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The Death of Birth: A Critical Interpretive
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THE DEATH OF BIRTH: A CRITICAL INTERPRETIVE ANALYSIS OF SECOND WAVE
LIBERAL FEMINIST EFFORTS TO INFLUENCE WOMEN’S CHILDBIRTH EXPERIENCES
IN THE UNITED STATES DURING THE LAST THIRD OF THE TWENTIETH CENTURY

By

Elizabeth A. Bogdan—Lovis

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Interdisciplinary Programs in Health and Humanities

1995

ABSTRACT

THE DEATH OF BIRTH: A CRITICAL INTERPRETIVE ANALYSIS OF SECOND WAVE
LIBERAL FEMINIS'I‘ EFFORTS TO INFLUENCE WOMEN’S CHILDBIRTH EXPERIENCES
IN THE UNITED STATES DURING THE LAST THIRD OF THE TWENTLET H CENTURY

By

Elizabeth A. Bogdan-Lovis

Mid-twentieth century “second wave” liberal feminists responded to
concerns over increasing medical appropriation of women’s reproductive
bodies with directed efforts focused on an agenda of increased lay health
awareness through individual agency. This agenda assumed that increased lay
medical knowledge would ultimately equalize the asymmetrical power
relationship with health care providers, thus enabling women to make
informed choices. It was further assumed that given a choice, most women
would choose a demedicalized birth experience. A review the state of
medicalized birth at the close of the twentieth century suggests that such
efforts have largely been unsuccessful. Liberal feminist assumptions proved
to be naive regarding individual choice and individual control. Individual
health choices occur in a climate limited by institutional interests which serve
to limit available choices to those in the institutions own best economic and

political interests.

Copyright by
Elizabeth A. Bogdan-Lovis
1995

This thesis is dedicated to my parents and their partners, who have taught me
by example that living means a lifetime of learning, and to my partner Bill
who continues to both pursue and embrace a lifetime of learning with me and

with our children, Will and Rachel.

iv

ACKNOWLEDGEMENTS

This thesis has benefited from the advice and assistance of several
people. I appreciate the direction I received from committee members Dr.
Howard Brody and Dr. Patricia Mullan, whose collective insights into the
intricacies of the health care system served to improve my many thesis drafts.
I wish to extend a special expression of my gratitude to co-chairs, Dr. Judith
Andre and Dr. Maxine Baca Zinn. Their professional dedication to student
achievement is selfless and noteworthy. I continued to realize how much I
had learned from both of them through every step of the production of this
work.

I will always be grateful to Dr. Peter Vinten-Johansen, founding father
and former director of the Interdisciplinary Programs in Health and
Humanities for his guidance, his support, and his daily modeling of the virtue
of social responsibility. My thanks also goes to the current director, Dr. Tom
Tomlinson for his continuation of this support.

The idea for this thesis grew out of the ongoing struggles experienced
by a forthright and dedicated group of women who saw then and continue to
see that the transformative experience of childbirth can be an empowering
and self-affirming event in a woman’s life. Without the many long, heartfelt
and passionate discussions with Kip Kozlowski, Susan Ekstrom, Katchen
Schibilsky, and Lynette Biery, this thesis would not have been realized. My
thanks to my sisters.

Finally, my heartfelt gratitude goes out to my mentor and life partner,
Bill, and to our children. Their continuous support and encouragement

allowed me to pursue my goals.

Chapter 1.
Chapter 2.

Chapter 3.

Chapter 4.

Chapter 5.

Chapter 6.

TABLE OF CONTENTS

INTRODUCTION

THE UNDERLYING STRUCTURE OF MY INQUIRY
Background

Justification for Research

Assumptions

Methodology

Background on My Childbirth Classes

MEDICALIZED CHILDBIRTH: A BRIEF REVIEW OF ITS
INCEPTION AND DEVELOPMENT

Review of the Liberal Feminist Response to a Growing
Awareness of the Medicalization of Women’s Lives

AN OVERVIEW OF FOUR ANALYSIS OF THE MEDICALIZATION

OF BIRTH BY SELECTED FEMINIST SOCIAL SCIENTISTS
Forced Labor: Maternity Care in the United Statfi
Nancy Stoller Shaw

Men Who Control Women’s Health: The Miseducation
of Obstetrician- Gynecologists

Diane Scully

In Labor: Women and Power in the Birthpla_c_e_
Barbara Katz Rothman

Birth as an American Rite of Passage
Robbie Davis-Floyd

TWO BIRTH ST ORIFB
Susan’s Story
Jane’s Story

Birth Story Analysis

SOCIALIZATION, TECHNOLOGY, POWER, AUTHORITY,

AND CONTROL: THE INFLUENCE OF LIMITING VARIABLES
An Example of Pain in Labor

A Critical Interpretation of Susan’s Birth

A Critical Interpretation of Jane’s Birth

Insight Gained From a Critical Interpretation of Liberal
Feminist Efforts

vi

28

33
33

37
42
45

&&

52
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8 d$$fl

Chapter 7. CONCLUSION
ENDNOTFS
BIBLIOGRAPHY

vii

98$

93

CHAPTER 1
INTRODUCTION

Second wave feminism, having its inception in the 1960’s, had then and
continues to have many faces (Grant 1993). In this thesis I first describe and
then critique the efforts of what 1 term liberal feminists; those who sought
modification of the social order through manipulation of the existing order.

Liberal feminists,

...maintained that the women’s problem was...ideological [and] it
could be effectively countered by a program that combined
persuasion, reeducation, the provision of “role models” and the
development of pressure groups. Liberal feminists see the social
subordination of women reflected in the sexual structure of the
organization of medicine, i.e., in a field where women are the
majority of health care workers, the upper reaches of the
medical hierarchy constitutes a virtual male monopoly...another
area of criticism concerns the nature of the doctor/ patient
interaction. [Male] physicians heal (or do not heal) from a
position of power; they relate in either a paternalistic or an
authoritarian manner to their patients...(Fee 1983: 19).

The liberal feminist critique thus approached problems of women’s medical
care at the point most visible and presumably accessible to middle— and upper-
middle-class individual women - as consumers. This View offered less to
female staff persons whose work maintained the everyday functioning of the
medical system, and less to underserved women from historically marginalized
populations for whom medical care was often unavailable and, who commonly
suffered from conditions of deprivation and abuse in everyday life.

In the reproductive arena of childbirth, such an approach focused on a

concern over the increasing medicalization of birth. Second wave liberal

1

feminists questioned benefits realized over such excessive medicalization.
They addressed such concerns by challenging the basic assumptions of the
medical model of birth, which were based on a representation of the female
body as both unpredictable and unreliable and in need of constant
surveillance, maintenance, and repair. Second wave liberal feminists thus put
forth an agenda that suggested the solution to the increasing medicalization of
birth was to manipulate the following three variables, 1) gender - suggesting
an increase the number of women physicians; 2) knowledge - suggesting an
increase in lay women’s birth knowledge; and 3) socially constructed
expectations - attempting to influence the birthing woman’s expectations of
the birth experience to include a demedicalized event. Such an agenda was
inattentive to conditions of everyday life for women from historically
marginalized populations. Moreover, the agenda proved to be naive
regarding the potential for individuals to either control or to influence their
“choices” in health care delivery.

In this thesis, I assume a social science critical interpretive approach,
which has a “commitment to understanding the distribution of power and
wealth and its effects on health and healing" (Morgan 1990: 945). As

explicated by anthropologist Merrill Singer:

Critical medical anthropology maintains that discussion of
specific health problems apart from macrolevel political and
economic issues only serves to mystify social relationships that
underlie environmental, occupational, nutritional, residential,
and experimental conditions...Importantly, the ultimate origin of
these problems is not environmental or biological but social,
namely the existence of inherently oppressive social
relationships of production and expropriation (Singer 1986: 129).

With this approach, I first critically review the history of medicalized
childbirth in the United States. I then follow this historical review with an
examination of how certain selected second wave feminist social scientists
exposed the failings of medicalized birth in delivering optimal care to
parturient women; all of the scholars utilized a comparative analysis of
alternative models for childbirth management to reach their conclusions. I
use their findings as a lens by which to further examine a range of second
wave efforts in the area of childbirth,with a special focus on those efforts
characterized as liberal feminist. I pay careful attention in this examination
to those suggested correctives by the respective author’s which manifest
liberal feminist assumptions. In doing so, I set the stage for the next part of
my work which is a critical interpretive analysis of the birth stories from two
women who had attended my childbirth classes with a desire to minimize
medicalization in their respective birth experiences. The resultant analysis of
their failure to achieve such a desired demedicalized birth, reveals the
hegemonic influence of the professional-medical-industrial complex in
controlling the limiting factors which constrain women’s birth experiences.

In my conclusions, I offer my assessment that liberal feminists stopped
short of putting forth an agenda which could indeed truly demedicalize
women’s childbirth experiences, that of birthing outside of the institution of
the hospital utilizing birth attendants other than physicians (midwives). This
paper critically assesses the influence and coercion of power, economics, and
politics in shaping the norms of social behavior and social policy in childbirth

practice.

CHAPTER 2
THE UNDERLYING STRUCTURE OF MY INQUIRY

Background

What should a normal birth be like for healthy women in the United
States? This question merits attention for many reasons, but certainly access,
safety, cost, and quality of experience are variables to be considered. The
dominant model of birth in the United States, the medical model, is based on an
assumption that birth, regularly, is essentially a pathological event;
sufficiently complicated and dangerous to warrant a hospital setting, a
plethora of technology, and a physician in attendance. Equally, it is believed
that medical intervention will optimize the health of the baby as it is travels
through the dangerous and unpredictable journey of birth. Consequently the
goal of the medical model of birth is to theoretically insure that all birthing
women have access to a hospital and are attended by a physician who is in
turn, supported by the latest available birth technology. Yet, beginning as
early as the 1940’s, research which questioned the efficacy of this model
began to surface (Dick-Read 1944).

Childbearing women became concerned about the potentially harmful
side-effects of particular technological and pharmacological “tools” regularly
employed by physicians. Specifically, their concerns were focused on the
risks to the baby from interpartum use of anesthesia for the mother, and the
use of forceps, a mechanical spoon-shaped device used to assist in pulling the
baby out of the birth canal. The use of forceps in delivery was

frequentlymade necessary by administration of anesthesia to the birthing

4

woman, as the anesthesia diminished the woman’s ability to actively
participate in pushing the baby out of her body. It was this concern on the
part of childbearing women over the potential technological and
pharmacological risks to their babies which paved the way for the
introduction of the consumer model of “prepared childbirth” (Lamaze 1956;
Karmel 1959).

Prepared childbirth was a popular strategy implemented by middle- and
upper-middle—class women to prepare women for the experience of childbirth
and was intended to teach women breathing strategies to cope with the pain of
labor and thereby minimize a reliance on anesthesia. It was also intended that
this strategy, when combined with a rudimentary knowledge of the anatomy
and physiology of birth, would provide a means whereby laboring women
might more fully participate in both the control of labor pain and in decision
making during the birth process.

Toward the end of the decade of the 1960’s and into the early 1970’s a
convergence of three distinct but related “grass-roots" movements occurred:
1) second wave feminist efforts to regain control of women’s bodies from
medical appropriation through access to reproductive freedom and
reproductive control, 2) “natural childbirth” efforts designed to encourage
women to experience childbirth without pain-relieving drugs, and 3) the
consumer movement which encouraged self-help efforts, second opinions and
health care shopping (Matthews and Zadak 1991). While this convergence was
neither easy nor uncontested,1 among the many efforts it spawned was one
intended to demedicalize the birth experience. As the focus on women’s
reproductive care broadened, concerns surfaced which questioned the

dramatic escalation of technological and pharmacological intervention in

women’s childbearing experiences. Feminist research proliferated which
questioned the benefits of technocratic, that is to say institutionally controlled
and technologically dependent hospital birth, over the risks to both the
mother and the baby.2 By constructing a social platform on this research,
second wave liberal feminists used childbirth preparation classes as a tool to
more fully educate women about not just the anatomy and physiology of labor
and birth, but also to educate them about the range of alternative choices
which were theoretically available to manage childbirth and its attendant
pain. Certain of the available liberal feminist childbirth preparation classes
retained controlled breathing strategies as the mainstay of labor control,
others modified it, while still others rejected it entirely. The new enhanced
agenda advocated by liberal feminists included strategies for conflict
resolution, positional maneuvers for pain management, both positional
maneuvers and strategies which attempted to enhance the progress of labor,
techniques to avoid an episiotomy, and many other such manipulative
techniques. It was felt that knowledge was power, and that the transfer of
such knowledge regarding birth management to pregnant women would serve
to equalize the asymmetrical and hierarchical power equation with health
care providers.

Through such resistance to the dominant, technocratic model, a variety
of alternative models surfaced. While some feminists rejected the
institutionalized model entirely and opted for homebirth, others sought care in
the few available out-of-hospital birthing clinics. However, by far the most
common and socially acceptable model was to attempt to manipulate the
existing institutional birth experience. Built on a modification of the medical

model, this approach maintained that change was to be accomplished through

the manipulation of the gender of the health care provider, followed by
increasing the birth knowledge of the pregnant woman and influencing her
birth expectations. Using gender arguments, liberal feminists advocated that
women as health care consumers seek care from woman physicians over male
physicians. Using the model of an educated and aware consumer, they
advocated educating pregnant women so that during labor and delivery, the
laboring woman could choose to construct the birth experience in such a way
as to meet her own individual preferences; and with altered expectations,
liberal feminists sought to reframe childbirth from an experience that was
fraught with potential pathology and danger to one that was a normal,
healthy, and powerquy transformative part of a woman’s life. Another goal
of this multifaceted alternative model was to theoretically insure that women
had access to either a female physician, or at a minimum, a male physician
who embraced the liberal feminist childbirth agenda. Further, this model
assumed that such a provider would thus be willing to honor the birth plans
articulated by a pregnant woman who was both educated about available
childbirth management choices, including alternatives to standard
technological, pharmacological, and surgical management, and who was,
moreover, willing to make these choices.

When this alternative model was introduced in the late 1960’s it received
a great deal of media coverage which heralded its benefits to both the mother
and the baby. In reality, however, it enjoyed very limited success for a very
select and privileged population of women.3 The women who were able to
fulfill the model’s expectations were largely middle— and upper-middle-class
women who had available to them, 1) the time to attend childbirth classes, 2) a

husband or close friend who was willing to provide labor support to them, 3) a

hospital which would allow such a support person into the labor and delivery
unit, 4) a supportive physician, 5) the self-determination necessary to avoid
the potential risks of anesthesia through distraction breathing techniques,
and finally, 6) a labor and delivery which met the care provider’s
expectations of normal (Nelson 1983). Certain aspects of the model, such as the
breathing gymnastics and a patient-supplied labor support person, did indeed
garner a great deal of credibility within the hospital setting and won
enthusiastic support from hospital staff. Yet, ironically, these two strategies
served hospital needs well by making women better patients; it made the
laboring women quieter and also had them assume the responsibility of
bringing their own labor support person (Shaw 1974). Notably, over this same
period of time, the rate of technological and surgical intervention in birth
increased dramatically (Arms 1975; Corea 1977; Marieskind 1979). Today,
despite thirty years of liberal feminist effort to demedicalize childbirth in the
United States, the dominant model of childbirth continues to be the
technocratic medical model. This thesis will explore why liberal feminist

efforts have failed to achieve their goals.

Justification for Research

If liberal feminist criticism of the medical model was justified, if routine
technological and surgical intervention was unnecessary for normal healthy
women, and if an alternative model existed, then the demedicalization of
childbirth in and of itself continues to be a worthy goal; and likewise critical
evaluation of past efforts to achieve this goal ought to prove valuable in
influencing the direction of future efforts. Careful examination of the maxims

girding past liberal feminist efforts, individual choice and individual control,

ought to be useful in revealing the inherent weaknesses in such an approach.
Furthermore, the demedicalization of childbirth in the United States could
potentially have significant and far-reaching beneficial consequences world-
wide.

Modernization pressures for full assimilation and proliferation of the
technocratic medical model of childbirth as the “ideal type” is currently
viewed as desirable by a professional-medical-industrial complex which
controls the birth experience, including the medical profession, the legal
profession, and the insurance and health care industries (Starr 1982). The
power inherent in this corporate endorsement influences the treatment of
pregnant women not only at the local and national level, but also at the
international level. Health care delivery in the United States is held up as an
ideal model for health care implementation on an international scale (Kay
1982). Hence, the way that childbirth is managed in the United States has
influenced and will continue to influence the way childbirth is managed for
the rest of the world (Jordan 1993).

Technocratic birth is also very expensive. Obstetrics as currently
practiced in the United States monopolizes an unwarranted and excessive
portion of the limited health care dollar pie, without contributing in an
equivalent manner to meet the health needs of women and children (Lazarus
1988). In 1987, the United States ranked 22nd in neonatal mortality statistics
(Collaborative Position Paper from the Women’s Institute for Childbearing
Policy 1994). The unmet needs of the underserved substantially contribute to
this unfortunate statistic.

Attention to ethical considerations is also an important consideration.

The need for careful adherence to the medical maxim “First of all, do no harm”

10

continues to provide an important yardstick by which to evaluate the worth of
medical effort. Efforts to objectify and scientifically measure normal life
events such as childbirth have created cultural, social, and psychological
barriers which ultimately serve to disrupt such life events (Davis-Floyd 1994:
1125). These barriers have served to constrain and negatively influence the
most often, non-pathological course of normal labor and birth. It is thus that
the underlying assumptions of Western birth had created a self-serving
ideology.

Childbirth as it is occurs in the United States is controlled by and is
responsive to the needs of major power groups, which control the
environment defining women’s health needs. Elaborating on Irving Zola’s
classic essay which revealed how medicine had became a twentieth century
tool of social control, sociologist Diane Scully noted how physician’s social
status as experts led to “almost unprecedented power over people’s lives”
(Scully 1980: 20). Rather than offering women the opportunity for greater
autonomy, more advanced technological tools in childbirth provide the
dominant culture of childbirth, the medical model, with greater access to
control (Jagger 1983).

The current medical model of birth as practiced in the United States,
with its accompanying average cesarean rate of 25%, deserves critical
examination. “Rates well below 10% have been maintained in some other
developed nations (and as low as 1.3% in certain practice settings) without any
demonstrated compromise in maternal and fetal outcomes” (Berwick 1994).
The burden of proof for its standard of excessive surgical intervention lies
with the medical model. It is clearly time to ask why this model has

perpetrated a climate of social acceptance for aggressive and unnecessary

11

intervention. As Brody and Thompson noted in a 1981 article in the Iournal of
Family Practice “although the use of sophisticated technology may be
appropriate for some high-risk birth, few interventions have been proven
effective in routine use.” Monies spent on sophisticated, unnecessary and
potentially dangerous invasive procedures would be much better spent on
truly high risk pregnancies where it i__s_ warranted (Rapp and Ginsberg 1991),
or conversely on public health measures to improve the general health and
living conditions of underserved mothers and babies in the United States
(Collaborative Position Paper from the Women’s Institute for Childbearing

Policy 1994).

Assumptions

This analysis is based on a number of basic operating assumptions. The
first is that major institutions are ultimately (but not exclusively) motivated by
economic forces; that is to say institutions have in their own best interest,
control of both the production of and access to limited or scarce resources.
Second, as a society based on a value of equal opportunity for all we, in the
United States, are uncomfortable in both the recognition and open discussion
of how this maxim applies to the institution of health care delivery (Arney and
Bergen 1984). Third, that technocratic, institutionally controlled, medicalized
birth is a manifestation of the social control of women (Conrad and Schneider
1992).4 Fourth, that the benefits realized by the use of technological,
pharmacological, and surgical intervention in birth for healthy women do not
justify the risks involved, or the harm done, by their routine use (Stoller Shaw
1974; Ruzek 1978; Scully 1980). Finally, that while a morally just burden to

those occupying a privileged social role is the social responsibility to be

12

attentive to the needs of those less-privileged who stand to either benefit of to
be disadvantaged by one’s efforts, self-interest in gaining access to limited or
control of scarce resources frequently creates barriers to assumption of this

responsibility.

Methodology

Employing triangulation, whereby a combination of methodological
strategies are used to enrich one’s analysis, I rely on two combined research
methods to guide my interpretation of the forces negatively influencing
women’s control over their childbirth experiences. My first method is
interrogatory. Through a series of three focused questions I examine four
scholarly texts spanning the last third of the twentieth century in the United
States each of which analyzes the medicalization of childbirth. In these texts:
Forced Labor: Maternity Care in the United States (Stoller Shaw 1974); Mill
Who Control Women’s Health: The Mi§education of Obsteuician-Gyaecologists
(Scully 1980); Giving Birth: Alternatives in Childbirth (Katz Rothman 1984);5
and Birth as an American Rite of Pasgge_ (Davis-Floyd 1992) the authors
deconstruct the medical model of birth from the vantage points offered by the
two disciplines in my areas of concentration: anthropology and sociology.

Using the authors’ respective analyses, the following questions inform
my own analysis.
1. What is the disjuncture between the authors’ insights on the social
construction of the American birth experience and the continuing and
rapidly accelerating rate of intervention in childbirth experienced over the

past thirty years, i.e., what really influences and controls the experience?

l3

2. Why have the insights offered in the respective analyses failed to
reverse the trend towards the ever-increasing medicalization of childbirth.
Indeed, over the past thirty years, the kinds of technological intervention
have become more subtle and more profound.
3. Why do certain of the authors’ suggested correctives either fail to
respond to or respond in a conflicting and at times paradoxical manner to the
intersecting limitations of race, class, gender and social location on women’s
birth experiences. This question is intriguing since, as social scientists, all
four authors recognize these limitations within their respective analyses.
These four books were chosen because they not only approach the
subject from a feminist social science perspective but, moreover, because each
of the texts moves from a description of the problem: the increasing
medicalization of women’s birth experiences, arising (as the authors
explicate) in part from individual women’s gender-influenced lack of power
and knowledge in an institutional setting, to suggestions for strategies to
implement subsequent changes. That is to say, these four books each bridge
theory and application.

In the second methodological strategy, I shift focus to my own personal
application of liberal feminism in childbirth preparation. Examining my
efforts as a prepared childbirth educator, I undertake an ethnographic
analysis using observations I made as a participant-observer in the birthing
process. These observations are illustrated through a retrospective analysis of
two birth stories which have been reviewed by the subjects for historical
accuracy. I do not maintain that the selection of birth stories is fully
representational of either the range of experiences of the women who took my

classes, or of the average experience. I choose them instead, to illustrate my

14

interpretation of certain selected contextual dynamics involving women who
participated in childbirth preparation classes with the intention of achieving
a non-technocratic childbirth experience. The dynamics involved in these
two narratives fig representational of those dynamics related by women in my
childbirth classes. I critically interpret the medical model management of the
two selected birth narratives by considering other management options for
each of the labors. I include in these alternative considerations midwifery
strategies for normal birth. Through this comparative analysis I reveal the
limitations of the liberal feminist approach in addressing the medicalization of
birth. With these same two birth analyses, I address the way in which the
information and strategies which I offered in my childbirth classes proved to
be ineffectual to the women in their attempts to demedicalize their respective

birth experiences.

Background On My Childbirth Classes

From 1979 to 1990 I taught childbirth preparation classes in a mid-size,
midwestern urban area. This study focuses on the last eight years of this
period when I was self-employed as an independent childbirth educator. The
women who chose to attend my classes were a multiracial, multiethnic, and
multicultural group. In fact, other than that the women who attended my
classes had voluntarily chosen to do so, and were pregnant, healthy, and
anticipating a normal birth experience (I will discuss this aspect in greater
detail later), my classes attracted a surprisingly representative sampling of
the diverse population of women in the United States. This included: the
unemployed, blue collar, pink collar and white collar workers; married and

unmarried teens, and married and unmarried adults; lesbian women who had

15

conceived through artificial insemination and married women who had used a
range of artificial reproductive technologies to conceive; rural and urban, full
or part-time homemakers; students and professionals. Approximately half of
my clients had learned of my classes through referral from their physician or
midwife, while the others had learned of them through word of mouth from
friends; often previous clients of my classes. Commonalities which lent
cohesion to this variable group were that (as reported by the pregnant
women), they were healthy, they desired to have some combination of their
partner, friends, or family members present at the birth in order to provide
labor support, they believed that the classes provided relevant birth
information and that this information would give them and their support
persons the skills necessary to guide the birth experiences in the ways they
desired, they were concerned about losing control, and they were seeking to
have a normal birth experience.

The term “normal birth” is subject to various interpretations. However,
a summary definition of the philosophical translation of the term as used by
these women is that they believed that childbirth was a normal physiological
event in a woman’s life that does not usually require medical attention.6 With
the exception of rare, unforeseen, and extreme circumstances, they felt that
normal birth required a supportive, safe environment, and the ministrations
of a competent birth attendant. For some women, this personal philosophy
translated into plans for giving birth in a hospital with a specialist (obstetrician-
gynecologist) in attendance. The women who made such a choice saw this
arrangement as one which allowed for a medical-specialist’s response to the
possibility of unforeseen emergency. For others, this philosophy meant

giving birth at home with a midwife in attendance. For the majority of my

16

clients, however, it meant birthing in a hospital with a primary care provider;
usually a family practitioner. For all the women, it meant that they were
highly motivated to give birth with a minimum of technological and
preferably no surgical intervention. The women believed that by actively
participating in my childbirth preparation classes, they would ultimately be
able to control certain aspects of the birth experience.

It was also the particular personal expectation of a normal birth
experience that brought them to my classes. The information I offered, my
teaching style, the message and content of literature I chose to distribute, and
the slides I showed reflected this same liberal feminist philosophy. I believed
that for healthy women childbirth was indeed a normal, non-pathological,
physiological event. While the event undeniably included an element of risk
for both the woman and the baby, in normal, healthy women, I believed the
element of risk to be minimal. Hence, I rejected the tendency to rank
pregnant women within a “risk” category and then to manage them
accordingly.7 I believed that for healthy women, physiologically sound and
morally responsible normal birth rarely required anything more than careful
and caring attendance by trained professionals.

As such, I saw my role as that of a consumer and health educator, and in
this capacity I felt my primary responsibility was to encourage the women in
healthy life habits, to educate them about the expected normal physiological
events of birth, and to inform them as to the range of choices available in
their preferred mode of birth such that they could participate in decision-
making throughout pregnancy, labor, and birth, with their health caregivers,

in order to actualize their model of normal birth.

l7

Influenced by the second wave feminist focus on consumerism and
health as manifested in such popular texts as: Our Bodies, Ourselves: A Book By
and for Women (Boston’s Women’s Health Collective 1973), and Immaculate
Deception: A New Look at Women and Childbirth (Arms 1975), I believed that
decision-making was a matter of knowing one’s options, and then making
one’s choices, that is to say, informed choice.

It was as a consequence of my teaching experiences that the problem I
chose to address in my thesis emerged; I came to realize that my teaching
strategies were ineffectual in achieving my pedagogical goals. In the eight
years of teaching as an independent educator, a pattern of change emerged
from my client’s birth reports. The pattern was that of a significant increase
in the incidence of technological and surgical intervention in the women’s
birth experiences. Specifically, an increase occurred in the use of aggressive
labor management (artificial rupture of membranes, pitocin augmentation),
analgesia and anesthesia (especially the use of epidurals), the electronic
monitoring of labor, and the incidence of episiotomy and cesarean deliveries.

As the women told their birth stories at the final postpartum class
session, they continued to espouse the model of normal birth which originally
drew them to my classes, explaining their personal failure to adhere to the
model as an unfortunate yet unavoidable consequence of some combination of
their own or their baby’s anomalous physiology or circumstances. They
expressed their beliefs that “in their case” the intervention(s) were
unquestionably necessary as ascertained and advised by the certain,
unquestionable judgement of their chosen provider. Provider judgements
were reportedly reached after assessing the abnormal deviation of a particular

labor or delivery from the sequence or timing of events expected in normal

18

birth. The determination of the need to intervene, either technologically,
pharmacologically, or surgically, was usually reached after assessment of a
particular labor’s deviation from the expected normal sequence or timing of
events, which, in turn, served to influence the choice to avoid pain,
uncertainty, or danger. As such, the determined deviation in turn served to
influence subsequent choices to avoid further pain (opting for analgesia and
anesthesia), uncertainty and danger (opting for aggressive labor management
including electronic monitoring, artificial augmentation of labor, and minor
or major surgery).8 Commonly accompanying these reports were stated
convictions that the information offered by their chosen providers leading to
the decisions to intervene, was soundly based on objective, scientifically
proven or experientially substantiated clinical certainty (Irwin and Jordan
1987).9 Only on very rare occasions, was the sequence of unforeseen events
reported to have been influenced by subjective, perhaps uncertain
information offered by a provider, hospital staff persons, or labor support
persons.

In the telling of their birth stories the women in my classes most often
claimed personal responsibility for the consequences of listening to
professional advice, and the decisions they subsequently made. In fact, to the
best of my knowledge, over the tenure of my teaching there were no lawsuits
filed by my clients against doctors, hospitals, or midwives. 10 In summary, my
clients continued to espouse the model of normal birth, but felt that “their”
particular birth or “their” particular baby was anomalous; an exception to the
model of normal birth. Moreover and importantly, largely as a consequence
of their participation in informed decision making, they usually assumed

personal responsibility for the outcome. Reports of a particular technological,

19

pharmacological, or surgical intervention were often accompanied by
disclaimer phrases citing absolute certainty and conviction that the
intervention was appropriate, was the “best” choice or the “only “choice to be
made at the time. My clients used such verbal descriptors as “I was ready...I
knew that it had to be this way...l wanted it...”

From my vantage point as a participant-observer, I most often did not
interpret the reported events in the same way as my clients. On a personal
level I began to suffer from cognitive dissonance; what I observed did not fit
what I believed. If I was to keep my model of normal birth intact, what
accounted for such a noticeable growing pool of pathology in my pregnant
clients? I was drawn to critically explore this paradox.

Through a reading of current literature, and attendance at childbirth
education teacher’s conferences, I was aware that the pattern of increased
intervention occurring with my clients mirrored a national trend. Intrigued,
I began to explore a number of possible influences to account for my local
microcosm’s reflection of the national picture. Staunchly clinging to my firm
belief that individuals can indeed exert control over the circumstances of
their baby’s births, I started with the two easiest and most obvious possibilities:
perhaps I had modified my teaching style, or perhaps my clients had changed.
Through careful review and evaluation of my teaching materials, my teaching
style and my clients profiles, it did not appear that either of these alternatives
could account for the observed change in the rate of intervention. Moreover,
as reported by my clients, they did not feel to be the victims of coercion. They
believed they were exercising their autonomous free will by making clear,
informed, and uncoerced choices in birth situations totally unique to

themselves and to their babies.

20

On occasion, I was invited to attend a client’s birth in order to assist in
labor support. From this participation and from the birth stories told at each
class’s final postpartum class meeting, I drew other conclusions. It was thus
that the model of normal birth which I espoused became increasingly more
vulnerable over time to a contradictory observed reality, further motivating
me to try to effect changes in my client’s birth experiences.

Consequently, I began to seriously question the accuracy and
effectiveness of the liberal feminist consumer education model of informed
choice in its attempt to help women avoid a medicalized birth experience. My
childbirth education classes were predicated on the liberal feminist
assumption that relevant education and knowledge could lead to increased
control over the birth experience. Yet as I listened to the birth stories, I was
compelled to confront my own failure. Equally, I felt a growing concern
regarding my inadvertent collusion with a system that l opposed. I modified
my teaching style regarding the issue of the patient/provider relationship,
from one which encouraged women to “shop” for a provider who shared their
values in order to establish a relationship of trust, to one which encouraged
my clients to view their providers with what I regarded as a healthy dose of
critical realism.

Certainly all parties involved sought a good outcome, a healthy mother
and a healthy baby; but it was clear that there was a great conflicting
disparity of opinion about how this goal was best achieved. Yet the language
used in the birth reports belied this disparity. As the clients told their stories,
they discussed consensual decision-making between themselves and their
providers. Since I believed the level of routine intervention to be excessive, I

no longer used role plays as I had in the past, to illustrate informed consent

21

scenarios. Instead I used them as opportunities to more accurately describe my
interpretation of the dynamics, which was that of “informed disclosure.”11 I
concluded that the term “informed disclosure” was more fully

representational of the actual dynamics involved, which, from what I had
observed first hand and from what I deduced listening to the birth stories was
more like “Now, I’m going to tell you what I’m going to do to you.”12 Providers
regularly supported informed disclosure information with further detailed
and sometimes graphic information on what they perceived to be possible
(read likely), worst case scenarios, if the proffered advice was not followed
(Brody 1982). Further, the providers often used statistical information to
support the menu of choices in light of perceived risks. Information framed
by statistical data influenced my clients in two ways. One, they were certain
that the information was surely grounded in scientific fact (Irwin and Jordan
1987); and two, the mention of risk usually persuaded them to comply with the
suggested regimen or course of action. When the women told their birth
stories, they often added emphatic phrases lifted from the interaction with
their providers that they (the women) believed imbued indisputable validity to
and corroborated the certainty of such information. Examples of
corroborating phrases such as , “If I were you...,” “If you were my wife...,”
“I’m concerned about the baby...” were related by the women as they told their
birth stories.

Thus, in my classes, I discussed the realities of liability dictating
practice and judgement; the seductive appeal of technology to both patients
and providers and, moreover, its revered place in a courtroom, and the
exigencies of imposing time limits on the stages of labor (LoCicero 1993). Yet,

to my great surprise, my clients responded to these suggestions with a degree

22

of animosity and disbelief. They loyally defended their respective provider’s
various positions and actions, expressing their own certainty that what their
respective provider offered was the 1313; and most current information,
reflecting sound judgement, firmly grounded in science buttressed by clinical
experience. Moreover, to defend their stance, my clients would often cite what
they viewed as a shared philosophy of normal birth between themselves and
their provider. This conviction was particularly strong if the provider
referred to my classes, in that the referral was viewed as evidence supporting
a perceived collective shared philosophy which it was further believed must
certainly translate into practice.

Stymied by my own failure to effectively assist women in obtaining a
normal birth experience, I decided to stop teaching and to try to understand
this puzzle of events from a different approach. To this end I entered the
Interdisciplinary Program in Health and Humanities and chose as my areas of
concentration the disciplines of Anthropology and Sociology. I did this so as to
explore the social construction of childbirth within in the United States as it

has occurred in the last half of the twentieth century.

CHAPTER 3

MEDICALIZED CHILDBIRTH: A BRIEF REVIEW OF ITS INCEPTION AND
DEVELOPMENT

American women routinely labor within the institutional confines of a
hospital, attended by nurses who are women, who are in turn assisted by all
sort and shapes of machines of varying levels of technological complexity.
The standard American birth presently occurs, with only rare exception,
within these same institutional confines attended by clinically trained medical
professionals, who are, most commonly, male physicians. Critical assessment
of historical factors leading up to this current cultural construction reveals
the influence and coercion of power, economics and politics in shaping the
norms of social behavior and social policy in childbirth practices (LoCicero
1993). A review of the history of the medicalization of birth provides
insightful clues into the development of current Western birth practices;
practices which are intimately linked to the rise in dominance and authority

of the medical profession.

At a deeper level, a...theory is that the male acquisition of the
domination of childbirth and society’s acceptance of this
situation represent a fundamental counter—attack on the female’s
strivings and achievements along the road towards political and
economic equality. Cynics see this as a salutary demonstration
that inroads into man’s territory have been accompanied by the
surrender of her own, woman’s territory - a universal
acknowledgement of her essential subservience (Tew 1990: 19).

24

The history of the transition of birth from home to the hospital and the
transition in birth attendance from midwives to physicians while complex, has
been extensively documented (Wertz and Wertz 1989; Waltzer Leavitt 1984;
Donegan 1984; Schrom Dye 1984; Edwards and Waldorf 1984; Bogdan 1978;
Donnison 1977; Barker-Benfield 1976; Ehrenreich and English 1973). For the
purposes of this thesis, I will provide only a very brief and admittedly partial
overview drawn from these histories. This overview will highlight issues of
medical ideology and medical self-interest, and will also examine how these
two aspects served to increasingly restrict women’s birthing options to those
available within the medical model.

In the United States, the medical model rose to prominence by replacing
homebirth, a model whereby women gave birth in their homes, sometimes
aided by family and friends, but most commonly aided by an experientially
trained female midwife. While midwives typically were informally rewarded
for their assistance through bartering and reciprocity, providing expertise in
childbirth assistance was not part of a formal market economy (Wertz and
Wertz 1989; Waltzer Leavitt 1984; Ehrenreich and English 1973). Childbirth
was first of all a personal, and then a social event. Information on childbirth
was part of an informal social exchange network.

As historians document, the end of the nineteenth century witnessed
ever increasing restrictions being placed on the practice of midwifery as
barber-surgeons strategically maneuvered their way into what has become, at
the close of the twentieth century, nearly a complete monopoly of the birth
market by the medical profession (Wertz and Wertz 1989; Waltzer Leavitt 1984;
Donegan 1984; Schrom Dye 1984; Wertz and Wertz 1977; Ehrinreich and English

1973). A common popular assumption is that a decrease was realized in the

25

incidence of maternal and fetal mortality and morbidity in the late 1800’s and
happened as a consequence of physicians assuming control over the
management of childbirth (Wertz and Wertz 1989; Donegan 1984; Schrom Dye
1984). Historical scholarship on the high rate of maternal mortality and
morbidity associated with barber-surgeon’s “meddlesome midwifery”
disproves this assumption. Professionally trained midwives who offered home
birth services, such as that which was available through the Frontier Nursing
Service13 had lower mortality rates than most hospitals of the time (Schrom
Dye 1980). Real benefits in improved health status were not realized by
pregnant women until the time of World War II. Again, as noted by Schrom
Dye (1984) “early twentieth-century comparative investigation of physician-
and midwife-managed births...found that midwives had fewer maternal deaths
than general practitioners.” Research in the 1840’s by Hungarian physician,
Ignaz Semmelweis on pathogen transmission by doctors from cadavers and ill
persons to the laboring women causing a high rate of iatrogenic puerperal
sepsis (childbed fever) did not influence physician practice in the United
States until 1885 (Scully 1980: 31). It was also “the increasing practice of
confining women to lying-in hospitals [that] heightened the probability of
spreading infection” (Scully 1980: 31). In the 1920’s 40 percent of all maternal
deaths were due to puerperal sepsis (Schrom Dye 1984).

The end of century trend towards the increasing social power of doctors
and the decreasing availability of midwives was followed by a post-Flexnerian
increase in number of large teaching hospitals and the firm entrenchment of
the power and authority of physicians. Women in their childbearing years
were actively solicited as patients since they were viewed as the gatekeepers

who provided access to the entire family as potential patients. Indigent

26

women were able to obtain medical care either for free or for a reduced cost in
exchange for their use as teaching material for student physicians (Scully
1980: 34). A major population shift from rural to urban centers mandated both
an increase in efficiency in order to address health care needs from a
convenient central location, and a shift in reciprocity/ barter relationships
among those without access to an established social network to a market
relationship (Starr 1982). Moving the primary location of birth from the
home to the hospital had two major and far-reaching economic consequences.
First, the choice of available trained birth attendants became increasingly
restricted to recognized hospital providers who required a fee for their
services. Second, as a consequence of this restriction, access to available
sources of birth knowledge for pregnant women became part of this same
market economy. Anxious to participate in modern technological society,
women themselves supported the transition from midwifery attended
homebirth to hospitalization for all childbirth (Edwards and Waldorf 1984:
153). In 1910, 50% of births occurred within the home but by the 1930’s this
number had dropped precipitously (Scully 1980: 31; Schrom Dye 1984: 328).
Variations in this number occurred by ethnic group, by class, and by region
(Edwards and Waldorf 1984: 153).

When physicians moved to hospitals as the preferred location for
delivery of services, they brought with them the technological and
pharmacological tools sought by women: anesthesia for the pain of labor and
birth, and forceps for difficult births. Prior to World War II, half of American

babies were born at home (Waltzer Leavitt 1984: 141).

It was at this period of time that,

Obstetrician’s abandoned the philosophy of restraint..[and]
redefined normality in pregnancy and labour to justify the
widespread practice of antenatal, intranatal and postnatal
interventions, so that the need, as they perceived it, for most
births to take place in hospital became inevitable. And since
obstetricians, despite their vaunted skills, could never predict
with accuracy when a complication would arise, the sensible
precaution was to take every step to ensure that all births should
take place in their kind of hospital. (Tew 1990: 9).

As one of the many “war efforts” during World War II the government
placed a “cap” on wage increases. This cap opened the door for the addition of
health insurance benefits as an alternative job incentive offered to the
American worker (Starr 1982: 331). The influence of the market continued
as mid-twentieth century, prolific post World War 11 mothers became the
beneficiaries of third party payment for hospitalization, including maternity
care coverage. Thus, the baby boom generation was most often welcomed into
the world with forceps deliveries, a technique made necessary by the
anesthetized state of the mother, within hospital delivery rooms. By this
period, over 95 percent of births occurred within the hospital (Walzer Leavitt
1984). The sheer power of numbers served to feed and support the increase in
popularity of the medical model. Concurrent with the expansion of post-World
War 11 medical technology, birth rituals within the United States became
intrinsically linked with the growing medicalization of birth (Davis-Floyd,
1991).

First in Great Britain and Russia, and then in France, new strategies
arose for coping with the attendant pain of labor without relying on analgesia
or anesthesia. (Dick-Read 1944; Lamaze 1956; Karmel 1959). Introduced to

middle-class women in the United States through books and magazines, these

28

techniques attempted to teach women how to modify their response to labor
pain in order to remain “awake and aware” (Karmel 1959). Conventional
methods of childbirth preparation emphasized control, meaning control over
socially visible and audible manifestations of the pain of labor. While the
promise of diminished pain in labor was enticing, the suggested breathing
gymnastics encouraged in childbirth preparation manuals failed to diminish
the pain of labor. Instead this form of labor control encouraged the laboring
woman to be a better patient; teaching her to physically mask the pain and
muffle her urge to respond to it vocally (Stoller Shaw, 1974). The legacy of
control in childbirth was bequeathed to the next major group of women
attempting to attempt to influence the medicalization of childbirth.

As second wave feminists entered into their own reproductive years,
they became aware of the increasing medicalization of women’s lives focused
especially in the area of reproduction. The medical model’s representation of
birth as an inherently risky event authorized the social practice of aggressive
medical management. Metaphorically, the cervix became a portal which
provided access for societal commentary and the increased social control of

women.

Review of Second Wave Liberal Feminist Responses to A Growing
Awareness Of The Medicalization Of Women’s Lives

A range of complex descriptions exists on the ethos of second wave
feminism; what it was, what it is, and what it should be (Grant 1993).
Proponents of different manifestations of feminist ideology passionately and
fervently defend their wide-ranging agendas. In the 1960’s, the early

formation of feminist ideologies served to infuse energy, create solidarity, and

29

foster coalitions among the ranks, yet these same ideologies were
simultaneously influencing and influenced by shifts in power relations
serving to limit the types of feminist expression considered acceptable.

An important organizing principle in second wave feminism, was that
the personal was political (Grant 1993). This slogan referred to the revelation
experienced by women through participation in consciousness raising groups,
that oppressions which women experienced within their individual lives were
often a reflection of larger social inequities contributing to group oppression.
While the recognition that individual oppression was reflective of group
oppression was certainly true for many women, second wave feminist
spokeswomen who rose to the fore were largely middle- and upper-middle-
class white women. Given their relative race and class privilege, they focused
on issues of oppression relevant to their lives and their social location; issues
which were not necessarily reflective of the concerns of women from
historically marginalized populations. The "default" consciousness of majority
(White) middle- and upper-middle—class feminists (here on, referred to as
majority feminists) allowed them to draw up a second wave liberal feminist
agenda based on their concerns. These concerns commonly reflected their
privileged social location.

Consequently, the agenda described was largely that articulated by
majority feminists. Virtually every aspect of a woman's interface with
institutionalized reproductive care was reexamined by majority feminists
including sexuality, menarche, menstruation, menopause, routine well-woman
care, birth control, sterilization, abortion, prenatal and obstetrical care. While
this agenda certainly included specific areas of concern to minority women,

the major profile of the agenda emphasized majority feminist concerns. In

3O

particular, liberal second wave feminist correctives to problems of increased
medicalization of women’s lives were most often correctives believed to be
within reach for those who could exert a certain amount of control over their
own lives as a result of majority privilege.l4

Careful inquiry into women’s treatment within the institution of health
care revealed that the medicalization of women's reproductive lives offered a
vulnerable site for societal commentary on women’s lives and social control of
their behavior. Many feminist scholars undertook the task of deconstructing
the medicalization of women's reproductive health care (Haire 1972; Boston
Women’s Health Book Collective 1973; Ehrenreich and English 1973; Stoller
Shaw 1974; Arms 1975; Gordon 1976; Rich 1977; Corea 1979; Marieskind 1980;
Scully 1980).

Predicated on the belief that knowledge translated into power, and that
the transfer of knowledge about women’s health to women would serve to
equalize the asymmetrical and hierarchical power equation with health care
providers and the institution of health care, majority feminists saw it as their
responsibility to educate women about their bodies, their health, and their
health care choices. The resultant exposure of the social construction of
women's reproductive health encouraged women to resist in myriad ways.
Spawned by gender consciousness-raising sessions, incipient self-help groups
arose and advocated that women learn normal female anatomy and physiology
(including use of the technique of self-taught vaginal self-examination).
Women were also encouraged to learn about choices in health care such as
access to safe and legal abortion, choices in safe and available birth control,
choices in safe and normal childbirth and alternative healing modalities to

Western biomedicine.

31

Alternative models of reproductive health care also arose, as evidenced
by a variety of self-help health organizations which attempted to minimize
professional domination over women’s bodies by increasing lay knowledge of
reproductive functioning through grass roots ‘self-help” organizations. This
groundswell of lay health activity was manifested by the organization of
groups such as the Boston Women’s Health Book Collective, the Women’s Health
Forum-Healthright, the National Women’s Health Network, and the Feminist
Women’s Health Collective.

Closely linked to the mission of consumer education was another
orienting concept in this menu of concerns and that was the theme of
"choice." Liberal feminists stressed the notion that an important point of
interaction missing in doctor-patient encounters was information sharing.
The veracity of the "educate ourselves and wrest control" model went
undisputed. Central to the second wave liberal feminist effort were two
assumptions: first, that women need to assume the responsibility for educating
themselves, and second, that such an education would in turn lead to greater
control over their own health care. Majority second wave feminists were
largely at this time in their own reproductive years. They focused efforts on
acquiring information about reproduction. five It Your Way by childbirth
educator, Vicki Walton ( 1976) is an example of the simplistic “self-
determination” style of book which supported the notion that women need
only to educate themselves in order to be able to control the particulars of
their health care. It was felt that increased awareness and education would
yield greater control. But the lessons learned from the history of power
struggles reveal that “the beneficiaries of hierarchical reward systems yield

their privileges only when failing to yield is more costly than yielding”

32

(Reskin 1991: 155). The idea that women theoretically could, and indeed were,
exerting control over the circumstances of their births continued to enjoy a
high profile. Maintenance of such a high profile misled many women into
concluding that when they failed to achieve their goals of a “normal” birth,
this failure was due to deleterious individual anomalies and not to more
pervasive and manipulative institutional influences. Since it superficially
appeared that majority women were getting their health needs met,
maintenance of this same high profile also served to distract policy makers
from the attention needed by the health concerns and issues of women’s
everyday lives.

Thus it both was and is paradoxical that despite such feminist efforts, a
review of birth statistics spanning the last two decades of the twentieth
century reveals a zenith of technological, medical, and surgical intervention
in normal healthy women’s birth experiences. 15 The rate of intervention had
increased so dramatically that by 1980 the United States government, through
the Department of Health Education and Welfare (HEW), commissioned a study
on the high rate of cesarean section. In this report, Dr. Marieskind
documented that the cesarean rate had risen from 5.5 percent of all deliveries
in 1970 to 20 percent in 1982 (Marieskind 1982). Through an analysis of
selected feminist contributions on the medicalization of birth framed within
their respective historical settings, and also through a retrospective analysis
of selected birth experiences from women attending my childbirth
preparation classes, this thesis next explores the way in which the hegemonic

medical model of birth has influenced women’s childbirth experiences.

CHAPTER 4

AN OVERVIEW OF FOUR ANALYSES OF THE MEDICALIZATION OF BIRTH
BY SELECTED FEMINIST SOCIAL SCIENTISTS

Forced Labor: Maternity Care in the United States
Nancy Stoller Shaw

In 1967 and 1968 sociologist Nancy Stoller Shaw was a participant
observer of obstetrical care delivery services at four diverse settings
including a large public hospital, a university research hospital, a rural
nursing homebirth service, and at a pre—paid health maintenance
organization. In 1974, she published an ethnographic analysis describing this
experience in which she critiques the extent of medicalized childbirth in the
United States. Lamenting women’s loss of control over the birth experience in
all the settings with the exception of the rural home birth nursing service,
she identified gender, race, class and institutional priorities as the
contributing factors which led to the inhumane treatment she observed in the
other three arenas (143).

Stoller Shaw paid careful attention to structure in her analysis. This
included the structure of the institution of health care, the structure of the
hospital, and the structure of the profession of medicine and medical training.
From her study she concluded that patients are powerless in an institutional
setting (129), and must submit to the legally and institutionally supported

authority of a male physician as the director (85). She also explored gender

33

34

issues which were significant, since at the time of her study, virtually all the
physicians were male, and certainly all the laboring women were female. As
such, gendered issues of power and control within the various respective
institutions occupied much of her analysis. She recognized the importance of
laboring women having an opportunity to compare notes and share
information, and as such, she lamented that hospital isolation discouraged
such an opportunity (118). Since institutions require standardization for
maximum performance, she concluded that hospital routines were determined
by hospital staff for their own convenience and not for the benefit of the
mother or her baby (109).

Stoller Shaw was particularly concerned about the dehumanizing
treatment of the poor, especially since she observed what she determined to be
kind, caring and fully adequate care and treatment offered to poor women
through the rural homebirth service. She noted the intersection of
sex/ race/ class/ and language as barriers which prevented hospital staff from
identifying and empathizing with their patients (115). Upon observing poor
women’s abusive treatment at the hands of the hospital staff, she concluded
that Black women in particular were treated as if they were “outside the moral
world of whites” (14). Poor Black women in particular were judged to be
immoral as a result of what the staff nurses considered to be promiscuous
extramarital sexual behavior. Stoller Shaw noted that the type of abusive
treatment these poor Black women suffered in the hospital was really what
was immoral, but to point this out would have challenged the nurses certain
characterization of these women as “the other.”

Since Stoller Shaw saw routine obstetrical care as gendered and

hierarchical (54), she concluded that the use of power and status by male

35

physicians left patients but three choices: to submit, to resist, or to leave the
system entirely (141). In particular, she concluded that the use of technology
to control birth was a social metaphor for male physicians asserting power
over women giving birth (133). Noting the occurrence of routine
intervention, she observed that this particular strategy failed to teach
residents when intervention was truly appropriate (100), and since the doctors
did not see birth as a normal body process, they were trained to intervene
routinely (70). Medical control through physical or chemical intervention
occurred for nearly all “normal” births that she observed (101).

Her observations at the Pioneer Nursing Service served as a contrasting
comparative model where laboring women in rural Kentucky utilized
midwives to delivery their babies at home (124). She compared the differences
in ideology and power relations in her observations between the hospital
settings which she studied and the homebirth service. She reached dramatic,
positive conclusions regarding the safety and efficacy of the homebirth
service. This alternative model of care favorably impressed Stollar Shaw such
that she lamented that it was only due to irrational fears about childbirth, that
homebirth was not an option for a larger number of women (127). After
drawing this conclusion, she did not aggressively pursue the origins or
perpetuation of the “irrational” fears to which she alluded, except to say that
women are socialized during their prenatal care to accept the hospital system.
In her analysis, she fully recognized the hegemony of the medical control of
childbirth. She cited a male physician’s need to show power over women as
the factor which encouraged them to technologically manage a birth.

In the few privileged patients using prepared childbirth strategies,

Stoller Shaw saw hope for resistance (75), stating her belief that it was a lack

36

of knowledge about birth which prevented women from making informed
decisions (57). She believed that mobilization for consumer-controlled care
would be the corrective by which “mutual respect and power-sharing”
between women and their physicians might be established (55). Knowledge
was equated with power.

In her analysis, Nancy Stoller Shaw failed to look at the economic aspects
of the medical model of birth. While she recognized the ways in which power,
authority and control influenced the way the women were treated, she failed
to explore the financial incentives which encouraged and supported this
observed hegemony. On many an occasion, she cited an incident that she
judged to be motivated by financial gain and not altruistic medicine. But while
it appears that she was aware of these incentives, she failed to include such
insights in guiding her correctives. Even if women went beyond their
irrational fears regarding birth, most still would not have access to either a
midwifery service or to a homebirth since the profession of medicine had done
a very thorough job of eliminating this option with only very few exceptions.

The correctives she explored were limited to ones which would
theoretically only be available to middle— and upper-middle-class women;
women who mirrored her own social location. Thus, she also failed to explore
options theoretically available to other groups of women. For example, if the
rural homebirth service did such a noteworthy job of providing quality care
which appropriately fit the diverse needs of the population it served, why did
the author fail to see this same model of care as appropriate for the center city
poor? While the author recognized the influence of race, class, gender, and
social location, she addressed each if these variables individually, and in doing

so, failed to look at the multiple influence of their intersection.

37

Men Who Control Women’s Health: The Miseducation of Obstetrician-
Gynecologists
Diane Scully

Sociologist Diane Scully performed similar research in an “elite medical”
training institution and at a general “mass medical” hospital in the early
1970’s and published the results of her analysis in 1980. Using the same
strategy of participant-observation, she focused on the surgical training of
obstetrician-gynecologists noting especially “how the practice of medicine
and physician’s professional goals interact to influence the development of
attitudes and skills that are at variance with the health care needs of women”
(2). She expressed her hope that the then current “demystification of
physicians will arm the consumer with a powerful tool-information”(2).
Once again, knowledge was assessed to confer power on the possessor of such
knowledge. As a result of her observations of the mistreatment of the poor in
teaching hospitals, in particular their use as “training material”, she was
hopeful that illuminating such mistreatment would ultimately lead to positive
change for the underserved.

Additional feminist scholarship exploring the medicalization of birth had
emerged in the intervening years between the publication of Stollar Shaw’s
work and that of Diane Scully. Scully was thus able to draw significantly from
insights gained through the contributions of these new works. She noted that
the publication of Immaculate Deception by photo—journalist Suzanne Arms
(1975) bridged a gap between feminist scholarship and childbirth education
“how-to” manuals which proliferated with the natural childbirth movement

efforts. With cross-cultural comparison and empirical data, Scully credited

38

Arms with illuminating the ways in which obstetricians had systematically
“devised a set of interferences [to control childbirth] resulting in even
greater, but more predictable risk” (Scully 1980: 35). Through the
incorporation of interviews with mothers and alternative health care
providers, lay and nurse midwives, Scully found that the research by Arms
offered a new way of evaluating a normal birth experience.

Scully also highlighted criticism of other aspects of the childbirth
experience, such as those documented by Doris B. Haire in her publication by
the International Childbirth Education Association titled The Cultural Wagp'mg
of Childbirth (1972). She pointed out that Haire’s classic essay was one of the
first comprehensive documents to expose the dangers to both women and their
babies inherent in unnecessary obstetrical intervention. Again, citing cross-
cultural research Haire drew attention to obstetrical practices rooted
primarily in institutional self-justification and not necessarily in either
“scientific research or in basic human physiology” (Scully 1980: 34). Along
with these empirical studies Haire pointed out that United States health
statistics for neonatal mortality placed it at that time fifteenth among
developing nations (35). Countries with a lower socioeconomic status, and with
lower levels of obstetrical intervention, had demonstrated better birth
statistics. Haire’s was also the first attempt to look at the institutional control
exerted upon laboring women by the physical environment of birth, i.e.,
within hospitals, and she called on the existing foundation of feminist
women’s health groups to demand changes in invasive maternity care and also
to encourage birthing alternatives through the support of both nurse and lay
midwifery (Haire 1972, in Scully 1980: 35). Additionally, Scully gave support
to the work by Gena Corea (1977) and Barbara Seaman (1972, 1977)

39

encouraging the expansion of the women’s self-help movement as a way to
provide women access to more knowledge in order to gain greater control over
their reproductive lives (18).

In her examination of the asymmetrical power relationship inherent in
obstetrics and gynecology, like Stoller Shaw, Scully paid particular attention to
gender issues. In 1974, only 3.5% of the members of ACOG (American College of
Obstetricians and Gynecologists), the profession’s representative organization,
were women (15). While she noted that there was inadequate evidence to
suggest conclusively that “women [would be] better obstetrician-gynecologists
than men” she mentioned data recognizing that “female residents were more
empathic than males” (94) and she further suggested that an increase in
female physicians and in non-physician health care workers could
conceivably decrease the number of what she viewed as unnecessary
surgeries (242).

While she was skeptical in her assessment that prepared childbirth
classes only reinforced women’s passivity and learned social behavior
emphasizing control, she recognized that some women who utilized a “Lamaze”
strategy were able to avoid a certain amount of medical intervention (96).
Scully recognized that there were economic, personal and social barriers to
institutional patients taking “Lamaze” childbirth classes (122). She also
recognized that few institutional incentives existed to change this, since
residents learned forceps deliveries and other obstetrical techniques on these
same indigent patients (123). Recognizing the financial incentives as well as
the incentive to increase one’s experience from doing surgery, she observed
obstetricians talking women into surgery using sales tactics (224) and related

that from the perspective of an outsider looking in, the profession itself

40

appeared deviant (234). Unlike Stoller Shaw, Scully was cognizant of the
discordant pressures within a “for-profit” health care system that required
“teaching material” for the ongoing training of medical students (10).

She called for women to overcome both traditional passivity and learned
reliance on men in order to reassert control over their bodies, stating that
“informed consumers have a definite advantage in the marketplace” (21). Yet
Scully’s suggested correctives for changing the existing order are curiously
paradoxical. The paradox is that her research both highlighted and
challenged the macro level structure; the institutional and professional
transgressions against the best health care interests of women, yet her
correctives were two—tiered along lines of social stratification on the micro-
level. She placed the onus of responsibility for changing the existing order at
the micro level, on individual women. Despite her recognition of the plight of
the poor at the hands of the health care system in general, particularly as a
result of the certain power inequity between indigent patients and
economically secure health care providers, she conceptually leapt to certain
individualized solutions to what she had previously described as collective
problems.

She suggested first, that women needed to assume the responsibility for
closing the gap in their health care knowledge (252). Further, Scully
recommended that women as patients should screen doctors to evaluate the
type of care offered in advance of utilizing their services, and also that they
seek second opinions on recommended surgeries (254); strategies, which given
her description of the existing system, would be accessible largely to middle-

and upper-middle-class women.

41

To address the abusive treatment of historically marginalized persons,
she suggested recruiting working-class individuals into medicine and
positions of power presumably, so that a projected “like-experience”
identification would cause these individuals to be more sensitive and caring of
their former peers (93). She also expressed her hope that highlighting the
plight of indigent patients at the hands of obstetrician-gynecologists would
encourage positive changes (3). Thus, like Stoller Shaw, Scully puts forth
correctives based on attention to the individual variables of race, gender,
class, and social location.

Indeed, a number of women privileged especially by social location
actively sought to further educate themselves about female anatomy,
physiology, and related health care issues. A minority of feminist health care
activists vociferously demanded that the existing health care system respond
to their stated needs. And indeed, in the area of obstetrical care, a limited
number of hospitals and physicians attempting to respond to such consumer
demands incorporated certain changes in the physical environment of the
birthing arena such as the use of birthing rooms, “gentle-birth” baths, etc.
Yet, following the period of Scully’s research scrutiny of hospital routines by
feminist scholars revealed that the majority of changes were limited to
cosmetics.

The rate of technological, pharmacological, and surgical intervention
continued to escalate. In particular, the rate of surgical cesarean section
deliveries rose precipitously (Marieskind 1979; Wainer Cohen and Estner
1983). In advocating consumer demand for change, the liberal feminist
perspective failed to look at the larger question of power relationships and

social location in the hierarchy of the institutions which controlled

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childbirth. Thus, the basic philosophy remained the same: normal birth was
dangerous and required both a physician and a hospital to optimize the
outcome.

In the 1980’s, empty hospital beds fed a fierce competition among
hospitals for available patients to fill them. Hospitals consequently relied on
polished marketing strategies to increase profits (Arney and Bergen 1984).
Building on the medical model of birth as inherently dangerous, advertising
campaigns played on women’s concerns over their own health or that of their
babies. Augmenting their existing technology, hospital advertising
highlighted the potential risks of childbirth and reassured the public that
they (hospitals) certainly cared about the well being of a baby, and if the
mother did so also, the way to insure a safe birth was to be in a hospital
equipped with the latest in available technology. Hospitals further competed
by augmenting existing services with even more and greater sophisticated
technology.16 It was into this competitive market climate that sociologist
Barbara Katz Rothman introduced the results of her analysis of medicalized

birth with suggestions for alternative choices.

In Labor: Women and Power in the Birthplace

Barbara Katz Rothman

Published first in 1982 in hardcover as In Labor: Women and Power in
the Birthplace, and later as a paperback under the title Giving Birth:
_A_lt_eflatives in Childbirth.17 Katz Rothman openly and directly compared the
medical model with the midwifery model of childbirth care (23). Confronting
the reality of the escalating technological and institutional control of birth,

she took the medical model to task by holding it to the standards it publicly

43

embraced including the safety and health of women and their babies. She did
so by uncovering institutional iatrogenic influences on the progress of
normal birth. Through comparative analysis she illustrated how medical
knowledge is both incomplete and often inaccurate (104). She gave a full
endorsement to the option of home birth citing a study by Louis Mehl which
matched homebirth with hospital birth and in this comparison found home
birth to be a safer option for both the laboring women and their babies(43).
Yet she realized that the real issues were not about safety, but about “autonomy
and control” (95).

Using the example of the breastfeeding lay support group, La Leche
League, she explored the strategic effectiveness of women talking to each
other, and how this simple strategy led to shared information and recognition
that expert knowledge was not always authoritative knowledge. Yet she did not
see the efforts of childbirth preparation educators truly responding to the
need for lay authoritative knowledge, since she viewed most childbirth classes
as putting forth efforts to socialize women to accept the medical model (80).
Katz Rothman portrayed the struggle over expert knowledge as a power
struggle for control of childbirth; in her analysis, knowledge alone did not
confer power. On one side was medical authority upholding the medical model
of birth, and on the other was an uneasy alliance of feminists and family-first
traditionalists who challenged the authority of the medical model (95). like
Stoller Shaw and Scully, she saw hope in the organization of diverse groups of
women around a single issue (110) and called for the reconceptualization of
birth for women of all social locations (246).

By focusing on the structure of the medical profession over gender

issues, in particular on the specialty of obstetrics and gynecology, she

44

attributed the tendency to intervene, to the type of skills valued in this
specialty i.e., surgical skills. She also pointed to the needs of the institution in
shaping the management of birth (271), and illuminated the way in which the
same institution relied on institutional correctives for misguided
institutionally precipitated physiological management.

Katz Rothman’s suggested correctives bridged those put forth by Stoller
Shaw and Scully, whose correctives, (as noted earlier) were socially bifurcated
according to a woman’s social location. She was clearly willing to take the
next step in reconceptualizing childbirth. While she first performed the same
historical analysis of the medical model of birth as the other two scholars, and
then followed with a similar sociological analysis of institutional and
professional control over the representation of birth, she diverged from them
in her formula for future change. Katz Rothman insightfully deconstructed
the medical model of birth and boldly called for a collaborative effort led by
women who were sympathetic to her cause, which was to attempt replacement
of the medical model with the midwifery model, and included a reconsideration
of the location of birth to include both out-of-hospital birth centers and the
home (282-2 87). She proposed that the midwifery model of care should be the
standard of care for all women. The work by Katz Rothman challenged
feminists to carefully examine their rhetoric and their agenda. If, as
feminists maintained, the medicalization of birth eroded what was essentially a
normal, physiological event in a woman’s life, then the way to demedicalize it

was to move it both out of the hospital and out of the hands of physicians.

45

Birth as an American Rite of Passage
Robbie Davis-Floyd

Anthropologist Robbie Davis-Floyd was sympathetic to this proposal. Like
Katz Rothman, Davis-Floyd drew energy from her own individual experience,
an experience which catalyzed her in such a way that she was led to explore
the medicalization of childbirth (248). While Katz Rothman had two reportedly
safe and satisfying homebirth experiences, Davis-Floyd was transformed by
her first negative experience of a planned and prepared for “normal” birth
which, ultimately, ended in a cesarean delivery. Her subsequent second birth
was a planned and prepared for homebirth that met her original expectations
of a normal birth experience. As Davis-Floyd discussed in the introduction to
her book Birth As An American Rite of Passage (1992), she continued to
uphold a model of normal birth akin to that discussed by Katz Rothman. Yet
her observations, much like those I made of the experiences of women in my
childbirth classes, motivated her to confront the fact that a disproportionate
number of women who anticipated and prepared for a “normal” birth ended
up with a technocratic birth. She pursued possible explanations for such an
observed disparity between the “the feminist critique of birth and the beliefs,
desires, reactions, and behaviors of women” (5). Through her inquiry into
this disparity she concluded that “the women’s choices for birth technology
[did not reflect] false consciousness, [but] choices...embedded in the hegemonic
cultural model of reality...consistently presented to us through our most basic
cultural rituals” (5).

The fact that she limited her sample of respondents to women who were

privileged with private health insurance is noteworthy (4). She assumed that

46

such privilege allows one the opportunity to exercise individual will in their
choice of options (4). As such, her analysis of cultural rituals appears to be a
generalization of all women’s behavior extrapolated from her limited sample
of women privileged by social location. Much like the three other feminist
scholars used in my analysis, in order to tease out the underlying assumptions
and belief systems of each model Davis-Floyd found it useful to employ a
strategy of comparative analysis between what she termed the “extreme
forms” of the technocratic and the holistic model (158). The comparison of the
two models is followed by a second analysis focused on the ways in which the
laboring women received these underlying messages (187-240). It is this
aspect of her research that I find most relevant to my analysis.

In an insightful exploration of how women conceptually resolved the
disparity in prior expectations over the lived experience, Davis-Floyd made the
connection between women’s underlying belief systems and the way in which
the choices they made in childbirth revealed those belief systems. Thus, if a
woman chose to birth in a hospital and experienced a technocratic birth,
Davis-Floyd sought clues which revealed the way in which that woman shared
the underlying values inherent in a technocratic society. For women who
managed to reject and/ or avoid the technocratic model of birth, the author
sought clues to the woman’s real conceptual cognitive belief system.

Thus, Davis-Floyd’s data suggested that the women she questioned were
continuing to exert their individual will to achieve a “normal” birth, only
they were in all likelihood unaware in advance what their (perhaps hidden)
values were. The values remained hidden until, in a clutch, they were
revealed through the experience of giving birth. 80 while she looked at the

way in which the births progressed through the medical model as reflective of

47

the women’s underlying belief systems, she failed to explore the way in which
middle- and upper-middle class assumptions regarding control over individual
life events might have influenced such cognitive belief systems. She also
failed to examine the ways in which the women’s choices were structured by
the medical model to conform to institutional parameters.

This anthropological analysis is revealing of two points which I wish to
explore further through analysis of the following two birth stories. The first
is the way in which women exhibit agency in exerting their will and
constructing their choices, the second is the way in which the institution
structures the range of available choices, and in doing so covertly structures
the experience to fit within institutional guidelines. In my exploration, I will
evaluate the effectiveness of advice I provided to these women as their

childbirth educator.

CHAPTER 5
TWO BIRTH STORIES

Susan’s Story

Susan was at the time of the birth of her first child an academic
professional who had done collaborative work with medical school faculty. As
a result, she enjoyed both a personal and a collegial relationship with many
medical school staff physicians. When she became pregnant, she sought the
care of a physician who was her academic peer. Additionally, she contacted a
nurse-midwife and myself to assist her husband in providing labor support.

Her labor began late one Monday evening with mild contractions. The
nurse midwife checked Susan’s cervical dilation and determined her to be in
early labor. She suggested that Susan remain at home and that we all attempt
to sleep through the night as much as possible. Additionally, Susan had
contacted her physician, who concurred with the nurse midwife’s assessment.
The physician knew the midwife, and at this point was willing to trust her
knowledge and judgement. The next morning the household was awakened by
an early phone call from the physician who requested Susan to come to the
office for assessment. The midwife got on the phone and questioned the
necessity of this since she (the midwife) was present and able to provide
information for phone assessment. The physician replied that she wanted to
see for herself what was going on. Susan and her partner went to the office
for the suggested exam, and I went off to work. The doctor agreed to allow

Susan to go back home to continue her labor.

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The midwife assisted in labor support and continued to encourage Susan
to eat and drink lightly, since she was vomiting with the labor pains; a fairly
common physiological response to labor. I arrived back at Susan’s house late
in the afternoon. Susan and her husband had just returned from a second
requested visit to the physician’s office. This visit was not as congenial as the
one earlier in the morning. The doctor performed a pelvic exam and
announced that although from all indications the baby appeared to be doing
fine, the baby’s presenting position was “asynclitic”, a position which could
make a vaginal birth difficult if not impossible. The midwife had given Susan
this same information on the baby’s position just before she left for the
doctor’s office. The doctor had expressed concern that the labor had gone on
“too” long and she wanted to rupture Susan’s amniotic membranes to speed up
the labor. Additionally, she had concluded that Susan was dehydrated from
vomiting, and suggested that the only remedy would be to start an intravenous
drip. She stated that she wanted Susan to go to the hospital immediately. Susan
politely declined, and said she wanted to go home for a couple of hours more,
that she had been trying to “go with the flow” of the labor but would now try
home remedies to “speed it up”if that was what the doctor wanted. She said
that she would be willing to meet the doctor at the hospital around 7:00 that
evening. A truce was called, and Susan went home feeling unproductive, tired
and discouraged.

Meanwhile, the midwife consulted with one of her colleagues regarding
available strategies to deal with the asynclitic diagnosis. The consulting
midwife suggested a prolonged (1/2 hour) hands-knees position to be followed
by aggressive walking (a minimum of 1 hour). When I arrived back at Susan’s

house that afternoon, Susan and her partner were taking a vigorous walk

50

around the yard. She continued with this regimen until she received yet
another phone call from her physician who again asked Susan to go to the
hospital. Susan repeated that she would be there at 7:00. Prior to the departure
for the hospital, the midwife decided that given the conflicted interactions
earlier it would probably be best for her to remain at the house. She felt that
her presence might be more of a liability than an aid. Moreover, she had just
done another check on the baby’s presentation, and determined that the
positional maneuvers were successful in changing its position. Before we left,
I asked Susan to put on make-up and drink as many liquids as she possibly
could. I felt that her appearance might affect the way in which the doctor
related to her, and that an increase in her fluid intake might allay the doctor’s
concern over dehydration.

When we arrived at the hospital the first information the doctor
requested was the whereabouts of the midwife. I informed her that the
midwife had decided to go home. She then commented on Susan’s appearance,
noting that she looked better than she had earlier and also concluded that
Susan must have finally stopped vomiting since her urinalysis indicated that
she was no longer seriously dehydrated. She then announced her assessment
of the baby’s position. She allowed as it was probably a good idea that Susan
had gone home, because in that time the baby had indeed changed positions.
She asked the nurse to begin an IV. and asked Susan to have a seat on the bed,
as she felt they needed to clarify things before they continued. Susan’s
contractions had been coming every 2-3 minutes. They stopped for the next 15
minutes as the doctor lectured her on their “failure to communicate.” The
doctor reaffirmed that she (the doctor) had “done more for alternative birth

than anyone else in town,” that she would not use the available technology

51

unless it was indicated, that she “only wanted the best for both Susan and her
baby.” Susan reassured the doctor that she was not trying to undermine her
authority, and the fact that she was at the hospital could be seen as testimony
to that fact. She said at this time she “just wanted to have the baby” and
followed with the comment that she would “be compliant.”

The nurse began the l.V., strapped a fetal monitor on Susan, and attached
an electrode lead to the baby’s presenting part, the head. I lowered the lights
and began to play a quiet tape of classical music on Susan’s tape player. Susan
labored for approximately two more hours and then commenced to push the
baby out. The doctor performed an episiotomy during the final pushing. After
the birth of the baby, she exhorted Susan to keep pushing to get the placenta
out. In an attempt to assist in this endeavor the doctor grabbed the umbilical
cord in her hand and pulled. The tension caused the cord to snap in the
doctor’s hand and blood poured from the severed end which spontaneously
retracted into Susan’s uterus. When this happened, the doctor appeared
extremely distraught, and verbally expressed her concern over the possibility
of excessive bleeding. She explained that she needed to prevent this from
happening, and in saying this, reached into Susan’s uterus with her hand and
manually removed the placenta. She then further explained that this
procedure would now allow the uterus to adequately contract to stop the
excessive bleeding.

Later, as the doctor began the job of perineal repair, she showed to me
and to Susan’s partner the extensive repair work she had ahead and explained
“See, her tissue is just like butter, that’s why I needed to do the episiotomy and
it is also why the cord snapped.” Susan stayed in the hospital for another day

and then went home feeling delighted with her baby yet defeated and

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depressed about the birth. She suffered postpartum pain at the site of the

episiotomy. The baby was pronounced healthy.

Jane’s Story

Jane became pregnant in the month of October after trying to conceive
for the prior twelve months. Twelve months was not an unusually long period
for conception to take place, especially in light of Jane’s age; she was forty
years old at the time of conception. She chose to continue her medical care in
pregnancy with her family practitioner with whom she had developed a long-
standing friendship. Initially Jane planned to have her baby at home. Her
plans changed when her doctor informed her that if she continued with this
plan, she, the doctor, would be unable to attend the birth due to an
inhospitable political climate relating to homebirth in the local community.
Jane weighed the merits of her two choices: homebirth with a direct entry
midwife or hospital birth with her chosen physician. Ultimately, she decided
to continue seeking care with her family practitioner and thus to give birth in
a hospital. She felt certain that her doctor’s holistic attitude and philosophy
regarding health care delivery would certainly translate into a similar attitude
and philosophy in maternity care practice. She was seeking to have a
“normal” childbirth experience and felt supremely confident that her own
vigorously pursued physical health would allow her to facilitate this
experience.

Throughout her pregnancy, Jane felt a strong sense of physical well
being, and she enjoyed the transformations brought on by her much desired
pregnancy. An instructor in the martial arts, she continued to practice the

martial arts until she could no longer maintain her balance at the beginning

53

of the eighth month of pregnancy. Initially, the pregnancy was also much
desired by Jane’s partner. Yet as her pregnancy progressed, Jane felt him
growing more distant and less interested. Six weeks before her due date, he
told her that he was not sure how he felt about continuing their relationship,
but that he would postpone a final decision until after the birth of their son.

This news, while not totally unexpected, left Jane in a state of anxiety for
the remainder of her pregnancy. She decided that her marital relationship
must be put on hold until the birth of their son. Her training in martial arts
guided her to “act” when threatened. She translated this strategy to apply to
the upcoming birth. She found it difficult to wait and psychologically difficult
to allow the baby inside of her the time it needed to complete gestation.

An unassembled baby crib that needed attention stood in the corner of
their room. While Jane anxiously waited for her partner to join her in the
task of assembling the crib, the crib became a metaphor for their future
relationship as parents. As time passed, and her partner showed no interest in
taking on the task, Jane became convinced that she needed to challenge
herself to do it alone. One night she closed herself off in the bedroom and over
her large, pregnant belly, attacked the assembly job with a vengeance.
Success at this small task metaphorically convinced her that she could indeed
take on the anticipated task of single-parenting.

In order to prepare for the task of labor and delivery, Jane attended my
prepared childbirth classes. Her partner accompanied her to the classes along
with a friend she had chosen to provide additional labor support. Jane was an
adept student and willingly practiced the strategies I taught her class such as
variations on positions for labor and delivery. She also willingly participated

in informed consent role playing. Other than the obviously distressing

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uncertainty concerning the future of her relationship, she felt ready for the
birth of her son.

During a vaginal exam at the time of her due date, Jane’s doctor
determined that Jane’s cervix was fully effaced. At the onset of labor which
was officially determined in an examination by the doctor, according to her
doctor’s calculations she was one week past her expected due date. Jane’s
interpretation of gestational length differed from that of her doctor; based on
her knowledge of the date of conception, she believed she was three days past
her date. When mild labor contractions started around 4:00 in the afternoon,
Jane walked over to the doctor’s office to be “checked” for progress. While
there was no perceptible change from the effacement detected at the exam one
week earlier, Jane did experience “bloody show” after the examination. She
described her emotions after the exam as feeling as if the events of the day and
the anticipated events to follow were a bit unreal. She was afraid of the
expected pain of labor, and afraid of how her life and her relationship might
change after the birth of her baby. Later that evening, her additional support
person came over and Jane and her friend passed the time taking walks and
sitting on her outdoor deck, and eating when she felt hunger. Meanwhile, her
partner slept.

As Jane described her state of mind at this time, she explained that she
felt disassociative with a split focus. She was acutely aware of her partner’s
profound ambivalence, and at the same time conscious of an aching rhythmic
pain which felt much like menstrual cramps. She concentrated on relaxing
and not resisting the pain.

The next day, her doctor came to her house every four hours and

performed a vaginal exam in order to assess the progress of the labor. At 5:00

55

in the evening, when the doctor determined that Jane had not made any
discernable progress, the doctor suggested that Jane take some Seconal in
order to get some much needed rest. Jane followed her doctor’s suggestion,
hoping that the drug would ease her excitement and perhaps stop the labor
long enough for her to get some sleep in order that she might then later wake,
rested and refreshed, and continue with labor in a more vigorous manner.

The Seconal failed to have the desired affect. Instead, Jane’s labor
intensified, and Jane felt drawn into a vortex of pain combined with a
disassociation presumably brought on by the drug. From 5:00 p.m. to 9:00 p.m.
Jane described her labor as “stint from hell.” While she experienced extreme
pain, she at the same time, felt out of touch with her body. She chose to be
alone at this time, as she felt that she needed the solitude to be able to deal with
the disassociative pain. Both her husband and her other support person
checked on her regularly to see how she was doing and to see if there was
anything that they could do to help her. At 9:00 her partner entered the room
and emphatically stated “This has to stop”. By this statement he meant that he
no longer wanted to have Jane continue this process on her own, and he felt it
was time to go to the hospital. Jane felt grateful for this small demonstration
of concern on his part, abdicated to his wishes, and called her doctor to meet
her at the hospital at 10:00 p.m. Her doctor examined her and determined that
Jane progress in labor had stalled at “a tight three” centimeters of cervical
dilation. The doctor made a number of recommendations for correcting this
inertia. Jane complied with her doctor’s suggestions and thus entered into an
extended contract of medical management of the birth.

The doctor ruptured her membranes and hooked up an internal

electronic fetal monitor. She began a pitocin drip to augment the contractions

56

and concurrently had the anesthesiologist begin an epidural for the pain.
Jane labored this way throughout the night, perceiving pressure with the
contractions, but not pain. Her doctor described the contractions as powerful.
At 6:00 the next morning, the doctor performed the last vaginal exam to check
the progress of the labor. Jane was dilated to “a loose three”. By all available
measures the baby continued to do fine throughout. The doctor suggested that
it was time to make a decision, and based on her medical judgement,
recommended that the baby be delivered by cesarean section. As a family
practitioner, Jane’s doctor needed to check with the obstetrical consultant.
The consultant offered that they could try “one more thing” but Jane declined
the opportunity and said “let’s do this”. Jane felt an underlying of feeling of
failure, yet an overriding sense of relief knowing that she would soon see her
baby; this part of her felt like celebrating.

The anesthesiologist gave her “something to relax her” that made her
disoriented and feeling “drunk.” Jane desperately wanted to watch the birth;
to be alert, but felt herself being pulled deeper into the drug-induced state of
disembodiment. As she was prepared for surgery she became aware of her
partner going through perfunctory motions and snapping pictures. Her other
support person was asked to leave and did so which upset Jane even more. The
ob/gyn who had assumed care, proceeded with the operation and removed the
baby at 6:20 a.m. Jane heard her son’s first cry and comforted him with “ Baby
guy, don’t cry” and felt comforted herself when he responded. The doctor said
“here’s your son” bringing the baby closer. Jane fought the effects of the
drug, desperately trying to lift her head and focus on her baby through a
cloud of hazy reality. She tried to read the baby’s expression, and interpreted

what she saw to be “Here I am, are you ready for this...” and simultaneously

57

felt a sense of enormous responsibility and peace. Jane fell in love; utterly
invested in her child.

While the doctor performed the repair on Jane’s uterus and abdomen, the
baby stayed with her for one hour. At this time her partner left and her baby
was then taken for a mandatory two hour observation period in the nursery,
accompanied by the other support person since Jane had expressed her wishes
earlier that the baby not be left alone with strangers. Jane was grateful for
the fact that her support person remembered this and honored her wishes,
and angry at her partner for running home. While Jane slept in the recovery
room, her friend brought the baby back to her. As soon as Jane was admitted
to the regular hospital room where she would remain for the rest of her stay,
she undressed her son and admired his absolute perfection. He was with her
without interruption from that point on. When they went home two days later,
her family and friends provided friendship, support and assistance. Her
husband left the relationship three months later. A divorce followed shortly

thereafter.

Birth Story Analysis

Informed by my analysis of the four texts which provided varying
degrees of insight into the ways in which social structure and culture have
influenced childbirth in the United States, 1 next attempt to unravel the
threads woven into the fiber of these two births. At the beginning of this
thesis, I maintained that there are certain variables by which one can
evaluate a birth experience. These variables were safety, cost, access, and the
quality of the experience. I then articulated the goals of the medical model

and the second wave liberal feminist modifications of the medical model. I

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now intend to examine these two births in light of both these four measures of
birth and the second wave liberal feminist agenda to demedicalize childbirth.

Both Susan’s and Jane’s births surely met the goals of the medical model.
The two women had access to, and used, both a physician and a technologically
well-equipped hospital. Each woman also had third party payor insurance to
cover the costs incurred and, as such, their access to the standard system was
not impeded by financial constraints. Both babies were healthy at the end of
the process. Both women eventually recovered from the process. Susan faced
the challenge of recovering from both the episiotomy and the negative
emotional sequelae suffered from the figurative battle in which she engaged
with her health care provider. Jane faced the challenge of recovering from
major abdominal surgery, and the negative emotional sequelae suffered from
the disappointment realized when the sequence of events went other than the
way she expected. In the telling of the two narratives, both women expressed
moderate to extreme disappointment and dissatisfaction with the sequence of
birth events.

In reviewing the events of the two births, one can posit the following
questions: Did anything go wrong? If so, what went wrong, and how could
the “errors” have been avoided? Both women had assiduously followed second
wave liberal feminist dictates to avoid unnecessary medicalization of their
birth experiences. They were attentive to preventive health measures
throughout their pregnancies, and each enjoyed a state of physical health
throughout the pregnancy period. They each selected a woman physician
whom they believed to possess essentialized female qualities of caring and
compassion. They each had established a conversation with their respective

doctors about their desires to demedicalize their respective birth experiences

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(Katz 1984). They sincerely believed that their doctors would attempt to
actualize this desire for them. Both Susan and Jane attended childbirth
classes, and were well-educated about the course of normal labor and delivery
and were, moreover, highly motivated to avoid pharmacological, technological
and surgical intervention, i.e., a medicalized childbirth experience. Yet, the
information, the tools and the strategies offered in my childbirth classes failed
them as soon as they entered the institutional environment of the hospital.

Each woman’s birth experience was accomplished through the
utilization of some form of expensive medical management and medical control
of the experience. Was the medical management necessary to either facilitate
or to insure the safety of the two births? What might have happened without
the medical management? What were the physiological consequences of the
management for the woman? What institutional incentives existed to avoid
medical management? The experience of childbirth has a profound effect on
women of all cultures, such that the significance of the experience is
commonly recognized by various symbolic rituals noting the importance of
the rite of passage for both the woman and the baby (Kay 1982). What was it
about the rituals involved in the medicalized birth experience for these two
women that the experiences served to demoralize them as they traveled
through such a transformative experience?

The level of pharmacological, technological, and surgical intervention in
Susan’s birth was not unusual when compared with a standard hospital birth
in the United States. It was, in fact, minimal compared to the average hospital
birth in this particular cityl8 and certainly fit within the standard of

community care, both regionally and professionally.19 But the outcome

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experience was not what Susan wanted. Susan expressed a sense of personal
dissatisfaction in the postpartum period with the course of events.

As seen from the physician’s point of view, Susan caused herself
unnecessary stress by her refusal to include the doctor in the customary
manner of birth management. Since Susan and her doctor were previously
academic peers who had enjoyed a friendly and warm collegial relationship,
the contentious nature of their subsequent interaction at the time of the birth
was unexpected. Perhaps Susan’s expectations were unrealistic; maybe Susan
should have realized that a doctor predictably relies on the social power base
and on the tools and technology available in medicine. Maybe Susan should
have anticipated that hiring two professionals who advocated different models
of normal birth might potentially lead to a power struggle for professional
authority. But she did not. She felt that she was acting wisely and covering all
possible permutations on birth by hiring professionals with expertise in
different arenas. Indeed, each had expressed admiration of the other’s clinical
experience when she discussed her plans with them early in her pregnancy.

The level of intervention in Jane’s birth was fairly routine, especially
considering that one in four to one in three (the numbers vary depending on
the month) women are delivered of their babies by cesarean section in the
tertiary care hospital where her doctor practiced.20 The level of medical
management also fit comfortably into the recognized and accepted standard of
community care, both regionally and professionally.

Like Susan, Jane was also very disappointed at the level of medical
management which occurred, but conversely, Jane concluded “all the
intervention that I sought to avoid turned out to be necessary.” Jane was

convinced that she must have unconsciously attempted to postpone the

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inevitable departure of her husband from their relationship by
subconsciously stalling the labor and delivery of their baby. In fact, her
family practitioner somewhat corroborated Jane’s interpretation of the
sequence of events, when she (the doctor) told Jane that she had submitted
Jane’s birth story to be discussed as “the case of the week.” She told Jane that
in the concluding comments of the medical staff they “chalked up [her]
failure to progress as the mystery of the week.” For Jane, the emotional
baggage of self-doubt was additive to the emotional pain and concern that she
experienced over her deteriorating relationship with her husband. Four
years after the birth, Jane continued to express confusion about, and to
agonize over her own perceived personal failure to attain her desired goal of a
non-medicalized birth. Again, one can ask did anything go wrong, and if so
what, and how might it have been avoided?

These two births reveal many subtle and overt dynamics involved in
routine hospital births, the social construction of which reflects the values of
the larger society as explicated by the four social scientists reviewed earlier in
the thesis. The following critical interpretive analysis will continue to invoke
a theoretical “yardstick” marked with the measures of safety, cost, access, and
quality, and using this yardstick, explore the multiple and intersecting
limitations of socialization, technology, power, authority, and control in these

two births.

Chapter 6

SOCIALIZATION, TECHNOLOGY, POWER, AUTHORITY, AND CONTROL:
THE INFLUENCE OF LIMITING VARIABLES IN MEDICALIZED BIRTH

Through ritual, the belief system of a culture is enacted...thus, an
analysis of ritual can lead directly to a profound understanding of

that belief system....analysis of the rituals of hospital birth reveals

their cognitive matrix to be the technological model of reality

which forms the philosophical basis of both Western biomedicine

and American society” (Davis-Floyd 1987: 156).

...All knowledge relating to the body is culturally constructed, negotiated,

and renegotiated in a dynamic process through time and space (Lock and
Scheper—Hughes 1990: 49).

The liberal feminist agenda suggested that an informed and healthy
woman could make objective choices, and should do so in order to demedicalize
her birth experience. But truly objective choices are nonexistent.
“Objectivity” is socially constructed, and as such bears the mark of multiple
subjective and most often invisible influences including socialization,
technology, power, authority and control (Gordon 1988). Examination of the
social construction of women’s childbirth experiences reveals the way in
which these factors limit women’s available and socially acceptable choices to
those within the medical model.

First, access to trained, competent health care providers has, with very
few exceptions until recently, largely been limited to physicians. Thus the
range of choices for birth attendants has been a limiting factor for
childbearing women. The second limiting factor is that of the physical context
in which birth is managed. The range of choice regarding the place of birth
has, also with very few exceptions until recently, largely been limited to

hospitals. Thus, the available options for the physical location of birth has

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been a limiting factor. Third, within the same physical context of the
hospital, both the range and the priority of available options for the
management of birth has been a limiting factor. Fourth, birth managed by
physicians is subject to physician’s professional medical judgement, and as
such, is limited by medical assumptions regarding childbirth. Fifth, both
society and culture provide strict guidelines for what is considered to be
acceptable health behavior. In part, such guidelines are delineated by and are
responsive to the diverse needs of competing institutions in the professional-
medical—industrial complex. Institutional constraints for acceptable social
behavior are limiting factors in women’s birth experiences and are revealing
of the hegemonic priorities of institutional control in medicalized birth.

I will first illustrate my strategy for the analysis of the multiple and
intersecting influences of socialization, technology, power, authority and
control by deconstructing the dynamics involved in just one area of
medicalized birth, that of pain in labor. I use a vignette from one local
institution’s recent response to managing childbirth pain. I will then use this

same strategy to examine both Susan’s and Jane’s birth narratives.

An Example of Pain in Labor

Most women experience what they describe as moderate to extreme pain
while in labor; and the way in which the institution at a policy level, and the
staff individually, respond to a woman’s labor pain will most certainly
influence how she “chooses” to deal with such pain. In my childbirth classes,
it was not unusual for a woman to be highly motivated at the beginning of her
labor to avoid pharmaceutical pain relief due to concern over its inherent

risks; yet, as Davis-Floyd also observed in her sample, many ultimately chose to

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use it. As an instructor, I listened to their birth stories, and as I did so,
contemplated on how the five variables listed above silently intersected in
such a way that the woman fully believed that her choice in doing so was made
objectively. Yet closer examination revealed that constraints imposed by the
medical model served to guide the choices made towards conformity with that
model.

The health care industry is a for-profit venture; even non-profit health
care organizations operate under a profit incentive to cover expenditures
(Kaye Abraham 1993). Within this industry, a hospital, as part of an
institutional organization, holds the authority and the power to control many
factors which serve to influence a woman’s choice regarding pain relief
while in labor. Such was the case when mid—way through my teaching tenure
one of the local hospitals made the decision to have anesthesia readily
available on a twenty-four hour basis in labor in delivery.21 This decision
meant that they had to adjust their current employment arrangement with
their anesthesiologists. In order to accommodate around the clock availability,
the hospital added new individuals to their staff of anesthetists. The labor and
delivery unit then modified their policy such that all laboring women admitted
to the unit were classified as pre-surgical patients.22 With this
reclassification, the unit adopted a subsequent policy whereby a staff
anesthetist did a pre—surgical visit to each laboring woman. This pre-surgical
visit was justified as part of normal pre-surgical protocol. Within this protocol
it was viewed as optimal to have the anesthetist meet the patient prior to
surgery in order to have the opportunity to discuss the risks and benefits of
the various pharmaceutical options, and also to evaluate any risks especially

in light of each patient’s individual health history.

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What followed was a dramatic increase in the rate of epidural
administration within the labor and delivery unit. Within one year following
the hospital’s initial decision to have twenty—four hour anesthesia available in
labor and delivery, I was contacted by a local pediatrician. He solicited my
assistance in helping him in his efforts to attempt to lower the rate of epidural
use during labor and delivery in this same hospital. He estimated the rate of
epidural administration to laboring women had risen from 40-50% to between
90-95%. He expressed his surprise that so many women now asked for this type
of pain relief. As a pediatrician, he was concerned about the increased
potential for harm to the babies, realized through the increased interpartum
use of pharmaceuticals (Doering 1982).23 His suggested strategy was to educate
women both about the attendant risks to their babies involved in the
administration of interpartum pharmaceuticals and alternative choices for
coping with the pain of labor. I politely refused his request for assistance.

Clearly, the above scenario can be subjected to different interpretations
depending on one’s vantage point. From the concerned pediatrician’s point of
view, women were naively taking unnecessary risks in asking for epidural
administration to relieve their labor pain. From the hospital’s point of view, a
wise business decision was made. This decision allowed them to increase their
profit margin through increasing their services to a laboring women for the
length of their stay at the hospital. This strategy is noteworthy at a time when
recent cost containment regulations mandate increasingly shorter hospital
stays. From my point of view, the hospital created a situation which allowed it
to increase profit through aggressive marketing of a service, and at the same

time to “manufacture consent” for such a service from a captive audience of

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laboring women (Herman and Chomsky 1988).24 In support of my
perspective, I offer the following insights.

The priority of available options serves as a limiting factor. The fact that
pharmaceuticals are most commonly offered as a fl;_s_t choice for pain relief
over many other less invasive available measures to ease discomfort and to
minimize pain is revealing of values within the medical model, and also
reveals the power and authority of hospital staff in controlling available
choices. Equally, the manner in which the anesthesiologist presents the
informed consent “risks/benefit” estimation of their pharmacopeia might
sway a woman’s decision. The menu of choices made available to the woman
will certainly influence w_ha_t she chooses.

Inexpensive, low-risk, low-tech options (touching, positional changes,
warm water baths, etc.) are rarely available choices in this setting; the choice
of such options are made obsolete by other hospital routines and conventions.
Consequently, the physical context serves as a limiting factor. As an example,
furniture options in a hospital labor and delivery room commonly include a
bed for the woman and a chair for her support person. The potential for
maneuvering positional changes with these two pieces of furniture in order to
effect pain relief is negligible. Since a laboring woman is most often
forbidden to eat (again a presurgical precaution)25, the institutional substitute
for sustenance is an I.V. solution of glucose. The I.V. equipment will limit her
ability to change positions. Some hospitals do have a shower accessible to
women in the labor and delivery unit, but most do not have a bath tub
available. While the warm water of a shower can give some comfort, women in

hard labor have a difficult time standing up by themselves for an extended

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period and again, I.V. equipment and also fetal monitoring machines preclude
either option.

Medical assumptions regarding childbirth most certainly will limit birth
management for pain relief to fit within professional expectations. In this
way, the attending physician most commonly relies on a long list of
pharmaceuticals to manage the pain of labor. Many physicians have a
standard protocol for pain management. Nurses are held responsible for
remaining knowledgeable about the various protocols for the many
physicians and for offering them to the patient as labor progresses. As
mentioned earlier in this thesis, consumer-led interest in using breathing
gymnastics to control one’s response to labor pain met with an enthusiastic
response from labor and delivery staff. Consequently, current institutional
dictates for acceptable social behavior place a limitation on what are
considered acceptable responses to pain. The institutional assumption
regarding childbirth is that women will indeed control their vocal responses
to labor pain such that women, who vocally respond to labor pain, will be
judged to be “out of control” or conversely labeled “a screamer” and
determined to be in need of the available pharmaceuticals.26 This sequence of
limiting factors illustrates the way in which the social construction of pain
management within the medical model of birth constrains a woman’s
“choices” to meet institutional and professional expectations.

Women conform to self-imposed constraints guided by negative social
sanctions. Consequently, the present social climate harbors social incentives
encouraging conformity to medical model social dictates for giving birth.
Thus, it is not surprising that most women follow them. Yet paradoxically,

negative social sanctions for conformity are not about the outcome, they are

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about conformity to social norms.27 When an unexpected outcome occurs in
birth, the focus centers on how closely all the individuals involved followed
the socially recognized and socially acceptable “rules.” When such outcomes
are not serious or life-threatening, and can be remediated by a medical
response, culpability is most often silently absorbed by institutional
rationalization. For example, when a woman suffers an infection from an
episiotomy, it is viewed as an unfortunate side effect from a procedure
necessary to facilitate birth, since within the medical model, performing an
episiotomy is an accepted way to manage birth. Most would agree that the
woman was not at fault for allowing her doctor to perform this procedure, and
most would also agree that the doctor was not at fault for doing so. Such is the
case because this surgical procedure is accepted standard practice. The
hegemony of the medical model obscures other possible management options
that fall outside of the socially accepted rules. Societal acceptance for surgical
insults to the mother become seamlessly woven into a social fabric of tacit
acceptance for routine procedures designed to mitigate unacceptable
circumstances.28 Certain dynamics involved in Susan’s birth exemplify this

paradox.

A Critical Interpretation of Susan’s Birth

As an academic who had worked closely with the medical school,
particularly in the area of women’s health care, Susan was highly cognizant
and also critical of the growing medicalization of women’s lives.
Consequently, she was highly motivated to avoid the medicalization of the
birth of her first child. She considered a homebirth, but felt that since this

was her first experience, she would feel better (safer) in a hospital setting,

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and felt that her chosen provider would facilitate a home birth experience in
the hospital setting. Additionally, she felt that choosing a midwife and a
childbirth educator for labor support would facilitate such an arrangement,
assuming that this arrangement could somehow further mediate unnecessary
medicalization. Susan’s actions fell within acceptable social norms in
choosing a hospital birth, yet the model of birth that Susan envisioned, that of
a demedicalized experience, was really that of birth at home. There is a
particular vulnerability experienced by a woman who is approaching the
term of her pregnancy, and Susan was reluctant to make such a socially
unorthodox choice. Many women in my childbirth classes considered the
option of birthing at home, but chose not to. Commonly accompanying this
decision in their conversation was the caveat, “I’d like to birth at home, but
what if something happened?” implying that if something untoward occurred,
they would have to assume responsibility for their decision, and it would be
their fault for making a wrong choice. Curiously, when something @ happen
at a birth within the hospital (infection of the mother or baby, cesarean
section, or other sorts of iatrogenic accidents), acceptance for the untoward
event was silently woven into acceptable social behavior. Women are
socialized to believe that both their own bodies and the process of birth are
inherently dangerous, and as such they learn to place their trust in
institutional and technological management to presumably make the birth
safer. Yet in Susan’s birth, birth management only made the sequence of
birth events more predictable.

When the doctor first went against Susan’s wishes to avoid an episiotomy,
and then followed by exerting excessive traction on the umbilical cord causing

it to snap from her efforts, she justified her actions by employing the

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metaphor “her tissue is like butter,” thus implying that it was Susan’s friable
tissue and not her own (the doctor’s) actions which led to the need to
intervene. Medical management and reliance on the use of “technology is
embedded in social institutions, and individual choices are made within a social
system that rewards some choices and punishes others” (Garner and Tessler
1989: 26). The standard of community care, a largely unwritten and often
specious perception of what is considered good care as it is practiced in a given
area, commonly guides medical practice. The standard of community care is
responsive to institutional needs, including efficiency as well as to
physiological medical management.

It is considered good “management” within the standard of community
care to insure that the placenta is out of the uterus very shortly after delivery,
usually within 1/2 hour at the most. The concern is that as long as the
placenta remains within the uterus, the uterus cannot adequately contract.
Uterine contraction is desirable because this process puts pressure on the
major blood vessels within the uterus to stop them from bleeding excessively.
Consequently, doctors are motivated to expedite this maneuver. When the
attempt by Susan’s doctor to assist in removing the placenta caused the cord to
snap, the doctor panicked and followed with accepted medical protocol by
manually removing the placenta, a procedure which Susan found extremely
painful. While it is true that a doctor tempts serious negative professional
sanctions if they practice outside of the net of “standard of community care”
this apparently innocuous procedure deserves further examination.

By framing the occurrence as a medical crisis, the doctor was fully able
to assert medical authority in remediating the crisis. Susan was not in a

position to refuse, and as the doctor explained the immediacy of the situation to

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Susan’s husband, neither was he. Among the Bariba of Benin, the matrones
who act as midwives recognize that “pulling on the cord...would kill the
mother” (Sargent 1982: 207). This wisdom is shared fairly universally in most
cultures (Kay 1982). But the concern is not for the same physiological
rationale that the doctor provided to both Susan and her husband, since any
blood from the snapped cord was placental blood and r_19_t the mother’s, and as
such was irrelevant to the mother’s well-being. The placenta is not attached to
the uterine wall, the bleeding over which the doctor expressed such concern
would continue only until the placenta itself exsanguinated. Folk wisdom
regarding traction on the cord has to do with concern over inadvertently
causing premature or partial removal of the placenta, which does cause
maternal hemorrhage.

After the birth of the baby, the uterine muscles continue to contract and
shorten causing involution of the uterus, and in so doing, this same action
disengages the placenta (which then slides out) and simultaneously causes
uterine bleeding to subside through the concomitant pressure exerted on
uterine blood vessels. Premature removal of the placenta could allow for
excessive bleeding since it would not necessarily be followed by the pressure
of full uterine involution. Excessive traction on the cord could also lead to
only partial evacuation of the placenta, with similar consequences. Beyond
the pain that Susan experienced when the doctor put her hand into Susan’s
uterus, this invasive procedure also increased the risk of a postpartum
infection, and again, folk wisdom would caution against taking such a risk. As
seen in Susan’s experience, technological birth tolerates such an exception to
folk wisdom since there are pharmacological and technological solutions to

the problem created. One simply manually and/ or instrumentally removes the

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placenta, administers pitocin to effect the uterine contractions necessary to
minimize bleeding, and then administers antibiotics to ward off any infection
which might occur from such an invasion. When Susan discussed the birth
with me at a later date, she stated that she was well aware of the fact that the
doctor set “the crisis” described above in motion, because she (Susan) could
feel the doctor pulling on the cord, but again, she (Susan) had just given birth,
was holding her baby, and was not in a position to challenge the doctor’s
authority.

What she did not foresee was the resulting power struggle between the
two authorities. Although Susan was a professional, she was not a medical
doctor, and within this context Susan’s behavior might be seen as rebellious or
even naive. As Irwin and Jordan (1987: 319) note, medical knowledge has
association with a stronger power base and “contempt for professionals is
easier for those who live among them than it is for those who may have to
submit to experts in a wider range of life experiences” (Nelson 1983: 295) as
“doctors, in fact, appear to resist and reject aspects of each client model in
favor of their own approach” (Nelson, 1983: 285). In Susan’s case her doctor
wanted Susan to believe in her (the doctor’s) abilities, her skill and her
beneficence. Susan wanted to use education and additional support as tools to
control the circumstances surrounding her birth. This presented a direct
threat to the doctor who viewed herself as the appropriate person to wield
power and assume control. She wanted to be the primary authority and the
decision maker. Irwin and Jordan note that medical power is often delivered
with a “veiled threat of powerful sanction” (1987: 319) as was the case when

the doctor lectured Susan when she first entered the hospital.

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What Susan had attempted to negotiate was impossible due to the existing
power structure in the institution of the hospital and the profession of
medicine. When Susan became a non-compliant patient, her doctor asserted
authority; verbally (the lecture) and physically (the l.V., episiotomy, and
manual removal of the placenta manifesting the power of “the dark side of the

force” within the medical profession (Brody 1992: 28).

A Critical Interpretation of Jane’s Birth

Jane’s birth illustrates a similar scenario of institutional control, medical
management, and medical correction for problems created by the medical
management. This scenario only becomes apparent by examining Jane’s
birth from an alternative stance. In the retrospective telling of her birth
story, Jane pondered “I wonder if I was really in labor to begin with...”
referring to the contractions which she experienced on the first day of what
was certainly counted by her physician as the beginning of her labor. A
retrospective analysis reveals that an alternative labor management strategy
might have been to encourage Jane to maintain normal daily activities and to
ignore the contractions until she could no longer do so. Instead, Jane’s
physician, in her role as a socially recognized authority in her capacity as a
doctor, determined that the labor had indeed begun and encouraged Jane to
move around in order to help the labor progress. Consequently Jane walked
and talked through the night, going without sleep. The regular vaginal exams
to assess dilation the next day were obviously well-intentioned on the part of
Jane’s physician, but such aggressive attention to cervical progress alerted all
parties involved to fixate on cervical dilation as the goal for which they should

strive. When the vaginal checks continued to affirm that cervical dilation was

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euphemistically “stuck” at three centimeters, Jane was amenable to her
doctor’s suggestion that she use Seconal to bring on some much needed rest.

Jane attributes her subsequent disorientation and inability to cope with
the pain as a consequence of the unanticipated side effects of the drug. When
Jane’s husband then responded to her manifestation of pain and disorientation
with the statement “this can’t go on,” she was willing to accept his assumption
of leadership. The subsequent institutional response to Jane’s being “stuck” at
three centimeters of dilation was her doctor’s suggestion to give her an
intravenous infusion of Pitocin to augment the effectiveness of the
contractions along with an epidural for the associated pain of labor. Jane was
then required to be recumbent and was allowed nothing to eat and only liquids
to drink. For Jane, the next night was unending as she was hooked up to the
l.V., confined to the bed, yet was unable to sleep through the resultant turmoil.
Repeated vaginal checks served to reinforce her belief that “nothing was
working” to progress the labor. When her doctor discussed “getting this over
with” the next morning, Jane no longer believed in her own ability to give
birth. Feeling defeated, she not only acquiesced, she welcomed the suggestion
of surgery to remove the baby from her uterus.

Thus, it would appear that while Jane was initially an exemplar for
liberal feminist dictates, like so many clients in my classes, she ended with a
highly medicalized birth experience. The dynamics involved in Jane’s birth
are reflective of many related by my clients. What is not immediately
apparent, is the way in which the choices Jane faced were restricted by the

first choice that she made, which was to birth within the hospital.

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Choices in health care are structured by the opinions of family and
friends, community values, and prior experience as well as the
actual facilities and options available” (Michaelson and Alvin 1988:
147).

As institutions, hospitals have a need to standardize care and to
implement routines. When these routines create problems and cause
physiological disequilibrium, institutions incorporate ways to regain stability.
Technological manipulation provides both the method and the technique to do
so. Doctors follow through with such institutional directives by carrying them
out in protocols within their practice.

I maintain that the only thing that was “wrong” with Jane’s labor was
that her certainly well-intentioned and caring physician began to pay
attention to it much too soon. In my childbirth classes, I always attempted to
alert women to the inevitable chain reaction of management events which I
had witnessed occurring as soon as a doctor started counting labor signs as
those of real (read imminent) labor. Many of the birth stories told by women
who were delivered by cesarean section recounted a scenario similar to that
which Jane experienced. In order to explain the reason for the surgical
birth, the women were given a diagnosis describing their anomalous labor,
“failure to progress,” “dystocia or ineffective labor,” and most commonly “CPD
or cephalo-pelvic disproportion.” I translated these diagnoses for my classes
to mean “baby won’t come out within the time we (supporters of the medical
model) believe a baby should come out in.” Using examples gleaned both from
midwives stories and from my own experience in doing labor support, I
described what I believed to be a long, but still normal labor as evidenced by a

healthy postpartum mother and a healthy baby. While my clients gasped as I

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described forty to sixty hour labors, they need not have, since this knowledge
was irrelevant within the medical model.

Emily Martin (1989) describes the institutional metaphor for a woman
giving birth as that of a machine which is intended to produce. The
institution sets parameters for the amount of time it should ideally take for the
woman’s body to produce a baby. Within a medical institution, time translates
into financial gain. Martin’s work also revealed that the production aspect of
birth it is not about mother and baby well-being, it is about time labor and
money. What her work best illustrates is how the medical model, as conveyed
through medical language, views women’s bodies as mechanisms in need of
control and repair. “Birth is seen as the control of laborers (women) and their
machines (their uteruses) by managers (doctors), often using other machines
to help” (Martin 1989: 146). In Jane’s labor, her body was seen as one which
needed ambulation (walking), sedation (Seconal), augmentation (Pitocin),
hydration (I.V. glucose), anesthetization (epidural), observation (internal
fetal monitor) and ultimately surgical intervention (cesarean section). Yet
according to Jane’s report, there was never an indication that her baby was in
any kind of danger. Certainly Jane was tired and anxious, but why the sense of
urgency, what was the hurry? And, finally in what light can the “cure”
effected be considered more advantageous and desirable than the exhaustion
and anxiety which she was experiencing? It was research by Emmanuel

Friedman in 1955, that:

mapped the instant-to-instant changes in cervical dilatation over
time and plotted an ‘ideal’ labor progress curve, a mean labor
progress curve, and statistical deviations around those curves...[he]
developed technology to monitor cervical dilatation over

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time...including an ideal course with which the woman’s labor could
be aligned by various techniques (Arney and Bergen 1984: 100).

What has happened within the institutional setting is that these averages
which in and of themselves are of questionable relevance since rarely do
one’s bodily functions conform to an average measure, and non-conformity is
of questionable use for indicating pathology in what is a non-pathological
event, are now used as the upper-most limit of what is considered safe for
normal labor. Hence, a further limitation on labor options is that imposed by
expectations that the labor fit within an artificially constructed picture of the
range of normal labor. This is a spurious and self-serving use of statistics.
Without this limitation, Jane could, instead, have been encouraged to ignore
the early labor contractions, to have a nice dinner, to go to bed, and to distract
herself the following day and from then until she no longer was able to.
Clearly, not only was birth not imminent, the focus on cervical dilation was
counterproductive to Jane’s mental state.

The physiological consequence of such a directed focus on cervical
dilation was the following domino-like chain of events: the subsequent sleep
deprivation - Seconal as a corrective - the subsequent disorientation and panic
- a Pitocin labor augmentation as the corrective - an epidural for the
associated pain of labor augmentation - confinement to the bed - no food and
no hope - a cesarean delivery as the corrective. Physiology was manipulated
to meet institutional goals of production. The rituals of Jane’s birth experience
demoralized her because they conveyed to her that she was reproductively
dysfunctional through her failure to give birth to her baby. Moreover, she

was unable to see how her subsequent choices were limited by her first choice,

78

to birth in the hospital (Kozak 1984). Consequently, she searched her own
behavior and psyche for both cause and culpability.

Powerful and persuasive social forces direct the perceived willingness
and consent of women to participate in rituals which ultimately sabotage them
by strengthening gender inequities enforced through the institutional social
control of women. In particular, negative social sanctions serve to effectively
influence and guide behavior. The ideology of the medical model of birth is
that birth is inherently potentially dangerous, and that it cannot and will not
proceed without medical/technological management. A corollary of this
ideology is that the medical/ technological management of birth is “safe.”
Since the practice of medicine is learned through apprenticeship, such
medical practice, including the management of childbirth, is based on medical
judgement grounded in a subjective and often conflicting combination of
scientific data selected by a provider to support their own personal beliefs and
clinical experience (Ehrenreich 1978). Conversely and ironically, my clients
believed medical practice to be both grounded in fact and supported by
objective, indisputable scientific inquiry. They were socialized to implicitly
trust medical judgement. Such socialization served as a limiting factor to
prevent them from questioning the authority and judgement of their
physicians. The inherent power structure within the institution of birth
rendered a consumer challenge ineffectual. Institutions confer on
professionals who pass through their doors professional authority, so that
historically “authority no longer depended on individual character and lay
attitudes; instead, it was increasingly built into the structure of the
institution” (Starr 1982: 20). Authority led the way to economic power and the

monopoly which physicians have wielded ever since. While physicians have

79

claimed to be above the control of the market, closer observation of physician
practice and profit belies the claim.

Ironically professional authority would have been impossible to establish
in preindustrial America where individuals in rural communities relied on
themselves and each other in a self-sufficient and independent manner. But
urbanization brought the need for specialized skills, which often had to be
purchased from strangers. Coupled with advances in science and technology,
the public was willing to believe that not only did science have all the
answers, it was better than trusting the old ways, or the whims of nature.
Childbirth was seen to be within the jurisdiction of medical authority. In this
milieu, childbirth preparation classes become a salve to soothe women’s fears
of the unknown and fears regarding a lack of control over the experience. As
with other institutional birth methods, they “symbolically [met] the demands
of parents-to-be while they maintain[ed] the control and prerogatives of the
obstetrical community” (Matthews and Zadek 1991: 40).

Yet is only through the comparison of standard medical birth
management in the United States with other available alternative models of
care that the potentially harmful effects of technocratic birth management
can be revealed (Chalmers 1978). It is clearly time to place the burden of proof
regarding safety, cost, access, and quality of experience on the medical model

of birth.

 

Insights Gained From A Critical Interpretation of Liberal Feminist

Efforts

...when a theory is transformed into an ideology, it begins to
destroy the self and self-knowledge. Originally born of feeling, it
pretends to float above and around feeling. Above sensation. It
organizes experience according to itself, without touching
experience. By virtue of being itself, it is supposed to know. To
invoke the name of this ideology is to confer truthfulness. No
one can tell it anything new. Experience ceases to surprise it,
inform it, transform it. It is annoyed by any detail which does
not fit into its world view. Begun as a cry against the denial of
truth, now it denies any truth which does not fit into its scheme.
Begun as a way to restore one's sense of reality, now it attempts to
discipline real people, to remake natural beings after its own
image. All that it fails to explain it records as its enemy. Begun
as a theory of liberation, it is threatened by new theories of
liberation; it builds a prison for the mind (Griffin 1982: 648)).

The ideology underlying the medical model of birth has perpetuated a
fictive model of expected normal birth events. The perception of normal
behavior is itself a powerfully persuasive incentive for social conformity to
group behavior. What is perceived as normal behavior feeds information into
a self-perpetuating reinforcement loop, a homeostatic mechanism of social
norms which then serves to exert control over potentially excessive or
disruptive deviant behavior; a deviation dampening feedback strategy. Social
reinforcement of behavior is both manifested and maintained through social
institutions. Social institutions maintain social order by rewarding
conformity and providing disincentives for those whose behavior deviates
from accepted norms. The institution of medicine regulates their model of
birth by restricting the standards used for assessment of efficacy and safety to
those defined as important or meaningful with the medical model of birth, and

selectively ignoring the consequences realized by the technocratic model of

81

birth in negatively influencing a woman’s ability to give birth, a deviation
amplifying feedback strategy.

A critical interpretive analysis of second wave liberal feminist efforts
reveals that certain aspects of their approach were misguided while others
were appropriately directed. Their concerns regarding the excessive
medicalization of birth were then and continue to be well-founded. The

technocratic medical model of birth has been reified.

We also reproduce a political ideology in the guise of a science of
(apparently) “real things”---biological and physical thinghood.
In this way our objectivity as presented in medicine represents
basic cultural axioms and modulates the contradictions inherent
to our culture and view of objectivity. (Taussig 1992: 84)

The reification of technocratic birth combined with the
comprehensively unrealistic picture of American reproduction as conveyed
to women through media representation is directly counter to the sweat, blood,
pain, exhaustion, tears, vomit and various other body fluids which are all part
of normal birth. Within western societies, the health system is one of the most
powerful existing institutions, and as such acts as an effective tool of social
control. Pressures to operate within established guidelines of accepted normal
behavior are pervasive within the institution and as such, these pressures
serve to regulate the behavior of both providers and patients. As research by
medical research statistician Marjorie Tew (1990) suggests, the assumption that
the medical model of birth is superior to the model which it replaced
(homebirth with midwives) is wrong. The story of the medicalization of birth
in the second half of the twentieth century is “a record of the successful
denial and concealment of extensive and unanimous evidence that obstetric

intervention only rarely improves the natural process” (Tew 1990: vii).

82

Liberal feminists singled out the gender of health care providers as
problematic. The mid-century predominance of men as obstetrical care
providers was viewed as a causal factor in the increasing medicalization of
birth. It was believed that women obstetrical care providers would participate
in the childbirth arena differently than male doctors. Liberal feminists
extrapolated from a belief in essentialized “feminine” qualities of caring and
support, that women providers would bring such essentialized feminine
qualities to the birth arena. Moreover, liberal feminists projected that women
providers would be more amenable to a laboring women asserting her desires
through a birth plan, and likewise would be more agreeable and willing to
honor this plan, even when it included non-traditional strategies for birth
management. Gender was seen to be determining variable in the way power
was wielded. Control of this variable was assumed to be within reach of
directed feminist effort as more women entered medical school. As women
enter the profession of medicine in increasingly greater numbers however, it
has become evident that liberal feminist assumptions regarding the influence
exerted on the quality of patient care by the gender of a health care provider
were uninformed. While their assessment of the impressive power of the
health care institutions to shape behavior and norms was correct, it is this
same power manifested in the profession of medicine which causes women as
physicians to identify with the values and norms of the profession over those
of gender. Consequently, it turns out that the type of care women offer as
physicians does not significantly differ from that offered by men as
physicians.

Consumer choice in a free market is upheld as a cherished classical

liberal right within the United States. If current common practice by

 

83

childbearing women in the United States can be construed to indicate
autonomous “choice”, then it would appear that there is a clear consensus that
the ideal model for normal childbirth is for it to be technologically,
pharmacologically, and surgically managed within the confines of a hospital,
attended by a physician. Over the past eighty years in the United States the
medical model of birth has indeed replaced most other models to become the
dominant model for normal birth. Yet a simplistic assessment that this is
indeed the ideal (best/safest) way to give birth belies the influence and
coercion of power, politics, and financial gain entrenched within social
institutions that serves to shape social behavior and social policy. The
frequency of technocratic physician-attended hospital birth reflects neither
individual choice, a range of birth options, nor the best in scientific or
clinical wisdom; it reflects the manufacturing of consent by the professional-
medical-industrial complex (Mehl, et. al. 1980). Within this context, choice is
illusory. Perpetuation of such an illusion satiates those who want to believe
that a model of classical liberal choice insures that one will be able to
influence and control their own care. The liberal feminist agenda was based
on an erroneous assumption that women were free social agents who could act
in their own best interests. Knowledge regarding alternative birth
management is inconsequential when options are limited by the multiple
influences of socialization, technology, power, authority and control
evidenced within the medical model

Germane to the issue of “choice” of birth location and birth attendants
are the political, social and economic contexts within which they occur; the
political economy. As such, one must contextually frame the issues of current

childbirth practices within their political and economic climate before

84

facilely assuming that the popularity of this current practice implies either
ideal experience or individual choice. The same may be said about the
assumption that individuals lacking health insurance prefer to choose lack of
insurance as an option, since choice is shaped by the availability of options.
Options in any arena are commonly delineated and limited by the powerful
within a given system of control. The history of the medicalization of birth
provides clues to the development of our current birth practices, which are
intimately linked to the rise in dominance and authority of the medical
profession. Critical assessment is required to uncover the influence and
coercion of power, economics and politics in shaping the norms of social
behavior and social policy in childbirth practices.

A major weakness in the liberal feminist approach was that it focused
on individualized efforts. Individualized efforts proved to be ineffectual
because they did not adequately address, nor challenge, the shifting power
relations underlying medicalized childbirth in the United States. Power
belongs to the institution (Jordanova 1989: 154). Issues of gender and
knowledge are handmaidens to larger social, cultural, and economic
constructs. The trajectory of institutional effort responds not to the concerns
of individuals for reform but to institutional needs and interests; interests
which represent the concerns of those in power which are currently
buttressed by escalating economic pressures.

One of the aspects of the underlying assumption behind liberal feminist
efforts, that increased knowledge would translate into increased power for
women and that this power would then translate into improved maternal and
child health proved not only to be naive, but also had several unforeseen

social consequences. First, women who embraced the notion of childbirth

 

85

education and preparation as a tool of empowerment, and participated in
childbirth classes as a way to participate in decision making at the time of
their birth, were, as a result of their participation in decision making, likely
to accept individual responsibility for a childbirth experience that went other
than expected. They then failed to see that their experience was reflective of a
larger pattern of social influence. Second, when liberal feminists articulated
the health agenda they assumed to be most deserving of attention, they
manifested a singular and somewhat exclusive identity agenda. Moving
forward as if they were speaking with one voice, they univocally proclaimed a
relatively narrow and self-interested agenda. Inattention to social location
resulted in an agenda that was partial. Social location constrains the range of
available choices for one’s role in life. The assumption of univocality allowed
them to believe that they were speaking with one voice, a voice that
represented a women’s health agenda most deserving of public attention,
resources, and reform.

Attention to the highly visible middle- and upper-middle—class agenda
served to divert attention from public health issues which, if given adequate
resources, could much more significantly influence the health of mothers and
their babies. Hence the liberal feminist agenda was inadvertently
complicitous in focusing choice and responsibility at the individual and
personal level, when the reality of this context was that personal choice and
responsibility for such choice is institutionally controlled. Maintaining a
focus on the individual level diverted attention from the public health
concerns and health issues of everyday life. The consequences of defining
women's “health” reality with a singular focus on reproduction proved to be

reductionist, with far-reaching yet certainly unintentional results for

 

86

minority women. Careful scrutiny reveals that the “default” consciousness of
majority feminists allowed them to refer to their own priorities to define the
most pressing feminist issues needing attention. Problematically, the self-
determination model paid inadequate attention to other factors such as race,
class, and institutional power; factors which are potentially limiting within
the social hierarchy due to gross systemic inequities.

Building on the conceptual contributions of Michel Foucault (1978)
whose insightful scholarship provided the tools for analysis which revealed
the body to be a locus of social control, philosopher Susan Bordo points out

that,

...the discipline and normalization of the female body—perhaps
the only gender oppression that exercises itself, although to
different degrees and in different forms, across age, race, class,
and sexual orientation—has to be acknowledged as an amazingly
durable and flexible strategy of social control (Bordo 1992: 14).

Consequently, the illusion of consensual decision making is a construct both
manufactured and perpetuated through the hegemonic social institution of
medicine within the United States (Herman and Chomsky 1988). Further, I
maintain that the final influence exerted by the economic gains at stake will
result in the total institutionalization of power relations, subjugating
biological birth to the expedient and legally reified dictates of a
technologically driven medical model of childbirth management. The ultimate
consequence is, perforce, the complete subjugation of physiological birth to a
medical model where women are reduced to technologically manipulated
vessels-~where birth is scientifically and artificially accomplished through

manipulation, management, and control to result in--the death of birth.

CHAPTER 6
CONCLUSIONS

Mid-twentieth century second-wave liberal feminists were largely
ineffectual in their attempts to either decrease or even to slow the rate of
technological, pharmacological, and surgical intervention in women’s birth
experiences. The initial second wave feminist focus on health care was solidly
grounded on the twin American cornerstones of individual choice and
individual control. Such a focus mistakenly assumed that if one could only
substitute female control for male control and educated choices for blind trust,
then available health care choices would be woman-centered and thus better;
better for women exerting their individual and educated will in choosing
sympathetic birth attendants while simultaneously eschewing a minimum of
technological, surgical, and pharmacological intervention to effect a desired
outcome.

liberal feminists were aware of many of these issues, but they lacked
the insights offered by more recent analytical tools which currently guide
such analyses. In these current analyses, the significance of both the political
economy of a system is revealed as well as that of the intersection of race,
class, gender, and social location. Policies reflect the priority of the structure
over values and principles. Within the present for-profit, institutionally-
controlled and regulated system of care, the incentives are largely weighted
towards making available those choices which further economic gain. As

long as birth occurs within a for-profit institutional setting, institutions will

87

control and dictate the parameters of the experience to meet institutional ends.
As long as women have doctors attending their births, their births will be
managed along the lines of physician dictates. I propose that these are the
most important variables to manipulate to influence both the experience and
the outcome of childbirth for women. If as feminists maintain, birth is not a
medical event, then it necessarily can and should be moved out of hospitals
and away from physician management.

As we face the next century, it is certain that changes are coming
within our current for-profit health care industry. Yet the shape of such
change is as yet, unpredictable. Certainly such a climate of change offers a
unique opportunity to incorporate an honest and fair evaluation of the merits
of alternative models of birth. Health care reform efforts which reduce health
care costs by decreasing technological dependency while improving outcome
are surely a worthy goal. A review of international practices in the available
literature suggests that a viable alternative model for normal birth has always
coexisted; the midwifery model. The midwifery model is “highly beneficial in
that it is primary care, is safe, enhances access, meets needs of virtually all
childbearing women, involves judicious use of technology, is associated with a
favorable liability record, is well-received by childbearing women, and is
cost-effective” (Women’s Institute for Childbearing Policy 1994).29 A
predicted future reliance on physician extenders, including nurse-midwives,
will probably somewhat change the nature of the current birth experience
(Annandale 1988). But if the profit incentive is allowed to remain within this
future plan of care, there is little to suggest that midwives will take a path that
differs significantly from that revealed by this examination of the medical

model of childbirth in the United States.

88

END NOTES

1. See Burt Ruzek (1979) for a discussion of the political struggles involved in
the convergence.

2. Anthropologist Robbie Davis-Floyd coined the term “technocratic birth”
(Davis-Floyd 1992: 5) to describe this type of birth model. In this thesis, I use
the term technocratic birth interchangeably with the more common term, the
“medical model” of birth.

3. In Medicine and the Management of livinngaming the Last Great Beas_t
(1984: 166) sociologists William Amey and Bernard Bergen erroneously cite
prepared childbirth as an example of the way in which medicine responds to
challenges, “the rapidity with which medicine responds to such proposals is
striking and is a distinguishing feature of medicine today.

4. Ludmilla Jordanova notes in Sexual Visions. “historians of women can list
institutions...that exercise power over women...many would see medicine and
natural knowledge as prime examples of such institutions” (Jordanova 1989:
154).

5. This book was originally published as In Labor: Women and Power in the
Birthplace (Katz Rothman 1982)

6. The term normal contextually situates birth within the dominant medical
model which controls the representation of birth. While these women talked
about birth as a normal, non-pathological event, the overwhelming majority
of women in my classes planned to birth in a hospital. During my teaching
tenure, nurse-midwives were not available to my clients since they (nurse-
midwives) had been unsuccessful in obtaining hospital privileges within any
local hospitals. Thus my clients had the choice of homebirth with a lay
midwife or a physician-attended hospital birth.

7. Sociologist Barbara Katz Rothman (Katz Rothman 1991) notes that the
medical model represents all birth as risky, either high risk or low risk.

8. Certainly all of the technological, pharmacological and surgical
interventions involved elements of pain, uncertainty and danger, but these
risks were silently absorbed within the framework of the medical model as
acceptable risks.

9. Howard Brody notes in The Healer’s Power that physicians generally hold
socially delegated authority to label what counts as medical truth. As a result
of this socially delegated authority a physician can “make something be the
case simply by saying it is so.” (Brody 1992: 17).

10. Much has been written about the way in which the litigious social climate
within the United States has served to influence physician behavior. It has
been demonstrated that physicians practice defensive medicine by both
ordering excessive testing and aggressively employing available technology

89

which are strategies which hold up a physician’s defense in the courtroom.
Many of my clients cited physician’s fear of losing a malpractice lawsuit as a
reason behind the escalating rate of cesarean deliveries. In a 1979 report
requisitioned by the US. government’s Department of Health, Education, and
Welfare titled An Evaluation of Cesarean Section in the United Sta1e_s, public
health consultant Helen Marieskind points out that the dramatic rise in the
rate of cesarean sections predated the increase in malpractice suits, dispelling
the speculative correlation between these two events.

11. In the classes, I used a role-playing strategy to teach my clients how to
garner information necessary to make decision. In the role playing, I took the
part of various physician figures who were some combination of
authoritarian, compassionate, exhausted, etc. I had the women and their
partners practice the following questions in order to gain information
necessary for situational evaluation and decision making: “Who are you,what
are you here for, what are you suggesting, why are you making this
suggestion, what are the risks (to the woman-the baby), what are the
alternatives to this suggestion--including doing nothing?”

12. I am indebted to Kip Kozlowski, CNM, for this insight.

13. This midwifery service will be explored in greater detail later in the thesis.
A history of this service can be found in “Mary Breckenridge, The Frontier
Nursing Service, and the Introduction of Nurse-Midwifery in the United
States” by Nancy Schrom Dye in Women and Health in America ,Judith Waltzer
Leavitt, ed. (1984).

14. Poet and feminist scholar Adrianne Rich recognized the limitations of the
early feminist agenda: “conditions which affect the majority of women in
labor - poverty, malnutrition, desertion by the father of the child, inadequate
prenatal care...are not the issues being addressed” (Rich 1976: 169).

15. Information on recent birth statistics is available from the National
Center for Health Statistics, “Advance Report of Maternal and Infant Health
Data from the Birth Certificates, 1990.”

16. The story of the very successful premature marketing of the electronic
fetal monitor carefully researched and documented by Judith Kunisch in

Healing Technology: Feminist Perspectives (Strother Ratcliff 1989), is a good
example of this phenomena.

17. Citations given in this text refer to those the second publication Giving
Birth: Alternatives in Childbirth (Katz Rothman 1984).

18. I make this judgement based on information obtained from a combination
of three sources. First, from my client’s birth stories as they were related in
each final session of classes over my eleven years of teaching. Second, from
information provided by labor and delivery nurses, physicians and medical
residents who attended my classes. Third, through information provided by
“inside “sources who were available to me as a result of my working with local
hospitals in a consumer advocacy organization during this same time period.

90

19. Standard of community is terminology used to refer to accepted guidelines
for what is considered good practice within a profession. For specialists, these
guidelines are established within the specialty at a national level. For general
practitioners, the guidelines are drawn from what is generally considered to
be good practice within a given geographic region.

20. This data was provided by local hospital representatives at a meeting of the
consumer group mentioned in endnote 18. This finding is in agreement with
the rate of cesarean sections noted nationally.

21. Again, I was privileged with access to this information from the same
sources noted in endnote 18. I also had the information corroborated by a local
pediatrician which I mention later in this text.

22. This same hospital had a 25-30% cesarean section rate (personal
communication). Given such a statistically high chance of obstetrical surgery
for laboring women, within this framework, this reclassification can be
viewed as entirely justified.

23. While I was certainly sympathetic to this physician’s concern about the
“other patient” i.e., the fetus/baby, I was also concerned about the increased
risk to the mother. There is a curious prioritizing of interpartum risks
whereby risks to the neonate frequently displace concerns about risks to the
mother.

24. When I discussed the marketing of epidurals in my childbirth classes, a
common response from nurses and physicians attending the class was to
protest that this was not a marketing strategy, it was a response to consumer
demand. This calls to mind an introductory quote by Milton in Manufacturing
Consent (Herman and Chomsky 1988) “they who have put out the people’s
eyes, reproach them of their blindness.”

25. The concern here is that there is a potentially mortal risk of aspirating if
vomiting occurs while under general anesthesia.

26. In her evaluation of the women’s varying class-specific responses to
different models of childbirth, Nelson (1983: 296) describes one interaction in
which a physician challenged a woman who was responding to labor pain by
screaming, with a threat of making her “go natural.”

27. As Kip Kozlowski, CNM observed when evaluating obstetrical outcomes
“Punishment is about breaking the rules.”

28. More serious outcomes in birth including death of the mother or baby are,
in the current litigious climate, most often delegated to the judicial system to
ascertain culpability; and fortunately, such occurrences are quite rare in a
population of healthy women.

29. A collaborative position paper by the Women’s Institute for Childbearing
Policy, “Childbearing Policy Within a National Health Program: An Evolving

91

Consensus for New Directions” combines the insights of four major women’s
groups working on health care issues including the Boston Women’s Health
Book Collective, the National Black Women’s Health Project, the National
Women’s Health Network, and the Women’s Institute for Childbearing Policy.
Their collective expertise provides the most comprehensive plan to date for
implementation of such a program

92

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93

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