CC BY-NC-ND
26
оо
THE JOURNAL OF SOCIAL POLICY STUDIES_
ЖУРНАЛ
ИССЛЕДОВАНИЙ СОЦИАЛЬНОЙ
ПОЛИТИКИ • ••
Maya Paltineau
MIDWIFES AND SOCIAL CHANGE IN FRANCE
Modern midwifery emerged in France during the 15th century. This profession has witnessed numerous changes in its responsibilities, legal status and social representations. All of these transformations occurred in parallel to social changes and major shifts in French reproductive healthcare. This study examines midwifery over the past few centuries in order to provide a better understanding of parental behaviour and the social characteristics of birth. The approach employed in this article combines a historical perspective with a sociological analysis. This socio-historical study reveals not only how mid-wives have helped women assert their individual rights as mothers but also how parents have supported the demands of midwives for the improved social and legal recognition of their profession. The combined action of mid-wives and parents are changing the French reproductive health system, both by transforming birth procedures within hospitals and by asserting the right to give birth outside of hospitals. This study echoes other research in Western countries by pointing out that women increasingly want to take an active part in control over delivery, with their relationship to the midwives playing a crucial role in their quest for authenticity.
Keywords: Midwifery; Social Change; Reproductive Health; Intensive / Identity Parenting.
Over the past twenty years, the two main global trends in parenting behaviour have been intensive motherhood (Hays 1994) and more recently identity parenting (Paltineau 2014). They involve an increasing interest on the part of parents in their own role during pregnancy and labour. In their current quest for the individual reappropriation of the body, reproductive health is the major issue and it involves several actors. An analysis of French midwifery can teach us interesting things about the global changes in parenting practices and reproductive health (Bluff,
1 Maya Paltineau - PhD. candidate at the Centre d'Analyses et d'Intervention Sociologiques, EHESS, Paris, France. E-mail: [email protected]
© The Journal of Social Policy Studies. Vol. 12. N 3
Holloway 1994). In France, midwifes are traditionally the main actors in childbirth, after the mothers themselves. They are given the responsibility to bring a child to the world, and the lives of the mother and child are in their hands. The social role given to midwives occupies a space at the intersection of the private and the public spheres. On the one hand, midwives have access to the intimacy of women and on the other hand, they represent society and the state, since they socialize birth according to the a priori procedures established by the state. Midwives transmit the messages behind national public health regulations and guarantee personalized follow-ups within the very core of the private sphere. This ambivalent status reveals potential transformations underway the case of French society, from the MiddleAges until nowadays.
France follows the World Health Organization's guidelines, which defines the profession of midwifery as follows:
Midwifery encompasses care of women during pregnancy, labour, and the postnatal period, as well as care of new-borns. It includes measures aimed at preventing health problems in pregnancy, detecting abnormal conditions, procuring medical assistance when necessary and carrying out emergency measures in the absence of medical assistance (WHO 2014).
In France, health has been historically controlled by the state; the private healthcare available in other European countries is practically non-existent. In this respect, even from its early stages midwifery in France has been a public institution. The learning materials, the methods used and the practices allowed by law have always been integrated into an official framework. Furthermore, the large majority of midwives are employed and paid by the state, which gives them automatically the status of state representatives (Faure 2005).
Recently, the legal status of midwives in France has changed and the state health system has been the subject of restructuring (Moatty, Ghiorghiu 2013). These major changes have had a serious effect on midwives and the observations made on these changes can be seen as symptoms of a wider social change, affecting parenthood and the reproductive health system.
This work focuses on midwives not only because of the interest awaken by the profession per se, but also for the impact it has upon the whole of social studies. First, a review of the historical development and of French midwifery and the changes that have occurred within it is offered. This is in order to provide a clear comparison of the historical with the current status of French midwifery. Then, the details of the contemporary working conditions of French midwives are provided, with an emphasis on the new challenges faced by this profession. In the concluding remarks light is shed on the transformations and revolutions brought about by the midwife profession in the fields of reproductive health and parenthood.
The present work is a part of a broader research conducted by the author in 2010-2014 in France. The main research methodology was qualitative semi-
structured interviews with parents and healthcare specialists1. Interviews were collected mainly in Paris, Strasbourg, Lyon and Toulouse. However, given that the goal of the research was to provide a varied overview of French birth practices and parental perspectives over reproductive health, interviews of parents and professionals living in rural areas all over France were also taken. Along with the interviews, the research materials also include data gathered during in situ observations of the CALM Birth centre in Paris, and an analysis of internet data2. To reconstruct a broader socio-historical context of midwifery practices an analysis was conducted of both secondary data on history of French midwifery and normative documents that regulate the obstetrics field.
The early stages
of the midwifery professionalization in France
The following socio-historical analysis will depict how midwifery emerged in France, how a traditionally female occupation developed into a recognized profession. Given its control of the health system, the most relevant focus would seem to be on the transformations experienced by the French state. In this respect, it seems sensible to examine the influence of state authorities, as it is expressed in laws and changes in medical infrastructures and professional statuses of different health workers (midwives, doctors, nurses).
Historically, women have been assisting childbirth at least since antiquity. In France, they were generally elderly ladies with no professional qualifications, who were known the "den mothers"3. Their knowledge was based on personal experience and they used traditional medicines, such as plants, herbs, etc. They were seen as "healers", since they often assisted with other health problems in addition to their role during births. Den mothers were frequently associated with witches and therefore not professionally recognized (Thebaud 1986).
For many centuries, den mothers were the only persons in charge of birth assistance (except for royal births, which were supervised by doctors employed by the clergy. Over the Middle-Ages, this profession started to become slightly more formalized, gaining some public acknowledgement along the way. The French term for professional midwife, "sage-femme"4, emerged in the 15th century, and until the 20th century, the two terms and occupations (the traditional "den mother" and the emerging "sage-femme") coexisted. Until the beginning of the 20th century, den mothers were more numerous in France than
1 72 interviews were conducted with 7 midwives, 2 obstetricians, 4 nurses, 8 child-care specialists, and 51 parents.
2 This includes French parenting forums such as aufeminin.com, magicmaman.com, doctis-simo.fr, parents.fr, infobebes.com and parenting associations forums ciane.net and onsff.org.
3 The French word is «matrone», coming from Latin "mater", i.e. "mother".
4 Literally a "wise woman".
midwives. However, it should be noted that the current midwifery profession is the result of the continuous evolution of the sage-femme occupation, with den mothers largely disappearing1.
Another major element in the historical development of midwifery has been the opposition between midwives and the medical authorities. By the Middle-Ages, the state had set itself the goal of controlling the various bodies involved in medical care as well as all official medical activity (Foucault 1976). Between the 15th and the 18th centuries, numerous doctors were recruited in order to reinforce the medical power of the state (Gelis 1988). These actions were aimed at substituting empirical knowledge of women possessed of their reproductive experiences with a new, rational knowledge, which would facilitate the imposition of control over women's bodies. Michel Foucault described the French public health system as "organisms coordinating medical care, centralizing information, normalizing knowledge, which resembled campaigns for teaching the population about health and promoting medicalization"2 (Foucault 1976: 217).
During the first stages of the profession, midwives used to work in hospitals, alongside doctors and surgeons. At that time, hospitals were meant for the poor and underprivileged people, since they were designated as people most in need of the help and protection of state. The majority of women, thus, gave birth at home, assisted by a den mother (Thebaud 1986).
From the beginning of the 17th century, the professionalization of midwives picked up pace; they were now expected to attend a three months training course at the Hotel-Dieu in Paris, where they received theoretical and practical training. At that time, midwives only worked in the cities (whereas the den mothers used to work in the countryside) and they were paid for their work.
The French Revolution in 1789 brought with it numerous deaths and many sanitary problems, resulting in major changes in the medical profession. The 19th century saw the introduction of several laws that ended the religious and royal authority over medicine, redefining the status of doctors, surgeons, and midwives. During that century, the functioning of hospitals also changed as they were structured by local, regional and national levels, an organisational form that has been retained up to the 21st century (Akrich et al. 2010).
The midwifery profession continued to be better defined and structured. In 1802, the first national school for midwifery opened in Paris, within the Port Royal hospital. After one year, this school was able to issue degrees in midwifery that could be used to work all over France. The school had an excellent reputation in Europe and contributed greatly to the improved reputation of midwives. Following the success of this first school, 57 midwifery schools
1 In this work English term "midwife" will be used as the translation for the French "sage-femme".
2 Translated by the author of the article.
were opened in the main French cities and, within the next few decades, 20 000 of their graduates began working in the countryside.
The development of midwifery education reflected official acknowledgement for this profession. It is important to emphasize that the tuition fees in midwifery schools were covered by state-funded scholarships. This is indicative of the intent of support given by the French state to the midwifery profession, which sought to obtain control over their skills, knowledge, and practices. Development of professional midwifery was considered by the authorities to be a way to reduce the infant mortality rate and to improve the sanitary and living conditions of the population (Beauvalet-Boutouyrie 1999).
The development of midwifery also contributed to women's emancipation in France. First, official recognition of their professional status through the whole of French territory gave ample demonstration of the possibility of qualified paid work for women. Second, midwives contributed to the liberation of women from constraints of rural living conditions and provided protection from the hygiene risks to the mother and child. In all these matters, midwives stood for the expansion of women's rights and represented a certain form of early feminism.
In the late 19th century, at the time of massive industrialization in Europe, further changes in birth practices occurred. The unsavoury nature of rural life compelled women to increasingly enter to hospitals for birth. Hospitals slowly became the most common birth place in France, with 1881 seeing the creation of a special professional status: "hospital birth attendants"1.
During the same period, medicine and science, mostly represented by male doctors, established more and more specific rules for childbirth. Doctors gave their support to the gynaecological position during labour, which obliged women to lie on their backs and surrender freedom of movement. The use of medical instruments and techniques increased and became the norm in French obstetrics, although the use of these was limited to doctors and surgeons (Faure 2005). An 1892 law defined the exact terms of the midwives' working rights and forbid them to use any instrument during birth, thus reinforcing the power male doctors could enjoy over female midwives (Loi sur l'exercice de la médecine 1892).
The 20th century witnessed numerous technological changes in medicine. However, the greater the scientific progress was, the more the reputation of midwifery declined. The French maternity system became more controlled by the state, as the government retained the goal of rising the birth rate and reducing infant mortality. Obstetrics emerged as a branch of medical science. The budget allocated by state for the medical monitoring of pregnancies and childbirth grew, and the symbolical importance given to obstetrics also increased (Schlum-bohm 2002). From 1930 onwards, maternity wards were no longer only viewed as places to give birth but as "centres for medical and social assistance as well
1 In French "Le corps des accoucheurs des hôpitaux".
as scientific work dedicated to reproductive health" (Beauvalet-Boutouyrie 1999: 354).
These transformations had a huge impact on midwives' status as they were no longer the main providers of care for mothers and babies. This certainly decreased the influence of the profession, particularly given the fact that most of midwives tended to work outside of hospitals. Moreover, in 1922 a national nursing degree was issued, which allowed nurses to work in maternity wards, and partially replace midwives in childbirth (Decree on the brevets de capacité professionnelle... 1922).
Another important change in the midwives status occurred in response to the 1930 French law on Public Health Insurance (Loi complétant et modifiant la loi du 5 avril 1928 sur les assurances sociales 1930): the newly created system waived medical fees for mothers and their babies. However, only medical visits and births attended by doctors were covered by the state, excluding those taking place with midwives, including those taking place in the patient's home. As a result, midwifery slowly fell out of favour among pregnant women with regards to follow-ups and the childbirth itself. More and more births took place in hospitals, and midwives experienced a decline in their status as birth experts.
In order to counteract with the increasing medicalization of birth and the marginalization of independent midwifery, French midwives created associations, federations, and an "Ordre des sages-femmes"1. In the same period, the midwifery degree gained strength and importance in the country. The education program was extended firstly from two to three years, and subsequently to 4 years. Nowadays it is even longer, demanding five years of compulsory study at university. While the first year is common to all medical students, during the following four years students specialize in midwifery and have several periods of work experience at hospitals. This Master's degree in midwifery is recognized by the European legislation regarding the harmonization of university degrees (known as the Bologna Process), which allows it full recognition and facilitates the professional integration of midwives.
Contemporary French Midwifery
French midwifery has transformed over the centuries and the profession has proven itself capable of adapting to a continuously changing obstetrical and reproductive healthcare system. The last decades of the 20th century, as well as the beginning of the 21st century have brought out many more transformations for the midwife status and role, with French midwives now experiencing another major professional crisis.
French midwives have often complained about the lack of recognition from both other birth specialists and the state. According to an official report of the
1 "The Official Board of Midwives", ironically presided over by a doctor and not a midwife until 1995.
French Midwifery Federation, midwives are deeply unhappy with the lack of security in their professional status and working conditions, as well as discontent over low wages (ONSSF 2014). In France, midwives can chose to work in a hospital or in a private practice. Each brings with it a two different status, either as a "hospital practitioner" or a "self-employed midwife". Both have the right to consult pregnant women and since 2009, they have been allowed to prescribe certain medicine, including contraceptives (Loi N 2009-879 2009). Both kinds of mid-wives can be on hand at childbirth, although only those with the "hospital practitioner" status are permitted to work in hospitals. Freelance midwives are only allowed to assist births occurring outside of hospitals1. As the home birth rate in France is less than 1 % (Brocas 2011), self-employed midwives are generally more engaged in the work of providing into pregnancy and post-partum consultations than in assisting with actual childbirth. Between these two kinds of midwifery services other differences are of interest. Wages are not fixed for freelance mid-wives and they have no obligation regarding their schedule or their workload. On the other hand, midwives working in hospitals are obligated to work a given amount of hours per month and per year, with compulsory shifts. Apart from this, freelance midwifes are their own bosses, whereas those working in hospitals have to work within a specific professional hierarchy. Their wages are also determined by law, according to specific payment scales (Loi N 2011-814 2011). In such a context, more and more French midwives are opting out of the hospital system and establishing their own private practices, with more focus on pregnancy follow-ups than birth.
Hospital midwives have regularly gone on strike and the social conflict created around their demands has only subsided from March 2014. The main conflict point was based around the request to change their legal status: until March this year, French midwives were in a paramedical profession. They were assimilated into the category of "public medical function"2, which means that they were not considered to be health specialists the equal of doctors, dentists, or pharmacists. This lowered status has an impact not only on their wages but also on their social rights and the level of credibility and valorisation of midwifery. The symbolical message behind this professional lack of recognition was that other specialists could take care of births and that the expertise of midwifery was replaceable. Striking midwives wanted the primary role they have always played during births to be recognized. As their education includes medical courses, they also demanded to be given a medical status equivalent to the status of doctors. The report by professors Philippe Puech, Gérard Bre-art and Jean-Christophe Rozé in 2003 advocated midwives to focus on non-pathological pregnancies, in order to do more for low-risk pregnancies so that
1 Exceptions are made for emergency cases, such as a homebirth that, for whatever reason, must be completed in a hospital.
2 "Fonction publique hospitalière" in French.
doctors would have more time for high-risk pregnancies (Breart, Puech, Roze 2003).
Once again, a tension between doctors and midwives can be found. Mid-wives do not want to subordinate or exclude the doctors; they want to be recognized as equals. From their own perspective, midwives are actually playing a vital complementary role alongside doctors, they refuse the principle of hierarchy or the idea that one of these professions can or should be in charge of births by themselves (ONSSF 2014). According to midwives' own accounts, they are the most reliable experts in the case of physiological births, whereas doctors are the experts of pathological pregnancies and labour. Following the principle of this claim, according to the National Midwifery Federation in 2013, midwives and obstetricians should be treated as equals in terms of social, legal, political and economic rights (Collectif des sages-femmes 2013).
The main idea behind this is that pathology and physiology are not a one and the same; physiology should not be treated from the pathological point of view. A physiological birth is totally independent from pathology. Physiology and pathology are not degrees of the same state, but are two completely different systems (Canguilhem 1966).
It is problematic to build a consensus between different medical specialists not only on the acceptance of this distinction but also on the classification of particular type of childbirth, either as physiological, or pathological. In this respect, the moment when the distinction is made is crucial. Indeed, French obstetrics defines birth as physiological a posteriori (Ben Soussan 2010). This means that during the whole delivery, the event will be treated as pathological and all medical actions, practices and attitudes will adhere to the pathological system. So even if it ends up being a physiological birth, this will not be recognised and treated as such until it has ended, by which point it is too late to adopt physiological methods instead of pathological ones.
This approach leads to a very medicalized codification of birth practices within hospitals. Deliveries are surrounded by medical instruments, machines, and technical gestures from the medical practitioners. This kind of approach puts midwives in a difficult position: Since they are not allowed to use instru-ments and they have only held a paramedical status until recently, it is quite hard for them to carry out their work in medical facilities. Even when they were in charge of a birth from A to Z and suffered no intervention from obstetricians, their symbolic legitimacy was threatened by the fact that no delivery occurring within hospitals is considered as physiological until it is finished. This ambi-valence is not always seen or understood by medical practitioners and puts mid-wives in a difficult position.
Self-employed midwives also face difficulties doing their work in accep-table conditions. Home birth is an extremely controversial practice in France (Jacques 2007). Parents who opt for it are often seen as marginal and their motivation for doing this is not generally well understood. Parents giving birth at home are frequently seen as irresponsible and are accused of putting their own lives and their babies'
lives in danger, given that the practice is not recom-mended by doctors. One mother who participated in my research said that even her husband was against homebirth at the beginning: "For him, it was too risky, way too dangerous, it was just irresponsible to do that"(Isoline, 34 years old, Paris, 2012).
Within such a negative context, midwives in homebirths have also been accused of taking irresponsible risks and demonstrating dangerous professional behaviour. In the past few years, insurance companies have withdrawn their coverage for midwives in homebirths. Given that homebirth is no longer covered by any professional insurance, in case of complications the midwife will no longer be protected. Obviously, this threatens the legitimacy of private midwives, as their job is not legally protected. As the practice of homebirth is not strictly recognized as a professional occupation, midwifery (at least symbolically) is strongly limited to hospitals as a working place, especially if midwives want to work during full births and not have their work limited to postnatal check-ups. Moreover, the public health system provides full coverage for hospital births, whereas homebirth must be paid for by the families themselves. By limiting opportunities for the practice of private midwifery, the French state emphasizes that births are under its protection, and that they should take place only in hospital settings.
Midwifery suffers from state regulations and as a profession finds itself in opposition to certain social norms surrounding birth and reproductive health. The example of homebirth shows that, in order to protect the interests of the profession, contemporary French midwifery has to either come to terms with social and legal norms or to fight against them.
Recent changes in the midwifery profession, in relation to identity parenting
Despite all the barriers and difficulties encountered by French midwives, it is also true that this profession can change social rules. The relationship between midwifery and society works in both directions: The social context shapes the profession but midwives, with the support of some parents, also have the ability to transform society.
One of the current trends in France is intensive mothering (Hays 1994) and, the product of this evolution, identity parenting (Paltineau 2014). The later includes parental practices focused on nature and physiology. This entails increased focus on the relationship between parent and unborn child, with far more respect paid to the care of the latter. As far as birth is concerned, a preference is given to natural birth, which questions the assumptions of modern medical practices and techniques. Parents have increasingly become aware of the downsides of modern medicine. For example, epidural anaesthesia is increasingly feared and criticized for the possible negative consequences it can have on the mother's and child's health, whereas ten or twenty years ago, such a technical tool was deemed to be a huge advantage for women giving birth.
Internet forums, such as the famous French forum "Au féminin", provide popular platforms where mothers can share their experiences of and attitudes toward medical interventions. The following example illustrates parental fear and doubts about the epidural anaesthesia:
I will never do it [epidural anaesthesia - M.P.], it is so much healthier to avoid sending these aesthetic products to the baby's tiny heart, and besides, it generates fetal distress. so no thank you! I gave birth without epidural anaesthesia and I loved it, even if it lasted 21 hours (dreakill3, 20 years old, forum "Au féminin", 2008).
This scepticism can also be observed in many other aspects of reproductive health, such as the artificial activation of labour, caesarean sections, labour monitoring and the early cutting of the umbilical cord, etc.
Identity parenthood as defined by Maya Paltineau (Paltineau 2014) implies the personal, deep and genuine involvement of both parents into the parenting role. It means that parenthood is experienced from a very reflective point of view and that each and every aspect of it is analysed. Intensive parents investigate all aspects of their parental roles and consider every step of the parenting process, including of course pregnancy and birth. Such parents become birth experts and, as a result, aim to make informed choices about every single decision they make. This entails frequent disapproval of standardized medical and birth procedures. Instead, they opt for very personalized obstetric care check-ups as well as custo-mized birth protocols. Since hospitals and maternity wards often do not offer a per-sonalized follow-up, more and more French parents chose to be accompanied by a self-employed midwife.
According to Rosalind Bluff and Immy Holloway, "midwives must be prepared to share their knowledge and should not see this as a threat to their professional authority but rather as an opportunity of helping women to achieve the type of experience they desire" (Bluff, Holloway 1994: 163). French mothers seem to be interested in sharing of responsibilities and in receiving more personalized treatment. As expressed one interviewee related:
At the consultations in hospital, you don't really count. For my first pregnancy I had five consultations with three different people <...>. But Johanna [her private midwife - M.P.], she saw me every week, so she understood how I work and gave me advice that were really tailored to me and who I am (Marjorie, 31 years old, Paris, 2011).
That is also the reason why birth centres1 are becoming increasingly popular in France although they have not yet been legalized by the French government2.
1 Birth centres are places for natural births (no epidural anesthesia or medical technique of any kind), where women are assisted by midwives (no obstetricians, surgeons or nurses).
2 The social conflict around birth centres has lasted for several years, and it is a delicate issue in the French reproductive health system (CIANE 2013).
Numerous French parents would like to give birth outside of the very medi-calized, technical and standardized hospital delivery rooms but the demand for out-of-hospital births outstrips demand, as very few private midwives are available to assist delivery and the legal framework does not provide parents with many other options (CIANE 2013). During the interviews, several parents told me that they given up or postponed their homebirth projects because they could not find a private midwife offering homebirth assistance in their region. One mother explained as follows: "for the first child, I wanted to give birth at home, but I didn't get on with the only midwife working on homebirth in our region... so my husband and I decided not to do it" (Violaine, 29 years old, Strasbourg, 2008). Here again, midwives and parents suffer from rigid regulation: Even though out-of-hospital births are attracting more and more parents, they are still not recognized as the norm and, as such, midwives cannot freely practice their profession in this context. Midwifery is still restricted and reduced to a very limited status and framework.
Despite being appreciated and requested by the spreading social trends, midwifes are not free to work in harmony with the current social changes. It seems quite relevant to highlight that social changes come before any alterations to midwifery's legal status. In contemporary France midwives, along with some parents, are attempting to build a new system to understand childbirth and shape new social trends and behaviour in this sphere. This creates a perpetual discrepancy between the responsibilities allocated to midwives by the state and the actual role they want to play for the mothers (CIANE 2014). This gap generates a seemingly permanent conflict within the midwifery profession, which makes it all the harder to be a midwife in France.
Conclusion
The role of the state in the development of midwifery is ambivalent; in the early stages of the profession, many laws permitted helped to establish the credibility and recognition of the midwifery profession. Midwifery owes its modern foundation and development to the state. Its professionalization in opposition to the traditional 'den mothers' was also achieved under state tutelage. The state opened schools and made their professional status official, providing them with the strength and the power to develop their roles as experts in childbirth. However, the French state has also expressed a desire to help doctors establish their medical power and become the official medical representatives of the state (Foucault 1976). Much of this has been done at the expense of the midwifery profession. Indeed, French laws have put doctors above midwives in a certain hierarchy, implying that the latter were less important than the former in childbirth.
Over the last decades, the state's position towards the midwifery profession has appeared to be increasingly coercive (CIANE 2014), with French mid-
wives fighting for their rights to emancipate themselves from the clutches of the French state. In fact, French midwives currently tend to leave public hospitals and sometimes criticize the present state of the French health system. They also refuse to accept an unequal status in relation to doctors, requesting improved recognition of their profession. All of this points to the conclusion that French midwifery is seeking to redefine its symbolic meaning and its professional organization. This involves emancipation from the state control, a goal that is being pursued with the support of parents.
To conclude, parents' activism, which is expressed through intensive and identity parenting, reinforces the midwives' claims and thus leads to changes in the legal status of the profession. These personal and professional social affirmations bring major changes in the state's health infrastructures. Indeed, more and more hospitals have set up delivery rooms with facilities such as bathtubs, balloons, etc. And it is no longer uncommon to have the chance to give birth naturally within hospitals (Akrich et al. 2010). More and more French parents are asserting their rights towards the institutionalized birth protocols by writing "birth projects"1, and refusing some medical interventions. What is observable is a growing awareness of individuals as health actors. French parents are gaining confidence in the medical system and assert their identity and their choices more and more easily (Paltineau 2012). What is more, this phenomenon is occurring not only in reproductive health but for the whole healthcare system. This individual assertion and identity "subjectivation" are part of major social change occurring nowadays in many Western countries (Touraine 2013). Contemporary societies are turning into postmodern systems, where individuals take control over their own lives and become social actors. This post-modernity is characterized by the economic current crisis and by a growing interest in the private sphere, personal well-being and a genuine awareness and connection with reality. The current values are no longer economic or financial well-being, as ownership and material richness are less and less valued. The major social change that we are currently witnessing is mainly made possible by, first of all, the transmission of information, and secondly, by the interconnections and networking of individuals. These two characteristics have been essential in the recent transformations in midwifery and they reflect further changes in the profession, in the whole reproductive health system and in society as a whole.
References
Akrich M., Bardes F., Phan E. (2010) Les lieux de naissance en France: quels choix pour les usagers? Spirale, (54): 149-158.
1 A list of wishes regarding the labor protocol written by parents and submitted to the medical team before the birth.
Beauvalet-Boutouyrie S. (1999) Naître à l'hôpital auXIXème .siècle, Paris: Belin.
Ben Soussan P. (2010) Des lieux de naissance si peu hospitaliers.... Spirale, (54): 159-168.
Benoit Truong-Cahn M. (2009) Les nouvelles compétences des sages-femmes après la publication de la loi HPST du 21 juillet 2009. Contact Sage-femme, La lettre du Conseil de l'Ordre, (21): 20-21.
Bluff R., Holloway I. (1994) They know best. Midwifery, (10): 157-164, Longman Group Ltd.
Bréart G, Puech F., Rozé JC. (2003) Rapport Mission périnatalité, Paris: Ministère de la Santé.
Brocas A.- M. (2011) La situation périnatale en France en 2010, Paris: Etudes et Résultats.
Canguilhem G. (1966) Le normal et le pathologique, Paris: PUF/Quadrige.
Chaumette P. (2005) Parents et sages-femmes: l'accompagnement global, Paris: Editions Yves Michel.
CIANE (2013) Procès Verbal de l'assemblée générale du 23 novembre 2013. Paris: CIANE.
CIANE (2014) Le CIANE dénonce la campagne de dénigrement à l'encontre des sages-femmes. Paris: CIANE.
Collectif des sages-femmes (2013) Les sages-femmes dans le projet de loi de santé publique 2014, Santé génésique des femmes et périnatalité. Availbale at: http://anesf.com/wp/wp-content/uploads/CAHIER-D0LEANCES_003.pdf (accessed: 15 September 2014).
Décret portant institution du brevet de capacité d'infirmières professionnelles (1922) Journal Officiel de la République Française. June 22: 6880.
Faure O. (2005) Les sages-femmes en France au XIXème siècle: les institutrices du système de santé?, Paris: Belin.
Foucault M. (1976) Il faut défendre la société, Cours au Collège de France, Paris: Gallimard. Gélis J. (1988) La sage-femme et le médecin, Paris: Fayard.
Hoerni B. (1998) La loi du 30 novembre 1982. Histoire des sciences médicales, Volume XXXIII, (1): 163-168.
Jacques B. (2007) Sociologie de l'accouchement, Paris: PUF.
Hays S. (1994) The Cultural Contradictions ofMotherhood, New Haven: Yale University Press.
Loi N 2009-879 (2009) Journal Officiel de la République Française. July 22: 12184.
Loi sur l'exercice de la médecine (1892) Journal Officiel de la République Française. November 30: 537.
Loi complétant et modifiant la loi du 5 avril 1928 sur les assurances sociales (1930) Journal Officiel de la République Française. May 1: 4819.
Loi N 2011-814 (2011) Journal Officiel de la République Française. July 8: 11826.
Moatty F., Gheorghiu M. D. (2013) L'hôpital en mouvement: Changements organisationnels et conditions de travail, Paris: Editions Liaisons.
Organisation Nationale Syndicale des Sages-Femmes (ONSSF) Communiqué aux sages-femmes. Available at: http://www.onssf.org/Documents/20140621_CSF_bilan_VD.pdf (accessed 21 June 2014).
Paltineau M. (2012) The Identity Work and Health of Intensive Motherhood. Health, Culture and Society, (3): 172-183.
Paltineau M. (2014) La parentalité identitaire, moteur de changement dans les normes parentales françaises. Paris: Ecole des Hautes Etudes en Sciences Sociales.
Schlumbohm J. (2002) Comment l'obstétrique est devenue une science. Actes de la recherche en Sciences sociales, (143): 18-30.
Thébaud F. (1986) Quand nos grand-mères donnaient la vie, Lyon: PUL.
Touraine A. (2013) La fin des sociétés, Paris: Seuil.
WHO (2014) State of the world's midwifery report 2014, New-York: WHO.
