Midwifery, social scientific and public health research alongside related national and global policies, have recognized that “all is not well with birth” [(1), 4]. Quality maternal healthcare aimed at improving maternal and perinatal health outcomes is unevenly distributed worldwide.¹ It has been shown that many people giving birth in different environments are systematically threatened, insulted, denied pain medication or coerced into “consent”. The disrespect for and mistreatment of birth givers, which activist groups in Latin American countries have termed “obstetric violence,” has been framed as a global epidemic. Associated with increased maternal morbidity and mortality, obstetric violence is understood as both a public health and a human rights-related issue. It has raised ethico-political concerns about women's health and wellbeing in relation to their autonomy and freedom of choice in childbirth (2–8).²

Professional midwifery care has been recognized as the best way to tackle ill-treatment of birth givers, contributing to better health outcomes and positive childbirth experiences (18–21). Midwifery's non-interventionist approach is said to be a humanized counter-program to technocratic, interventionist and obstetric dealings with birthing bodies.³ It is argued that midwifery-specific birthing care supports women to cope with birth not only in terms of a physical event but also as a transformative biographical and sociocultural rite of passage. Instead of disciplining and objectifying bodies-in-labor and controlling and alienating women's subjective birthing experiences, midwives foster “normal” physiological births and allow for individual choice and control (22–28).

While the effectiveness of midwifery birthing care techniques in improving labor care has been repeatedly demonstrated, it has not yet been sufficiently articulated, in terms of what they consist of in detail and how exactly they contribute to producing “good” childbirth experiences. In this paper, I draw on insights derived from care studies as a branch of science and technology studies and empirical ethics to demonstrate how midwifery birthing care techniques craft trustful and empowering relationships which involve birth givers as active participants, establishing the conditions for “physiological” births to take place.

Continuity of midwifery care has been shown to provide what matters to “[m]ost healthy childbearing women”: “safety and psychosocial wellbeing” [(29), 2], subsumed under a “positive childbirth experience” [(7, 30); see also (31–33)]. This continuity of care is the provision of “care from the same midwife or team of midwives during pregnancy, birth, and the early parenting period in collaboration with obstetric and specialist teams when required” [(34), 3]. Continuous midwifery care has been shown to foster respectful, woman-centered interactions and to provide safety not only in obstetrical but also in emotional terms (35). In order to demonstrate “the power of midwifery” (19), classic maternal health indicators focusing on life-saving interventions and health outcomes such as maternal mortality [(36), 1750; (13), 2] have been extended to include relational qualities and birth givers' experiences of maternity care. On that basis, two characteristics of maternity care practice have been shown to impact positively on maternal and perinatal health: the timely and indicated use of evidence-based obstetric interventions and respectful and supportive maternity care relationships. The midwifery model of maternity care emphasizes the primacy of the midwife–woman relationship. It equips birth givers, including those from vulnerable and marginalized groups, with a sense of personal achievement. This sense of achievement provides them with an “inner” resource for long-term empowerment (15, 22, 32, 37–43).

A wealth of midwifery research has emphasized the importance of developing trustful and responsive midwifery care relationships over time to care “well” for women giving birth (31, 34, 44–53). Despite their significant impact on perinatal health outcomes and childbirth experience, midwifery care relationships together with techniques aimed at crafting, nurturing and sustaining responsiveness, intimacy and trust have been largely invisible in birth scholarship and birth-related discourses. As opposed to obstetric interventions directed at the body-in-labor which figure in birthing care protocols or guidelines, midwifery birthing care techniques are often attributed to not only a physical but also a psychosocial domain. Evading singularization, standardization and measuring, midwifery techniques which instill “a feeling of trust and safety in a woman who then feels confident to go with the flow of her labour” have “no name”, are “not recorded,” and are “not monitored or accounted for” [(54), 10067]. Traditionally, these techniques have been framed as “expectant management” [(43), 1132], “watching and waiting” [(55), 372], “non-intervention” [(56), 4], or “watchful attendance” (54).

These descriptions of midwifery care techniques have emphasized the relevance of an embodied co-presence of midwives with birth givers. To differentiate them from a medical model of birthing care built on a risk-averse, interventionist approach, these framings have foregrounded a more receptive “non-doing”, also suggesting that there is not much happening to talk or to write about. Ideally rather passive and thus unobtrusive (non-/low-interventionist) midwifery care practices have also been argued to foster birth givers' position as active and competent choosers. The position of “‘consumers’ making choices about birth” has been idealized since the 1970s, especially in contexts located within the Global North and associated with the middle classes [(1), 40]. Care ethical approaches have been introduced by midwifery scholars as a radically relational alternative to positioning birthing women as autonomous agents (57–61). Midwifery scholars have also argued for better articulation of specific midwifery birthing care techniques beyond just watching and waiting. In addition to focusing on what midwives do not do, or do less of, namely using obstetric interventions, more studies are needed on what midwives do when attending births (including using obstetric interventions), how exactly they do it, and with what effects (54).

In this paper I aim to contribute to these discussions on how to conceive of and to talk about midwifery care practices. My inspiration comes from feminist science and technology studies' (STS) engagements with caring in terms of empirical ethics, namely as situated practices of “doing good” (62–65). In this tradition, care as a practice is not confined to healthcare alone, even though healthcare studies—particularly nursing theory—were instrumental in drawing academic attention to care as a set of central socio-material activities that shape and constitute daily life (65). Sensitivities informed by Science and Technology Studies (STS) have contributed to decentering human actors and agency by focusing on the relationships between people, technologies, environments, and words. The identities of people, bodies, or things cannot be predefined once and for all; rather, they emerge as effects of the relationships they establish within specific care practices. This approach posits that “everything in the social and natural worlds [is] a continuously generated effect of the webs of relations within which they are located” [(66), 141]. It assumes a “radical relationality” [(67); see also (60)] that serves as both a methodological framework and a methodical tool. This radical relationality also extends to the ways in which care practices are studied and understood in and through research. Researchers, too, establish and cultivate specific relationships with their research “objects.” Within this scholarship, research practices are understood as “re-scriptive”: the questions researchers ask and the methods they use to answer them actively shape and bring specific research objects into being, rather than “discovering” them as pre-existing or given [(67), 179]. Against this backdrop, it has been emphasized that “if care studies are not carefully attended to, there is a risk that they will be eroded” [(65), 7]. Consequently, research in this field often investigates specific, local care practices—typically through ethnographic or, more precisely, praxiographic methods (68)—with the aim of “improving care in its own terms” [(69), 2]. Both care practices and research practices are inherently normative, as they are “oriented towards achieving something good.” Describing—or re-scribing—care practices in terms of empirical ethics involves attending to the “goods,” the norms, and the values that midwives, birth givers, or birthing environments implicitly or explicitly strive for or mobilize, as well as “the ‘bads’ they want to avoid” [(67), 177].

Informed by this approach, I investigate midwifery care as an embodied practice that contributes to restoring, sustaining, or improving birthing situations [(70), 185]. I illustrate how, in birthing care arrangements that strive for “giving birth” well, entities such as bodies-in-labor are brought into being or “enacted” in various ways. For example, they may become both corporeal actors and objects of different interventions and assessments (71).

To develop an empirically grounded vocabulary for the specific appreciative and creative forms of midwifery birthing care relationships, I draw on a wide array of literature⁴ that shares the theoretical commitments described above. These studies challenge conventional notions of agency as a human property confined within individuals and shaped by external structures, as subjectivity in opposition to objectification, or as activity contrasted with passivity. Instead, they use empirical material to generate relevant and often surprising insights that not only deepen our understanding of the practices being described but also contribute to theoretical developments on selfhood, embodiment, and ethics.

Against that background, (that has not yet been received within midwifery research) I propose a radically relational understanding of midwifery care practices. My contribution introduces a relational and distributed notion of birth givers' agency, emphasizing how agency emerges through the dynamic interplay of birthing care relationships, practices, and environments. To do this, I address the following research questions: How are birthing care relationships configured in midwifery care practices? Which modes of giving birth “well” are enacted through midwifery birthing care techniques?

The ethnographic material used in this paper originates from Germany. In Germany, pregnancy, birth, and postpartum care are typically fragmented, occurring in various settings and involving multiple obstetricians and midwives. The common pathway through the contemporary landscape of German maternity healthcare begins with monthly, and later biweekly, prenatal care provided by obstetricians in their practices. This is followed by prenatal classes taught by midwives in designated facilities. Birth takes place in a clinical labor ward, attended by both midwives and medical doctors, with the latter being in charge. During the subsequent days, nurses, midwives, and medical doctors care for women and newborns in the maternity ward. From the third day postpartum, a midwife conducts home visits until twelve weeks after birth. Six weeks after delivery, the woman and child return to the obstetrician for a follow-up examination. I utilize material gathered from both Eastern and Western Germany, as historical, structural, and societal differences have led to variations in the organization of maternity care and working conditions. In the former German Democratic Republic (GDR, 1949–1990), maternity care was centrally and state-organized, with out-of-hospital births being virtually nonexistent, at least officially. In contrast, the Federal Republic of Germany (FRG) has seen a greater variety of care models, including midwife-led birthing centers [Geburtshäuser]. The data supporting my arguments include eleven semi-structured interviews conducted in 2022 and 2023 with midwives working in hospitals, private homes, midwife-led birthing centers and ob-gyn practices in the eastern states of Germany.⁵ The aim of these interviews was to gain a deeper understanding of how midwives facilitate, maintain, and restore physiological birth, as well as to clarify what constitutes physiological birth under various conditions. To achieve this, we employed a purposive sampling approach, selecting midwives who have worked in both clinical and extra-clinical environments for at least five years and who chose to become midwives more out of a sense of calling than merely as a job [(76), 93].

In addition, I used ethnographic material from the fieldwork I conducted as a PhD student between February 2015 and March 2016 in var­ious sites where midwives work in northern and eastern Germany, including six observational protocols, eight formal interviews and various informal conversations with midwives and women.⁶ In this project I addressed the following research questions: What are midwifery care techniques? What do bodies become in midwifery care arrangements? How can “good” midwifery care practices get strengthened in and through research?

In both research projects, several ethical considerations were meticulously addressed to ensure the well-being of participants and maintain the integrity of the research process. Prior to participation, all individuals were provided with a detailed written and verbal explanation of the respective project, including its procedures and objectives. This approach created transparency and fostered trust between the researcher and the participants. To further protect participants' identities and safeguard their privacy, anonymization and pseudonymization of the data were implemented throughout the study. Informed consent was obtained from all participants regarding their involvement in the research. Participants received a consent form that clearly stated their participation was voluntary and could be withdrawn at any time without any negative consequences. Additionally, I signed a confidentiality agreement to ensure that all information collected during the research would be treated with confidentiality. These ethical measures were crucial in upholding the standards of the research and strengthening participants' trust in the project, thereby ensuring a responsible and ethical approach to data collection and analysis.In order to analyze the data set, I used a reflexive thematic analysis (reflexive TA) approach (80–82) with the aim of developing sensitizing concepts as pointers to “suggest directions along which to look” [(83), 7]. As an alternative to presenting a coherent explanatory theoretical framework that can be “applied”, for example, to evaluate midwifery care practices “in general”, I seek for contributing to further refining the theoretical concepts that address the qualities and effects of particular midwifery care practices in order to strengthen and to improve them.

In the results section, in which I theorize midwifery care attachments, I introduce the conceptual themes through excerpts from two interviews which form part of the above-mentioned data set. One of the interviews was with a midwife I will call Madeleine⁷, who was working in a midwife-led birth center. The other interview was with Saira who had given birth in a hospital. I set Madeleine's and Saira's quotes in dialog to study midwifery care attachments and their techniques across environments (hospital and community), models of care (medical and midwifery), genres of knowledge (clinical expertise and “patient” experience) or perspectives (midwife and birth giver).

In keeping with ethnographic practices that prioritize depth and nuance over breadth, I present two cases from a larger dataset comprising 19 interviews, eight observational protocols, and informal conversations. The selection of these two cases is informed by a comprehensive analysis of the entire dataset. This ensures that the cases exemplify the themes identified during the analysis of the full dataset. This approach allows for providing rich, detailed narratives that illuminate the complexities of relationships within midwifery birthing care over time. I have also chosen to set these two cases in dialogue specifically to challenge common juxtapositions often found in discussions of midwifery birthing care. These include (a) the perspectives of the midwife vs. the birth giver, (b) the birthing care environments (midwife-led out-of-hospital settings vs. hospital-based contexts), and (c) the birthing care models (midwifery model of care vs. medical model of care). By examining these cases in conversation with one another, I aim to complicate and move beyond these traditional binaries, offering a more nuanced understanding of midwifery practice and the dynamics of birthing care relationships.

When presenting the results, I draw on literature inspired by Science and Technology Studies (STS) that (re)conceptualizes agency. I cite this literature not only to acknowledge its influence on my thinking but also to emphasize the importance of reflexivity in my research process, including its outcomes. Ethnographic results are not merely raw data; they are interpretive, and literature citations help to make this interpretive nature visible.

The interview with midwife Madeleine was held in 2022. Madeleine had worked as a nursery teacher for nearly twenty years before she decided to become a midwife. After the training she started to work on a labor ward at a university hospital. She resigned after a year because she did not appreciate what she described as a rule-based approach, which applied “a specific perspective even though that perspective doesn't apply to everyone,” and which followed rules “just because that's the way it always has been.” Madeleine instead decided to work at a midwife-led birth center, where she has been working together with six midwives organized in teams for the last eight years. Madeleine and her colleagues provide prenatal, birthing and postpartum care and accompany births both at the birth center and in people's homes. In her work, Madeleine feels that “the situation is more important than the rule” and care is provided based on “a good overall view.”

The second interview and set of quotes I use stem from an interview I held with Saira in 2015. Accompanied by her husband, Saira had given birth to her first child in the hospital where I was doing my ethnographic fieldwork. Saira agreed that I could observationally participate at her birth and conduct an interview with her two days later.

I have described midwifery birthing care relationships that go beyond the often focused-upon dyadic relationship between women and midwives, understood as midwifery's primary ethical relationship. Giving birth happens and is made to happen through social and material midwifery care collectives of not only birth givers, their companions, midwives and medical doctors, but also birthing care surroundings and their material and emotional affordances, their standards, goals and ideals. Two care collectives were analyzed in this paper: one situated in a midwife-led birth center and the other in a hospital. In these care collectives, bodies-in-labor are configured as central actors also through obstetrical articulations. That means that in both environments how bodies-in-labor are and can be inhabited is also mediated by obstetrical descriptions and interventions. Through the midwifery care techniques of “spooning” and “labor and birth positioning” Lisa and Saira are invited to actively participate in working with their bodies-in-labor. They learn to become sensitive to their bodies-in-labor in ways that allow them to affect their bodies-in-labor instead of being overwhelmed or alienated. These techniques aim at cultivating midwifery birthing care attachments that I understand as collective, co-responsive, active-passive commitments aimed at sustaining endurable or even pleasurable relationships between embodied selves and bodies-in-labor. These midwifery care attachments are brought about through highly organized activities – and passivities – extending co-presence or non-intervention.

I argued that instead of the midwives striving for Lisa and Saira to control themselves, their bodies-in-labor and what happens to them or to surrender to their bodies and the events, Lisa and Saira are caringly invited to engage with their bodies-in-labor, trustfully and interestedly, in order to give birth “spontaneously” in both the out-of-hospital and the medical environment. Lisa's and Saira's capacity to act is distributed over and mediated by various other actors or participants which are interrelated and interdependent: their midwives, the birthing care surroundings, obstetrical definitions and procedures, even motivational words and caresses. In practice, their positions stand thus in stark contrast with consumerist agendas presupposing liberal subjects being in control and making choices. Promoting a “logic of care” instead of a logic of choice and control (69) makes it possible to articulate the collective creative techniques mobilized in midwifery care practices. These midwifery birthing care techniques grapple relentlessly and adaptively with more-than-medical uncertainties and fragilities as part of giving birth. These techniques act speculatively upon what might be “good” for this particular person and body-in-labor in their particular circumstances, without any participant, however, knowing for sure what exactly this “good” might entail.

Being “with woman” is not just an ideal or ethical obligation, especially important in continuous midwifery care constellations, but a laborious, shared and hands-on endeavour. It necessitates cultivating particular responsivities towards the offerings of the environment, the midwifery care relationship or the body-in-labor in order to make giving birth work (48, 52, 91). By understanding and articulating the relationalities of physiological birth through midwifery birthing care attachments, as situated, dynamic and collective endeavors, we may also present alternatives to two challenging trends in birthing: the relentless expansion of repertoires of risk avoidance because of the unpredictability of giving birth; and the “blame culture” associated with these strategies, pinning adverse outcomes systematically down to wrong decisions made by individuals, be it birth attendants or birth givers [(92), 209].

While my findings are specific to the environments in which the events occurred, they can still be relevant in other contexts. Instead of generalizing the insights presented here, they can be utilized as a methodological and conceptual lens for exploring midwifery care techniques that foster supportive attachments, such as “spooning” or “labor and birth positioning”, in various settings and times.

Obstetric violence has often been framed as a public health and human rights-related concern but less attention has been given to studying the concrete social and material conditions through which birth givers “can claim and recognise selfhood in their actions” [(93), 34]. While depictions of obstetric violence and humane counterprograms do not leave much space to examine the more nuanced and “broad spectrum that lies between complete lack of connection, on the one hand, and actual “intersubjectivity,” on the other hand” [(94), 244], my suggestion is to lay open and analyze that space through studying midwifery care relationships in practice. This approach helps to carve out surprising and important nuances. While one might assume that obstetric violence “has much in common with the more general experience of alienation and objectification within medicalization” [(95), 241], with alienation being “at the kernel of birth trauma narratives” [(96), 496], my investigation of concrete and situated midwifery care practices shows that birth givers may actively take part in objectifying their body-in-labor in order to “reach their goals”, thereby exercising agency and avoiding alienation. Approaching agency in childbirths through a logic of care instead of a logic of control allows acknowledgement of “interdependency as the ontological state in which humans and countless other beings unavoidably live” [(97), 4] and an avoidance of “maternal separation” (60).

In one of the cases presented in this paper, I have demonstrated that decisions not (yet) to give pain relief cannot be necessarily understood as a “failure to meet professional standards of care” [(2), 11] but may also constitute an act of caring. My analysis suggests that defining what “bad” or “good” maternity care consists of in terms of singular (non-)interventions may not be sufficient. The concrete and particular socio-material contexts have to be considered to understand better how “goods” and “bads” in maternity care are constituted.

Investigating situated midwifery care techniques allows to capture the specific and detailed qualities of what is done in particular childbirth situations. Thus, this contribution demonstrates how “investigating local minutiae might actually be crucial to provide general insight” [(98), 158]. This facilitates tracing midwifery care relationships as “the hidden threads in the tapestry of maternity care” (44), so they can be seen, meaningfully engaged with and further strengthened.