Obstructed Labour: Race and Gender in the Re-Emergence of Midwifery (review)

The recreation of midwifery in Ontario and its integration into the health care system in the 1990s have drawn the attention of policy makers and sociologists alike. The Ontario midwifery model served as a template for other Canadian jurisdictions, some of which have now established similar midwifery regulation and education programs. And yet, the path chosen by Ontario has not been free of criticism. Did Ontario’s new midwifery exclude Aboriginal midwives and international midwives of colour? Did this process give preference to white cultural competencies, to the exclusion of other ways of knowing?

In Obstructed Labour, Sheryl Nestel presents substantial evidence for the implicit and explicit forms of racism that helped to shape Ontario’s new midwifery in a form that made it difficult for non-white midwives to enter the system. Her methodology was varied: she studied relevant secondary data sources, interviewed women who had been involved with implementation and regulatory bodies, and interviewed midwifery students, practising midwives, and midwives who sought to practice in Ontario.

The first two chapters of Obstructed Labour describe how the Ontario midwifery movement mirrored patriarchal relations by dividing women on the basis of class, ethnicity, and country of origin. The movement penalized those who deviated from a standard white, middle-class, home-grown background. Nestel problematizes the midwifery movement as follows:

Feminist projects that posit a shared female identity across categories of difference and that fail to take into account how women are positioned as both dominant and subordinate in relation to one another are themselves fated to reproduce relations of domination.

(p. 17)

She argues that the gatekeepers for the new midwifery based their standards for entrance not only on clinical skill, but also on white cultural competencies. This bias excluded not only many midwives of colour from professional practice in Ontario, but also “[n]urses, rural women, counterculture women, and women who have not attended institutions of higher education” (p. 18).

Nestel goes on to present evidence for overt and covert forms of racism in the pre- and post-regulatory midwifery community. For instance, she demonstrates how a large number of immigrant midwives were interested in practicing midwifery in the province, but relatively few of these women were able to navigate the costly, time-consuming process of Prior Learning and Experience Assessment. English language proficiency testing, required of all applicants who had trained abroad (not only those for whom English was a second language), was particularly contentious among the applicants.

They referred to technical aspects of the exam, such as the speed of the audio tape. They also asked why the ability to interpret highly local sociocultural expressions seemed to be part of the assessment process.

(p. 62)

While Nestel argues that Canadian cultural competencies were requirements for admission into the midwifery profession, she points out that international experience was greatly valued in Canadian-born midwives. Her third chapter, “Midwifery Tourism,” discusses this paradox. In short, experience gained by working at high-volume birth clinics in the South allowed Canadian midwives access to professional practice in Canada. Nestel examined “some of the transnational processes that have made birthing women’s bodies in the Third World available for the educational consumption and material advantage of First World women” (p. 70). This tantalizing chapter introduces the reader to the personal experiences of some midwifery trainees who gained experience at clinics at the US/ Mexican border, where the work was intense, at times violent, and much more varied than they would have seen in a low-risk Canadian midwifery practice. Particularly striking was the irony that fluency in Spanish was not required of Canadian trainees working in border clinics where many birthing women spoke no English, a sharp contrast to the English proficiency requirements for applicants to the Ontario midwifery profession.

Nestel’s fourth chapter, “Ambassadors of the Profession,” returns to a point made earlier in the book about how the Ontario midwifery project was biased not only against women of colour, but also those...