Paradigm Conflict in the Sociology of Service Professions: Midwifery as a Case Study

Paradigm Conflict in the Sociology of Service Professions: Midwifery as a Case StudyAuthor(s): Cecilia BenoitSource: The Canadian Journal of Sociology / Cahiers canadiens de sociologie, Vol. 19, No. 3(Summer, 1994), pp. 303-329Published by: Canadian Journal of SociologyStable URL: http://www.jstor.org/stable/3340720 .

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Paradigm conflict in the sociology of service

professions: Midwifery as a case study*

Cecilia Benoit

Abstract. Functionalist scholars have long regarded health service professions as enjoying special privileges because of their pivotal societal function: quality care of citizens. Fusion of service ethic and technical expertise grants service professions monopoly over possession and transmission of knowledge, autonomy to organize working conditions to their own choosing, and authority over clients and allied

occupational groups. Many sociologists remain critical of this functionalist position, however, maintaining that it presents an idealized picture of practising professionals who, for reasons internal or external to themselves, fail to realize their avowed service goal. In this paper I delineate three competing approaches in the post-functionalist debate on service professions - professional dominance, professional decline and patriarchal control. I use an age-old kind of service work, midwifery, to uncover theoretical shortcomings in the various stances profiled. In the third section of the paper, I blend interactionist and state perspectives to conceptualize primary and secondary data on midwives

working, in some times and places but not in others, as genuine caring professionals of birthing families.

Resume. Les partisans du fonctionnalisme ont longtemps considere les professions reliees aux services de sante comme un regroupement de professions b6n6ficiant de privileges sp6ciaux a cause de leur fonction sociale essentielle: soinsde qualite aux citoyens. Le fusionnementde l'6thique etde 1'expertise technique accorde a ces professions le monopole de la possession et du transfert du savoir, l'autonomie d'6tablir leurs propres conditions de travail, et l'autorite sur les clients et groupes professionnels allies. Plusieurs sociologues demeurent toutefois critiques a l'6gard de cette position fonctionnaliste, soutenant qu'elle pr6sente une image id6alis6e des professionnels qui, pour des raisons personnelles ou hors de leur contr6le, ne parviennent pas a r6aliser leur objectif d'offrir des services personnalis6s.

Dans cet article, je d6cris trois approches concurrentes du d6bat postfonctionnaliste sur les

professions de service en g6n6ral, plus particulierement sur les professions m6dicales et de soins complementaires -perspectives de la dominance professionnelle, du d6clin professionnel et du controle patriarcal. J'utilise par la suite le cas d'un ancien type de travail social, la profession de sage- femme, afin de mettre a jour les d6fauts th6oriques des differentes prises de position dfmiies. Dans la troisieme partie de cet article, j'incorpore deux autres traditions sociologiques, perspectives interactionniste et d'etat, pour conceptualiser des donnees primaires et secondaires sur les sages- femmes travaillant, en temps et lieux precis, telles de v6ritables professionnelles de la naissance.

* I would like to thank Dr. Rick Ogmundson and Dr. Bill McCarthy for their assistance, comments and criticisms, Dr. Nico Stehr and three anonymous reviewers for their helpful suggestions, Steve Pepin and Suzanne Reneau for translating the abstract and Mikael Jansson and Annika for emotional support throughout the entire process. Please address all correspondence and offprint requests to Dr. Cecilia Benoit, Department of Sociology, University of Victoria, Victoria, B.C., V8W 3P5.

Canadian Journal of Sociology/Cahiers canadiens de sociologie 19(3) 1994 303



Introduction In this paper I explore a central problem in sociological theorizing on service occupations in industrialized societies: conflicting conceptions of professional care1 of citizenry. Monopoly over possession and transmission of abstract, specialized knowledge, autonomy to set terms and conditions of work, and authority over clients and affiliated workers all flow from the hallmark charac- teristic of expert care of the public. On this basis a core of classical sociologists distinguish service or "caring" professions from other occupations (Comte [1851-4] 1968; Durkheim [1891-2] 1965). Service professionals manifest a special sensitivity toward clients (art of caring), as well as practical techniques in managing their life problems (science of caring). This unique blend of art and science distinguishes professions as "philanthropic sciences," demarcated from private business where norms of profit and self-interest prejudice quality of services rendered (Tawney, 1937; Carr-Saunders and Wilson, 1933; Marshall, 1939).

Sociologists writing in the immediate post-World War II era share this view of service professionals as competent and dedicated workers whose service ethic and therapeutic performance are fundamental to integration of modem industrial society. The work of Talcott Parsons' (1951) stands out in this regard. Parsons (1968: 545) identifies service professions as constituting one, if not the most important, homeostatic structures underlying the social order. According to Parsons, superior technique and collectivity-orientation of the service professional encourages protection "by a series of symbolically significant practices which serve to differentiate him sharply from the businessman..." (Parsons, 1951: 464). Parsons maintains that industrialized societies award "practising professions," including medicine, monopoly over knowledge and its transmission, a high degree of clinical autonomy and authority over clients and associated occupations in exchange for acceptance of normative constraints that place severe limits on the self-centred behaviour of individual practitioners: noblesse oblige is rewarded and exploitation of the public penalized. Neo-functionalist students continue to recognize the medical profession as noble steward of one of the most sacred values of life - people's health (Haber, 1991).

This optimistic outlook on the capacity of service professions to render quality care to the public has not been universally embraced. Three arguments stand out in the literature, all proposing different critical views on service professions as caretakers of the public: professional dominance, professional decline and patriarchal control.

1. Not that this paper is about conceptualizing quality care itself (e.g., Noddings, 1984; Fisher and Todd, 1983; West, 1984). Rather it focuses on views held by social scientists on health service professions, in general, and about their caring capacity. I am indebted to one of the anonymous reviewers of the paper for this insight.

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In the first section of the paper I elaborate on these three post-functionalist approaches to service professions. In section two I consider the heuristic value of each in light of primary research findings on the historical transformation of maternity care in the eastern Canadian province of Newfoundland and Labrador and secondary data on maternity arrangements in present-day Continental Europe and Nordic Countries. In the third and final section I propose a multi- paradigm approach merging two sociological traditions often neglected by students of service professions-interactionist and state approaches- to conceptualize research findings on midwifery as a genuine profession at some times and in some places but not others.

Critical perspectives on service professions

Professional dominance approach In a sequence of work dating from the early 1970s, Elliott Freidson established the ground work for the perspective of professional dominance (see, in particular, 1970a; 1970b; 1986). Contrary to the structural-functionalist view of service professions, the professional dominance stance focuses on how professionals wield individual and collective power to maintain and increase their privileged position in society. These writers use Max Weber's writings ([1922] 1978) on the relationship between collegial groups and status closure to make sense of major shifts in the organization of professional services in the last decades of the 20th century.

In the professional dominance standpoint, professionalization has little to do with quality care by empathetic experts; rather, professionalization involves an ongoing movement by well-positioned occupational groups to gain strategic control over lower-ranking workers and clients; that is, schemes to secure professional dominance. Like other empowered groups of actors, service professions employ demarcationary strategies in an effort to win a monopoly over provision of desirable skills and competencies (Johnson, 1972; Berlant, 1975; Parry and Parry, 1976; Freidson, 1970b; Larson, 1977; Willis, 1983; Waddington, 1984; MacDonald, 1985). Demarcationary strategies are typically accompanied by exclusionary strategies-what Gerald Larkin (1983) refers to as "occupational imperialism"-whereby service professionals, located at the apex of the hierarchy of closure, exercise power in a downward fashion, subordinating less- powerful occupations and clients (Parkin, 1979). Thus service professionals are able to maintain and even enhance their favourable access to rewards and opportunities. Freidson's (1970a) description of the medical profession as Janus- headed aptly captures how dual closure strategies operate in practice; apart from control over knowledge and its transmission, work autonomy and authority over the practitioner-client relationship, physicians also enjoy a unique position of dominance within the health division of labour, as well as in society at large.

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In analyzing various tactics employed by privileged professionals to gain closure, Freidson and his colleagues identify use of legalistic tactics that involve acquiring a monopoly through licensure. Reliance upon credentialist tactics is equally important, particularly specification of formal and informal qualifica- tions for inclusion/exclusion. As Anthony Giddens (1975: 186) states: "the most significant type of difference in market capacity is undoubtedly between the capacity to offer marketable technical knowledge, recognized and specialized symbolic skills, and the offering of general symbolic competence." Not surprisingly, these scholars detect no necessary positive correspondence between superior credentials and client care (Collins, 1990). Indeed, a less than benign motive is in operation. As Freidson (1970a: 79-80) states:

The content and length of training of an occupation, including abstract knowledge or theory, is

frequently a product of a deliberate action of those who are trying to show that their occupation is a profession and should therefore be given autonomy. If there is no systematic body of theory, it is created for the purpose of being able to say there is.

The reality, then, is that so-called experts on people's health and other social services are concerned less about quality of client relationship than about enhancing their career interests (Saks, 1992). Some analysts even suggest that service professionals - with physicians topping the list - belong to "disabling professions" that are a major threat to public welfare (Illich, 1975; Szasz, 1970). Despite an absence of clear evidence of improved health status, critics record an alarmingly wide range of health events that are today undergoing medicalization; developments in medical science and ideology are now being applied to a diversity of domains of human activity outside areas of conventional medical control (Conrad and Schneider, 1980; Zola, 1972; Foucault, 1973). But perhaps the greatest danger of all is medicine's narrow focus on the isolated physical state of individual clients and, consequently, virtual neglect of other, non-medical, factors affecting health outcomes.

Some scholars acknowledge that professional dominance may not be shared equally among colleagues. Freidson (1986) argues that an extensive regrouping of professionals, from informal colleagueship to formal hierarchical rankings, is underway. Three main divisions within service professions are now observable: "producers," "knowledge elite" and "administrative elite." Producers are the rank-and-file segment involved in direct client care; the knowledge elite are workers in academic education and research; and the administrative elite occupy strategic managerial roles. Some lower-ranking members of the professions may be experiencing a gradual loss of power as a consequence of this growing specialization and diversification of authority. Yet, as corporate bodies, service professions continues to shape the care of individual clients by retaining hegemonic control over rank-and-file members, allied occupations and the general public (Freidson, 1986).

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In brief, the professional dominance thesis argues that the medical profession has adapted to changing external circumstances by altering its internal structure. It nevertheless retains extensive "professional powers" as the twentieth century reaches completion. The result is a continuation (though perhaps less all- encompassing) of medical dominance over adjacent health occupations and citizenry, whose primary health concerns remain low priority.

Perspective of professional decline Not all critics of the Parsonian characterization of service professions share a

professional dominance viewpoint, however. Others assert that, due to external circumstances either because or outside their own doing, service professions are in decline - they are becoming a) deprofessionalized and even b) proletarianized. In the process, the public's health and other service needs are poorly met, if at all. Both arguments are summarized below.

a) One group of analysts suggest that social relations between service professionals and consumers have depreciated to such an extent that the former are experiencing the beginnings of deprofessionalization. Marie Haug (1988) defines this trend as service professions forfeiting their monopoly over esoteric knowledge, clinical autonomy and authority over clients and neighbouring occupations. Deprofessionalization is a direct result of a concerted challenge, some argue revolt, by a substantial minority of citizens against their would-be professional caregivers. As Haug (1973: 206-7) notes, "tension between the public demand for accountability and the professional's insistence on final authority has not yet erupted in general warfare... But there have been skir- mishes."

Consumer challenge is partly a result of a rise in the general population's level of education, a change that has narrowed the "competence gap" between practitioner and client (Haug and Lavin, 1979; Linn, 1980). Canadian medicine is a case in point:

It is apparent that a growing segment of the population, particularly the more highly educated, is more knowledgable about medical science than were previous generations and is increasingly familiar with the medical services it receives. This increased knowledge and familiarity tends to

demystify medical knowledge and make patients more critical of the health care they receive and of those who deliver it, particularly the physicians. In this situation the physician's authority and

prestige tends to suffer (Blishen, 1991: 147)

The unmasking of medical and other forms of professional knowledge by an educated public is accompanied by their growing awareness of an underside to many technological innovations heralded by specialists, as well as of the depersonalizing effects of bureaucratic organization (Cassell, 1986; Jackson, 1985). One consequence for health care delivery is client demands for tighter restrictions on professionals' clinical autonomy, including access to medical records, and legal acceptance of the principle of informed consent. As Jay Katz

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(1984: xiv) notes: "newly imposed legal requirements of informed consent- the dual obligation to inform patients and to obtain their consent - is only modem proof that trust in the professional is no longer viewed as sufficient protection of the integrity of the physician-patient relationship." Perhaps even more damaging is the increase in legal challenges by disgruntled consumers (Betz and O'Connell, 1983), particularly in writs served (for comparable U.S. and Canadian data see Rozovsky and Rozovsky, 1984: 16). The ultimate result is a citizenry increasingly questioning and contesting, caring claims of service professionals (Toren, 1975).

b) A second strand of the professional decline position, more directly drawing upon Karl Marx's insights on the nature of industrial capitalism, highlights parallel challenges to the economic sphere. The argument here is that service professionals are losing face in the public domain at the same time that they are being forced to the margins of the health process by a powerful corporate elite. Hence the notion of emerging "proletarianization" across the professional complex, not least of all among physicians (McKinlay and Arches, 1985; McKinlay and Stoeckle, 1988).

Some neo-Marxist scholars (Navarro, 1986) trace the seeds of proletarianization to the origins of capitalism itself, at which point in time the professional-client relationship was distorted to meet the concerns of wealthy patrons, and to allow the ruling class as a whole to secure a profit out of the people's health. Writers analyzing the recent "corporate take-over" extend this argument to professionals and clients in the late twentieth century. Although this development is more advanced in the United States (Starr, 1982; Bumham, 1982), they point to Britain's plans to rationalize and restructure the National Health Service (NHS) in the direction of internal markets and privatization of key health services, including formal care for the aged (Klein, 1988; Carrier and Kendall, 1990; Krause, 1992). A similar privatization trend is also underway in Canada, and includes U.S.-based nursing home corporations (Cobur et al., 1987: 656), hospitals in the form of "health factories" (Torrance, 1987), in addition to a national pharmaceutical industry, ninety percent of which is controlled by subsidiaries of multinationals (Clarke, 1990: 291).

Scholars proposing a proletarianization perspective point out that physicians and ancillary health professionals are increasingly found in an expansive "medical-industrial complex" (Relman, 1980) where private corporations own hospitals, clinics, diagnostic laboratories, pharmacies, nursing homes, home care agencies, and insurance companies. For-profit chains place exacting limits on professional autonomy by determining medical fees, capital investments, and standards of practice; they also make it arduous for graduates to establish private clinics of their own. Professionals who manage to resist corporate encroachment are forced to be even more entrepreneurial than in the past. As George Ritzer and David Walczak (1988: 11) note, medical advertising "is the clearest example of

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the erosion of the distinction between professional and capitalist... [With] physicians advertising their services on television and in the newspapers, it will be harder for them to put forth an altruistic image. Patients are more likely to question the authority of physicians selling their services side-by-side with used car salespeople."

Professionals located inside the medical-industrial complex are under con- straint to follow protocols of their private employer-increased productivity and decreased costs. The result is a reduction of patient services that are not profit- making (e.g., preventive and primary care) and shorter lengths of hospital stays, especially in medical institutions embracing prospective payment systems that reward professionals for keeping organizational costs within a tight budget. In addition, proprietary hospitals profit by concentrating on services desired by the

best-paying patients, thereby "skimming the cream off the market for acute

hospital care and leaving the remainder to non-profit hospitals" (quoted in Relman, 1980: 968).

Stripped of work autonomy and authority over the practitioner-client rela-

tionship by large-scale market forces, physicians and other health professionals find their esoteric knowledge and special techniques increasingly useless. Practitioners across the health division of labour are reduced to "mental workers" (Derber, 1982), with little opportunity to organize the healing process in a manner beneficial to clienteles.

Perspective of patriarchal control Similar to professional dominance and professional decline analysts, feminist scholars are sceptical of the depiction of service professionals as philanthropic scientists. However, feminist writers reprimand their critical counterparts for one important oversight: a virtual silence on the pivotal concept of gender, a theoretical weakness shared with functionalist proponents. Why has the "gender order" (Stacey, 1988) of human services in industrialized societies gone largely unrecognized in sociology of service professions? Ascribed characteristics of sociologists themselves-academics who, like physicians and other prestigious service professionals, have until recently enjoyed membership in a mostly-male profession-contributes to this void. As Elianne Riska and Katarina Wegar (1993: 1) write:

The failure to observe the gender dimension in health care in general and the gender division of labour within the medical profession in particular is no uncommon feature in the work of

sociologists. Structural accounts of social phenomena - be they functionalist, Weberian or Marxist as in the sociology of professions - tend to give precedence to gender-neutral explanatory factors such as technology or the economic system. Such explanations delegate other social factors, like gender and race, to merely secondary importance, if they are recognized or attributed any significance at all.

Concerning the medical profession itself, polemic about the changing nature

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of the physician-client relationship central to the critical discourses described above correlates with a steady increase in numbers and proportion of women in medicine. Canadian data lend lucid support to this observation. In 1957/58, 8.5 percent of the students entering medical schools in Canada were women; in 1989/90 the equivalent figure was 43 percent. The proportion of Canadian women among active practitioners has risen as well, from a low of 6.8 percent in 1961 to 17.1 percent in 1981 (Blishen, 1991: 82, 74) to 21 percent in 1986- the latest data available (Census Division, Statistics Canada).2

These recent developments encourage a rethinking of existing conceptualizations of the medical profession in Canada and the rest of the industrialized world. Until now, medicine has been a paradigmatic example of patriarchal exclusionary closure (Witz, 1992), whereby manifest and latent discrimination historically barred all but a few women. Women's struggle to gain access to requisite medical training and clinical practice has been long and difficult and, for the most part, carried out with zealous opposition from male physicians (Riska and Wegar, 1993). It is only since the 1960s and pressures generated by the women's movement that better representation is enjoyed by women in the medical profession.

Despite noteworthy strides in gaining access to medical schools and hospitals, evidence suggests that patriarchal strategies continue to keep women near the bottom of the profession's internal hierarchy. Women physicians cluster in areas that demand large amounts of emotional labour3: so-called feminized specialties of general practice, family practice and primary care. Yet, it is in these domains that women physicians lack professional power to render quality care to clients (Butter et al., 1987; Elston, 1977). Women physicians are forced below a "glass ceiling" of what remains in many ways a dual medical market. One is a favourable male medical sector based on monopoly over development and transmission of esoteric knowledge and special techniques, autonomy in health work settings and authority-in fact, dominance-over the practitioner-client relationship and allied (mainly female) caregivers. The other is a less-advan-

2. Similarly, in the United Kingdom, relative proportion of women physicians rose from around one-fifth in 1970 to more then one-quarter in 1990. In the United States, proportion of women

physicians increased from 7 percent to 15 percent between 1970 and 1986 and is projected to reach 30 percent by the year 2010. In Nordic countries - Denmark, Finland, Iceland, Norway and Sweden - proportion of female physicians had already realized these upper levels by 1970, and is expected to increase even further. By 1995, between one-fourth to one-third of all

physicians in the Nordic countries are projected to be female. In Finland the projection is even

higher, to the extent that women are forecasted to comprise 56 percent of the total of Finish

physicians before the year 2000 (Riska & Wegar, 1992: 2-3). 3. Emotional labour is "the labour involved in dealing with other peoples' feelings, a core

component of which is the regulation of emotions... [T]he forms emotional labour takes and the skills it involves leave women subordinated as unskilled and stigmatized as emotional" (James, 1989: 15).

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taged female medical sector, based on exclusion from knowledge strata, limited work autonomy and little by way of authority within the occupational health structure and vis-a-vis clientele (Lorber, 1992).

Feminist scholars suggest that blockage of female physicians' input is closely related to low quality care of women clients in particular, and the public in general. Thus reorganizing health and other vital services "with a heart" (Drachman, 1984) requires that women professionals transform the enduring shortcomings of the (male-dominated) physician-client relationship. Given equal opportunity, women physicians will promote the interests of individual clients, and redesign health services so that needs and concerns of the public are

placed before those of the medical profession (Altecruse and McDermott, 1987). According to Judith Lorber (1992: 28-9):

To promote women and men physicians equivalently would mean that those presumed qualities of womanhood - nurturance, community, and relational abilities - were as valuable to those in

positions of authority as they are to those who give primary care (and, of course, bedside care).

Feminist scholars recognize that women physicians and other women health workers share a similar fate. Female nurses, who comprise about two-thirds of the present-day health labour force in most industrialized societies and approxi- mately ninety percent worldwide (Pizurki et al., 1987), are an obvious case in

point. Like women in medicine, nurses have recently taken steps to overcome their historical subordination by a male-dominated medical profession (Reverby, 1989; Bullough, 1975). Despite their achievements, the overall picture of

nursing care in most industrialized societies remains largely under patriarchal control (Salvage, 1985; Carpenter, 1977). As Aant Elzinga (1990: 164) states: "the world of higher-status professions (such as medicine) and the social and

cognitive hierarchies of science and the traditional academic system, as well as

hospital- and health-care institutions, tend to be dominated by men, male attitudes and male perspectives." Unless this prevailing gender hierarchy in the

professional structure is toppled, common interests of nurses and citizens will remain backstage, and recent insights about non-medical causes of ill-health left unheeded (Growe, 1991).

Feminist health scholars point out that midwives are granted similar disregard as female physician and nursing counterparts, with the result that birthing women are short-changed by their caregivers. With or without analgesia, alert and aware or drugged into semi-helplessness, most birthing women are casualties of male- medical experts and intrusive technology. The hierarchical structure of hospital maternity wards, control by male physicians, and overarching view of pregnancy and delivery as "medical events" demanding immediate technological intervention, results in fragmentation of the birthing mother's psycho-social and physical concerns (Sullivan and Weitz, 1988). Patriarchal control is especially entrenched in North America where obstetricians (who remain predominantly men) impede female caregivers, most of all midwives, from properly caring for

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pregnant women and their families in a way that enhances health and well-being for all. In sum, the medical bureaucracy, in all its guises, virtually excludes women-attendants and clients-from active participation in the most essentially female function of all, human reproduction (Rich, 1975; Arms, 1975; Callaway, 1978; Rothman, 1982; Burtch, 1994).

Disillusioned with North American birthing practices, feminist writers look to the other side of the Atlantic, hoping to discover a way of avoiding pitfalls of patriarchal obstetrics. At first glance, large numbers of formally-trained midwives at work within the (NHS) would seem to indicate that male-medical dominance is less prominent there, allowing midwives to care for birthing women in a humanistic fashion. Closer attention to the arrangement of present- day British maternity services, however, leaves some feminist writers sceptical. Mere presence of midwives on obstetrical wards does not necessarily mean that birthing clients in Britain enjoy quality care. The prominence of medical specialists, a large proportion who are men, effectively removes many midwives and pregnant women from centre stage in the reproductive process, in much the same way as present-day North American obstetrical nurses and nurse-midwives are alienated from expectant mothers placed under their care.

In sum, feminist scholars point out that current evidence on medicine, nursing, midwifery (Riska and Wegar, 1993), and the health labour force in general (Butter et al., 1987), suggests that the gender order of industrialized societies limits quality care of citizens, particularly women, not least of all because female practitioners are placed in a Catch-22 situation: women carers render the bulk of primary "hands-on" services recognized as indispensable to individual and societal well-being, yet they have little professional power to re- organize work activities to fulfil their inherent capabilities as knowledgeable and empathetic practitioners.

Examining the evidence: Midwifery as a case study The most common strategy for assessing the relative value of the four perspectives reviewed above is to scrutinize secondary data on contemporary medical practitioners to verify/refute their avowed goal of expert care of citizenry. Another less-common approach is to examine evidence on a service occupation that is seldom, if ever, discussed by scholars as a caring profession or, when addressed at all, is viewed as such only in the distant past: midwifery.

In the following analysis, I consider each perspective' s power to explain primary and secondary data on the midwifery case, showing each in turn to be theoretically weak in this regard. I then draw on concepts from two other sociological traditions, interactionist and state perspectives, to grasp more effectively the complexity of research findings on midwifery, a service profession able to realize quality care for birthing families in some times and places but not others.

Functionalist analysis of service professions in industrialized societies typically exclude midwifery. At best we can surmise how functionalist scholars 312



would weigh midwifery by their study of parallel, female-dominated service occupations. Viewed in this light, midwives, similar to nurses, social workers and school teachers, are "semi-professions" (Etzioni, 1969) which achieve some, but not all, hallmark characteristics of an authentic service profession, or exhibit each trait but only in a circumscribed fashion.

Functionalist writers would likely point out that midwives of old, and lay/ independent midwives of today working in home settings, possess only general know-how and practical techniques about maternity care that form part of common or everyday knowledge available to all birthing women. Even midwives holding nursing degrees and formal certificates fall short of recognition as legitimate service professionals because they lack "esoteric knowledge" imperative to successfully dealing with inevitable "uncertainty" (Parsons, 1951; Fox, 1957) during the reproductive process. This "mastery of the indeterminate" entails possession of unique abstract or theoretical knowledge and "technique" transmitted in formally- organized professional schools attached to universities and service organizations (e.g., teaching hospitals). Common knowledge and practical know-how transmitted in apprenticeship and vocational training programs, and even recent "caring science" acquired in academic nurse-midwifery programs (Elzinga, 1990), still leave midwifery graduates dependent upon "specialists in uncertainty, who deliberately work in the realm of the uncertain and unknown" (Swazey and Fox, 1970: 40). Only knowledge experts-physicians, in particular, obstetricians- possess superiority managing the medical "risk" of pregnancy and birth. Falling short on this fundamental trait of mastery of the indeterminate, midwives are left without means whereby to provide a level of calibre service to birthing families that would render the status of caring professionals.

How adequate is this depiction of midwifery as a semi-profession? Historical and current data on lay midwifery indicate that, indeed, midwives undergoing apprenticeship types of preparation for maternity work regularly find themselves virtually helpless in the face of obstetrical crises, and may lack insight on when to call for medical aid. Primary data on Newfoundland and Labrador lay midwifery (Benoit, 1989) indicate such shortcomings did occur, as the following quote from a "granny midwife" (the local term for the traditional lay midwife) recounting with sadness her own birthing experience indicates:

I had trouble with the midwife 'cause she didn't help me. He [my infant son] had his little arm like that, and she didn't known how to get him. Well, I come out of it but he didn't... I sooner have someone else 'cause she didn't handle things right.

Similar to seventeenth-century English midwives (Beier, 1987)4 and may of their contemporary counterparts (Weitz and Sullivan, 1988), granny respondents 4. According to Lucinda McCray Beier (1987: 16), [s]urgeons accused midwives of ignorance.

Indeed, midwives themselves were aware of their own need for reliable training. In 1616 several London midwives, with the help of Peter Chamberlen, petitioned the King and Parliament for the incorporation of a midwives' company which would be responsible for the training and licensing of midwives. However, the formation of such a company was blocked by the Royal College of Physicians...".

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longed to expand their experiential and common knowledge of maternity care, to especially master new ways to reduce drawnout, painful labours and to prevent deaths. As one reports:

Experience was our teacher; we didn't have no other. I think we learned a lot by experience but... I wanted to know the whole works, to know if they [birthing women] get sick we could do something for that and not always let nature have its way.

Data on nurse-midwives at work in Anglo-America today also suggest that the functionalist perspective may indeed help conceptualize research findings on this particular geo-cultural location. Although now in flux in Canada, most North American nurse-midwives work as members of an obstetrical team; they are "hand-maidens" (Rothman, 1982) acting in a semi-independent fashion (DeVries, 1985), ultimately subservient to the "presiding" physician (Burtch, 1988). As Mavis Kirkham (1986:37) puts it:

Previously all pregnancies were seen as normal until judged otherwise, a judgement usually made

initially by a midwife. The reverse is now true, as all pregnancies now fall under medical

management and are 'normal only in retrospect'. By this logic the midwife as practitioner in her own

right is defined out of existence.

Even in Britain, where nurse-midwives remain the senior practitioner at over seventy percent of births, they are "accepted within the official health-care division of labour but in a position subordinate to medical practitioners" (Stacey, 1988: 78). The result is that the reproductive process is organized and managed according to obstetrical policies and dictates, rather than within a midwifery model of care (Towler and Bramall, 1986: 298). According to Jean Donnison (1979), "the baseline of normality by which we judge abnormality is in the

process of being lost. This medical coup has caused a crisis for the midwives who have suffered loss of identity and reduction of status [author's emphasis]."

However, not all formally-trained midwives are deprived of opportunity to be

knowledge-based workers serving families undergoing normal reproduction. Findings from my primary research mentioned above indicate that a category of trained midwives located in small cottage hospitals worked as genuine professionals during normal pregnancy and childbirth and, in the view of local families, provided calibre care to all (Benoit, 1991). Cottage hospital midwives possessed vocational training, largely under the guidance of midwifery educators themselves; the small-scale, team approach of cottage hospitals gave midwives substantial autonomy to organize their work relatively free from communal, medical and bureaucratic controls. As one respondent explains, the consequence was an opportunity to work as caring professionals in day-to-day practice:

What I didn't learn from midwifery training, I could learn on the cottage hospital ward [because] we had to do these things, emergency things, including practical delivering of babies, with only the other midwife to help. We were around all the time, along with the cook and the janitor. A very small staff; there was no administrator and only occasionally a doctor. [W]e enjoyed it; it was a great life.

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Secondary data from the Netherlands (van Teijlingen and van der Hulst, forthcoming) lend support to my Newfoundland and Labrador findings. Dutch midwives today legally practice as caring professionals, without supervision by physicians as long as pregnancies and deliveries show no indication of obstetrical complication. As Beatrijs Sumlders and Astrid Lumburg (1988: 233, 243) state:

[Dutch] midwives are independent practitioners responsible for the regulation of their own

profession... During her pregnancy the pregnant woman visits the midwife twelve or fourteen times. The midwife takes care of the mother both technically and psycho-socially. It is the midwife's task to recognize abnormalities as early as possible. All women with an increased risk factor are screened out and sent to an obstetrician...

Societal recognition of Dutch midwives as knowledge-based professionals of normal maternity, and the consequent distinctive care birthing families receive from professional midwives, is paralleled in Nordic Countries. In Sweden -

which (after Japan) holds the record for the lowest perinatal mortality in the world, with Finland, the Netherlands and Denmark just behind - midwives are "well trained, both in assisting at normal births and in recognizing abnormalities" (Jordan, 1983: 45). Swedish midwives work in "local neighbourhood mothercare centres" where they provide primary maternal care across the reproductive cycle, referring only potential obstetrical cases to general physicians or obstetricians (Seward et al., 1984; Rooth, 1979). Data on present-day midwives in Finland (Valvanne, 1988) and Denmark (Houd, 1988) provide additional testi-

mony that, contrary to the functionalist status label of "semi-professional," midwives in these particular situations practice as legitimate front-line professionals.

Evidence shows that scholars endorsing a professional dominance perspective make a different mistake-one of over-generalization about the all-encom-

passing powers of medicine-when analyzing the health division of labour in industrialized societies. There are ample data to support the claim that physicians, in particular, obstetricians, in most areas of Anglo-America are credibly portrayed as dominant, even imperialistic (Larkin, 1983) whereas midwives are

depicted as subordinate (Arney, 1982; Scully, 1980; Oakley, 1984; Barrington, 1985; Biggs, 1983). Similar findings are also reported in Australia (Willis, 1983). Enjoying exclusive license to oversee normal and abnormal reproduction, prescribe pain-relieving drugs, admit birthing women into hospitals, and act as

gatekeepers on the maternity ward, the obstetrical profession holds a virtual

"monopoly" (Berlant, 1975) and "cultural authority" (Starr, 1982) over provision of maternity services, whether or not midwives are part of the scene. As Barbara Katz Rothman (1982: 76-7) accents:

American nurse-midwives have bought in to medical control, in much the same way as ancillary occupations have. They have sought power by way of "upgrading" the profession, notably by extending educational requirements. But no matter how much the midwife models herself on the

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surgeon, no matter how longs she trains in his hospitals, no matter how many of his techniques she masters, she has not changed the fundamental balance of power.

Such evidence supporting professional dominance of medicine, however, should be considered side-by-side divergence research findings from other times when midwives were largely free from outside controls and able to enjoy substantial autonomy in daily practice. As a case in point, Newfoundland and Labrador midwives practising in cottage hospitals during their heyday (1950-70s) enjoyed protection from familial/patriarchal controls -the predicament of their granny forerunners, as well as that of some present-day lay midwives practising in the home setting (Benoit, 1992)). Nor did cottage hospital midwives have to contend with medical and bureaucratic controls, the typical work experience of most other North American and many British midwives. This freedom extended to training new recruits and regulation of their profession (Benoit, 1992). Midwives literally worked as "free hands" on cottage hospital wards, enjoying work in a setting that did not subject them to continuous, sometimes intrusive, surveillance of family and community members, yet free from interference by "powers that be" (staff physicians and administrators).

Contemporary midwives in other geographic locations share these features of day-to-day work. To quote once again from Smulders and Limburg (1988: 245- 6): "[t]he tradition of the independent midwife has contributed to the belief in Holland that delivery is a natural event, and that medical treatment should only be resorted to when there are complications. A balance between [obstetricians-] gynaecologists and midwives now exists, with neither party holding a monopoly in obstetrics." Edwin van Teijlingen and Leonie van der Hulst (forthcoming) echo this interpretation, contending that midwifery in the Netherlands "has more power and autonomy than midwifery in most other industrialized nations vis-a- vis the medical profession."

A comparable state exists in both Sweden and Denmark, further questioning the generalizability of the medical dominance perspective. As Brigitte Jordan (1983: 65) maintains, Swedish midwives enjoy autonomy to organize a style of maternity care that is both safe and personally rewarding for birthing clients: "medical decisions are made by the physician on call, but since midwives are highly trained technically, the range of what is normal and can be managed jointly by the woman and the midwife is considerable." Secondary findings from Denmark suggest that midwives there savour autonomy in the area of normal pregnancy and childbirth, that infant and maternal mortality and morbidity rates are among the lowest in the world, and that "Danish women like their midwives. There is a long tradition of good, solid midwifery care, and it is absolutely out of the question that GPs should take over" (Houd, 1988: 185).

What about the perspective of professional decline? Does it hold up to the available historical and cross-national data on midwifery? As noted in the former

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section, writers embracing this approach on service professions maintain that for two decisive reasons - consumer challenge and corporate takeover - service

professionals are becoming deprofessionalized and even proletarianized, in either situation unable to fulfil their avowed service goal.

Although few if any of these analysts actually mention midwifery by way of example, there is some evidence in Anglo-America that nurse-midwives in bureaucratic hospitals experience alienation and even outright rejection from some clients. One of my Newfoundland and Labrador nurse-midwifery respondents, once located in a cottage hospital and now working in a large referral

hospital, points out that today she feels like a "mechanical midwife," unable to utilize much of her technical skill and experiencing a loss of personal contact with clients. One result is that "you don't get the same rapport with the women in the big hospital as was the case in the old cottage hospital." Another

respondent noted that "ligitation is a problem now. That's what has spoiled the

job for many midwives. They feel that everything must be written down, but all the time you're thinking, 'will this stand up in court?' In a different way, Caroline Flint (1988: 22) points out that the many British birthing clients are equally discontent with their nurse-midwifery attendants:

Midwifery in Britain is currently in a state of crisis. On the one hand there are women clamouring for a more gentle, normal way of birth, for respect and acknowledgement that it is their birth, their

baby, their body and their birth and that the experience of that birth will affect them for the rest of their lives. On the other hand there are the obstetricians who in their powerful and self-confident way are saying, 'This is dangerous, we need to control it. This is scientific, we need to be in charge. The

ordinary midwife looks around her for allies... It is too painful for her to take on the role of being 'with women'. Instead she turns away from women and becomes 'with doctor'... (author's emphasis).

Despite some data on professional decline among Anglo-American midwives in the eyes of the public, evidence remains scanty to support anything approxi- mating a large-scale outright consumer "revolt" or rejection of all forms of formal care (physicians and nurse-midwives can hardly be viewed as deserted by clients when lay midwives in Anglo-America attend less than five percent of deliveries). Nevertheless, as suggested in the quotes above, the discontent and

possible distrust North American and British families feel toward nurse-midwives on large maternity wards may be more pervasive.

Yet evidence supporting a consumer challenge to midwives and their subse- quent decline in professional status are not generalizable to other situations. Primary research findings on cottage hospital midwives (Benoit, 1991) are similar to conclusions drawn from research on midwife-client relationships in Sweden today (Seward et al., 1984), suggesting widespread consumer content with the existing state of affairs. As Gosta Rooth (1979: 1171) points out, antenatal and postnatal clinics managed by Swedish midwives are virtually ubiquitous throughout the country. Midwives as a rule "get to know the local population very well and the acceptance of these clinics is such that about 99%

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of pregnant women attend for all the planned visits from the beginning of pregnancy until the infant is four year old." Secondary data on the Netherlands is a further case in point (Jordan, 1983). In certain times and in different geographic locations even today, it seems, midwives retain high professional status in the public eye, a finding that does not bode well with analysts adhering to a consumer challenge/revolt.

A similar criticism applies to the second strand of the professional decline perspective - corporate takeover of health services. There is evidence that in the U.S. maternity and other forms of health care are "big business" (Light, 1986) and nurse-midwives in the emerging for-profit health chains, like their physician counterparts, increasingly find themselves forced to place organizing principles of corporate managers-minimum cost/maximum profit-above clients' needs. At the same time, American nurse-midwives, whether working in hospitals or birthing centres, face escalating charges from powerful malpractice insurance companies. The result is absorbent insurance premiums and unemployment for some nurse-midwives unable to secure malpractice insurance. Not surprisingly, "proletarianization" of American nurse-midwives negatively affects recipients of maternity care:

Even though nurse-midwives deliver only 2 percent of the nation's obstetrical care, 50 percent of those services go to the poor... Between raising fees (to compensate for increased premiums) and closing practices, the poor once again are the ones who have lost the most, in terms of their access to medical care (O'Reilly et al., 1986: 206).

It is nevertheless important to realize that the market-driven system of the U.S. (along with that of South Africa) remains exceptional across the industrialized world. Even in Britain, where market forces have apparently gained strength in recent decades, only two percent of the total health care

budget is privatized and involves non-maternity provisions (Harrison and Schulz, 1989). Similar to most other health workers, including medical practitioners, British midwives work reasonable work weeks for a secure salary, and enjoy fringe benefits and job security that by far exceeds material rewards of the average factory or fast food worker. The same holds true for nurse-midwives in Canada. In the Nordic countries such as Sweden, available evidence indicates that rationalization of health services has not lead to significant growth of a private health sector. Instead, national health planning in Sweden attempts to transfer resources from in-patient to out- patient services and to primary and preventive care. The result is increased autonomy, rather than proletarian status for Swedish midwives (Lane and Arvidson, 1989).

Finally, we come to the perspective of patriarchal control. How generalizable are feminist findings of male-medical subordination of female midwives and repression of birthing women in the industrial period? On the one hand, feminist writers garner convincing proof of a hidden gatekeeping

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system or a "glass ceiling" in the health division of labour on both sides of the Atlantic (Riska and Wegar, 1993). In the area of maternity care, transformation of pregnant women into helpless "patients" passing through the "sick role" (Parsons, 1951) and dependent upon (predominantly male) medical expertise (Jordan, 1983: 35) has lead to intemperate medicalization - including inadequate prenatal care (especially among disadvantaged groups of women), frequent use of fetal monitors and medication during normal childbirth, high induction rates and surgical procedures such as episiotomies and cesarean sections (Sullivan and Weitz, 1988). Adrienne Rich (1975) has a point when she states that modern America witnesses the "theft of childbirth" - from both midwives and pregnant women.

Yet this portrayal of patriarchal control of maternity care, and its consequent iatrogenic effects on pregnant women and their families is not

all-pervasive. As mentioned above, history provides us with an example of the survival of autonomous female midwifery in the Canadian province of Newfoundland and Labrador, despite strains placed upon it by modernization. Although confined today to northern regions, until only a decade or so ago there existed a province-wide general acceptance by (male) physicians, other health professionals, and the public at large that female midwives were fundamental to quality care of birthing families. The outcome was that female midwives' and male physicians' work roles were complementary rather than hierarchial. In this historical instance, female midwives were far from "handmaidens" of male service professionals. Cottage hospital midwives worked as gatekeepers, calling on the male physician only when they deemed it beneficial for clients. As one of my respondents puts it: "We were well-rounded midwives, used to coping with everything. The cottage hospital was a family-centred place; it was not clinical, not an alien atmosphere. Maternity care was flexible and without doctor interference."

Cross-national research on the European continent and Nordic Countries support this conclusion. In Sweden, for example, birthing women are awarded a central place in the reproductive process and, apart from family and chosen friends, the midwife acts as confident and guide throughout. Similarly, Dutch women and their significant others enjoy the opportunity to make crucial decision about birthing arrangements. As Jordan (1983: 64) explains, "Dutch midwives work with the assumption that a woman knows what her body is up to. Thus, they are not likely to give 'doctor's orders'." Literature on maternity organization in Finland (Valvanne, 1988) and Denmark (Houd, 1988) also indicate that exclusionary gender tactics found in Anglo-American obstetrics are much less salient in these countries where perinatal rates are among the lowest in the world and client satisfaction with the existing midwifery-based system remains high.

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Toward an alternative perspective on service professions Primary and secondary findings on midwifery across time and place expose inadequacies in the four perspectives discussed above. Sociological concepts of professionalization, professional (medical) dominance, professional decline and patriarchal control are useful in inspecting maternity care arrangements in Anglo-America from different angles of vision, shedding light on the network of social forces that shape the present-day circumstance of midwives and birthing clients in this particular geo-cultural location. However, primary data from the most-eastern Canadian province of Newfoundland and Labrador, and published findings on contemporary maternity provisions in Nordic Countries and the Netherlands suggest a more inclusive way of analyzing service professions in regard to quality care of citizens. Proposed here is a multi-paradigm approach linking two alternative stances-interactionist and state perspectives-both neglected by recent students of service professions. Review of the full range of these alternative approaches is beyond the scope of this inquiry.5 A brief sketch will suffice to frame my research findings on midwifery as a caring profession in some times and places but not in others.

It has long been argued by analysts embracing an interactionist perspective that service professions need to be studied as interdependent groups of workers who claim the attribute of altruism or "caring" as they strive for professional status and its endowments. As Julius Roth (1974: 17) argues,

Various occupations play the attribute rating game in an effort to increase their relative standing in the occupational world and to reap its attendant rewards... Perhaps an historical perspective to the

development of occupations is the best antidote for the attribute rut. If we can see in some detail how

present-day professions developed, we would be less inclined to conjure up a vision of a list of characteristics toward which certain lines of work are moving and see it rather as a long-term process of negotiation.

This view on service professions clearly calls into question the pivotal assumption held by functionalist writers that possession of "esoteric knowledge" and "technique" make a caring professional. Yet it also suggests problems with critical perspectives on service professions that tend to overlook the diversity within and among service professions depending on time and place. As Everett Hughes wrote more than three decades ago, service professions in industrialized societies are not frozen structures but "in transition" (Hughes, 1958). It is the "process" of continuous negotiation/conflict over work mandates that is the important and proper subject for study in sociology (Strauss, 1985). Sometimes

5. Interactionist and state approaches frame my research in process, "Envisioning Quality Care: View of Midwives and Complementary Health Professionals". This project aims, among other

things, to discover similarities and differences in ideology and practice in the system of

professions serving birthing families of one geographic area of British Columbia today. An additional research goal involves documentation and analysis of provincial health authorities' recent endeavour to improve calibre of existing maternity services while controlling health costs.

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occupational boundaries are internally contested and occupations fragment and

split into smaller segments (Bucher and Strauss, 1961). Sometimes occupations attach themselves to more established/powerful professions and gain a secure mandate via this route (Halpern, 1992). Still other segments experience "occu-

pational death" (Anisef and Basson, 1979). Andrew Abbott (1988: 33) recently extends the interactionist model's focus to jurisdictional/work mandate interac- tions themselves. This allows for analysis of different levels of interaction

single occupations linked within a "system of professions" embedded within a

particular geo-cultural environment:

Each profession is bound to a set of tasks by ties of jurisdiction, the strengths and weaknesses of these ties being established in the processes of actual professional work. Since none of these links are absolute or permanent, the professions make up an interacting system, an ecology... From time to time, tasks are created, abolished, or reshaped by external forces, with consequent jostling and

readjustment within the system of professions.

The interactionist perspective helps to make sense of the intricate order of historical events that shaped the social transformation of maternity care across industrialized societies, highlighting the shifting work boundary and professional status of key players struggling to gain control of the maternity mandate in the

promise of improvedcare forbirthing families. Contrary to the viewpoints discussed above, the interactionist perspective grants midwives and birthing women a place in history as social agents who sometimes have little control over their own fate, and other times play significant roles in shaping the diversity of maternity arrangements that presently endure in the industrial world.

Yet the interactionist perspective leaves us with an inadequate understanding of

why such diversity exists in maternity arrangement at all, even with culturally similar countries such as Britain, Canada and the U.S., and between them and continental Europe and the Nordic Countries. Increasingly, students scrutinizing the

system of health professions are granting heed to the role of third parties, most

importantly today, the state (Coburn, 1993; Torstendahl andBurrage, 1990; Ruggie, 1992). To drawn upon the insight of Theda Skocpol (1985), we need to 'bring the state back in'. It is noteworthy that in each of the successful cases of midwifery as an authentic profession touched on above - Newfoundland and Labrador cottage hospital midwives, present-day midwives in the Netherlands and Nordic Countries - the state has been a pivotal arbitrator, taking a "strong" and "pro-citizen" role (Wilsford, 1991) to improve infant and maternal mortality and morbidity across societal groupings. In each of these socio-historical instances, the state has acted to "control medical professionals" (Freddi and Bjorkman, 1989) - that is, to suppress medical dominance while allowing for professional autonomy of physicians, on par with other health professionals. In these societal settings, midwives have received tangible state backing and publicly-esteemed positions as front-line professionals. I quote van Teijlingen and van der Hulst (forthcoming) on the contrast between British and Dutch midwives in this regard:

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The supportive intervention for midwifery by the Dutch state is distinctive. In Britain, for example, national legislation was minimal, with the first midwifery act being introduced in England and Wales in 1902, over 80 years after the first Dutch legislation. British legislation also tended to be restrictive, rather than supportive, of midwives professional development.

If the British state can be distinguished from its Continental neighbour in such a manner, than Canadian (Coburn, 1993) and, most of all, American (Bjoerkman, 1989; Ruggie, 1992) counterparts stand out as latecomers in controlling the medical profession so that quality and efficiency are cornerstones of the health service. The peculiar Anglo-America relationship between state and medicine is in influx, however, and it may well be that all knowledge-based groups deemed crucial to the well-being of citizens of Britain, the U.S. and Canada-medicine, for sure, but increasingly a diversity of complementary healing arts hitherto suppressed or marginalized-will in the future negotiate their jurisdictions, much like Nordic and Continental countries, through state regulations and institutions (Torstendahl and Burrage, 1990).

This appears to be the situation unfolding in Canada at present, at least in the maternity service. Provincial health authorities, seeking to improve services for birthing families while simultaneously control health budgets, are making both enemies and friends among the competing professional groups: while medicine and nursing cry wrongdoing by a brawny state, midwives are at the moment basking in the limelight, for the first time in history enjoying (or soon to enjoy) legal status in three provincial jurisdictions (Ontario, Alberta and B.C.). Despite state legitimation for midwives in Canada, we should not rest assured that quality care for birthing families is henceforth secured. While sharing gender status with pregnant women, Canadian midwives must contend with a dilemma central to the interactionist approach (Becker, 1970; Roth, 1974): how to balance professional self-interests (money, prestige and power topping the list) with the needs and concerns of birthing families. The shape of the maternity system emerging across Canada, then, also depends on choices fashioned by midwives themselves, choices as persons, as members of the midwifery profession and as service workers. According to Raymond de Vries (1993: 217), "[i]t is too often assumed that all three of these [persons, profession and service] are of one piece, that an improvement in any one bring an improvement in all the others... But this is decidedly not true. Often the interests of the profession are at odds with the interests of clients." As shown in this paper, it is conceivable yet not inevitable that such will be the outcome for Canadian midwives and birthing families.

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Paradigm Conflict in the Sociology of Service Professions: Midwifery as a Case Study

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