposed to the practice of medicine’ (106). Thus, midwives sought the assistance of physicians and sometimes referred their clients to hospitals when faced with complicated labour cases, for instance, involving breeches, high fevers and preeclampsia. Although self-taught through reading obstetric text books, midwives also received informal apprenticeship and basic medical education from physicians. By 1970, many organisations had been established and professionals offered alternative childbirth classes to consumers, some of whom became childbirth educators and others transitioned to midwives. The home birth movement recast midwifery and home birth as modern and safe middle-class phenomena unlike their old reputation as archaic and risky practices for blacks, minorities and the poor who resided in remote geographic areas.
The movement emerged as ‘isolated pockets of consciousness’ (132), and different developments occurred in rural, urban and suburban environments across the nation. The common denominator was that, everywhere, some white middle-class people were fighting to achieve alternative childbirth experiences as they were unhappy with hospital birth which they had previously experienced. For example, in suburban Washington DC, middle-class midwifery emerged, and on the West Coast of California, hippie midwives provided a form of spiritual midwifery which was blended with science, to their counter-culture clients. Those women who chose home birth believed that, unlike hospital birth, it would enable them to experience childbirth as empowering, comfortable and pleasurable.
Kline presents lay midwives as the protagonists mainly responsible for challenging the status quo on childbirth issues. Through the ‘Bowland Bust’, she shows that they were ‘determined to reclaim home birth as a civil right’ (97), even if it earned them legal persecution. Unlike abortion activists, they refused to operate underground but dared the system by publicising their work. Although organised medicine rejected them and classified them as inferior and dangerous to the health of mothers and babies, they were confident of their competence and challenged licensing departments to examine them for licensure, in vain, as exemplified by the case of the Fremont Birth Collective of 1977. Even with licensure, midwives were required to be backed by physicians in order to practise and yet most physicians refused due to professional rivalry. Many were, thus, pressured to enrol for formal training at colleges and universities. Since there were no non-nurse-midwifery schools, they found the training to be ‘exceedingly frustrating’ (52) as some topics seemed irrelevant to midwifery. Sometimes, they outcompeted medical students in handling childbirth because of their practical experience. Therefore, the book raises questions about the validity of licensure requirements as benchmarks for competence and the appropriateness of midwifery training programmes.
The book ends by showing that the anti-establishment and anti-hierarchal stance by lay midwives was untenable, regardless of their achievements. Licensure and professionalisation were important as they would ‘provide them with the protection, legitimacy and visibility needed to sustain and grow their trade’ (135). Hence, ultimately, they moved towards formal educational training and professionalisation as symbolised by the establishment of the Seattle Midwifery School in 1978, which offered training for direct entry/non-nurse midwifery. In 1982, they also formed the Midwives Alliance of North America (MANA), a professional organisation which included lay midwives and certified nurse-midwives (CNMs), unlike the American College of Nurse Midwives (ACNM) which had excluded lay midwives.
The organisation of the book reflects a clear historical progression of issues. In the first chapter, although under attack, home birth and midwifery practices survived extinction, laying a foundation for the home birth movement. The middle chapters reveal different forms of home birth activism which occurred in different places. The movement finally converged in the fifth chapter as activists held ‘The First International Conference of Practicing Midwives, in El Paso, Texas, in 1977’, and began moving towards formalisation and professionalisation. Kline’s primary and secondary sources demonstrate extensive research. They include interviews and archival records of midwives, their personal journals and those of health organisations, books written by the midwives like Raven Lang’s Birth Book and Ina May Gaskin’s Spiritual Midwifery, print and visual media documents. Kline presents insights from varying sections of society. However, she mainly concentrates on lay midwives and neglects the role of CNMs in the home birth movement, such that they appear to have hijacked the situation when they initiated the dialogue leading to the formation of MANA. Kline is silent about the ‘American midwife controversy’Footnote 2 which might have enabled her to give useful historical background on American midwifery.
In conclusion, Coming Home historicises childbirth in an accessible, convincing and exciting way. Maternal and infant health care reform remains unfinished business in the USA. Most countries in the developing world are also struggling with how best to reduce prevailing high maternal and infant mortality rates. Thus, the book is relevant to the USA and globally.
