Childbirth Advice Literature As It Relates to Two Childbearing Ideologies
Address correspondence to Jane Pincus, P.O. Box 72, Roxbury, VT 05669.
I write this article as a women's health advocate who has long supported midwifery and worked for changes in obstetric and maternity care. As co-author of the pregnancy and childbirth chapters in the women's health book, Our Bodies, Ourselves, for 31 years I have been gleaning childbearing experiences from hundreds of mothers, supplementing their stories with information I find in books by childbirth educators, social scientists, and maternity care practitioners.
This essay represents the evolution of my own thinking. Through my writing I always sought to empower women by creating a “climate of confidence” in which they could be pregnant and give birth ( 1). Yet, the “medicalized” language and hospital routines surrounding childbirth in the 1960s, my own experiences of giving birth to my daughter and my son (awake, but with many interventions), and my ignorance about midwifery philosophy and practice meant that my writing, despite my best efforts, was oriented toward the medical world. I reacted against its strictures without knowing about any real alternatives.
During the seven successive updates and rewrites of Our Bodies, Ourselves, a new generation of midwives surfaced. I have had the good fortune to become engaged in an ongoing, nurturing, and challenging dialog with an independent midwife friend, and to be present at my friends' births, at home and in hospital. My thinking and attitude slowly changed, a process that continues to this day. Now, when I read, write, or speak about childbearing, and listen to others, I measure my own words and attitudes and evaluate theirs in the light of the vision that follows.
Woman-Centered Ideology and Care
Imagine a society in which true woman-centered childbirth exists, placing mothers at the heart of the childbearing experience. Its institutions value women's strengths and perceptions of their needs and pay careful attention to the social, economic, spiritual, and emotional circumstances of their lives. It views childbearing as a creative, healthy, joyous life transition, and the actual birth process as worthy of great respect. Women are treated with dignity and trusted to know or to learn what they need to know to be healthy, to give birth well, and to care for their children. Compassionate, experienced midwives “journey with” women during pregnancy, labor, and birth, offering information, reassurance, support, and continuity of care. These midwives, integral members of their communities, learn their craft through apprenticeships, in midwifery schools, and occasionally in hospitals. Babies are born in homes, in community birth centers, or in hospitals when necessary, with the community providing resources to nurture and support every child. Family physicians and obstetricians hold women, motherhood, and midwifery in high regard. As medical and surgical specialists, they provide backup when needed, in consultation with the attendant midwives, in homes, birth centers, or nearby hospitals.
Reading Childbearing Information and Advice Books
The childbearing information and advice books written over the past three decades have reflected the two significant and sometimes conflicting ideologies and trends in current maternity care: an expansion of options represented by the advent of nurse- and lay-midwifery practice and the creation of birth centers, and an increasinglymedicalized perspective, resulting from the consolidation of obstetric power and the development of ever-new technologies.
I was intrigued to find that it was only the rare writers, some of them laywomen, most of them midwives, who presented a woman-centered, midwifery point of view and offered a strong, clear, consistent, positive message ( 2–10). Very few current books follow that same clear path ( 11–13; Leonard C, unpublished manuscript, 1998). Most authors, in contrast, after encouraging women to value their own needs and desires and to learn as much as possible so as to make “informed choices,” send their readers directly into the arms of the obstetric establishment. Throughout the 1990s, I worked on a Critique of Childbearing Advice Books addressing this subject (Pincus J, unpublished manuscript, 1998).
Obstetric Ideology and Practice
Obstetrics, a surgical subspecialty, dominates maternity care in the United States. Its concerns about risk and death form the philosophical base of practice, engendering fear in women and practitioners alike. It treats every woman's pregnancy as a potential illness, and birth as a purely medical event ( 14). Obstetric care is invaluable when treating women whose pregnancies have medical complications. Most physicians view labor as unbearably painful and much too long, and birth as excessively messy, risky, and dangerous. Common obstetric practice relies on extensive testing, monitoring, probing, intrusion, and interference during pregnancy and labor, using drugs, devices, and procedures that have become the norm simply because they exist, their risks often undisclosed, their benefits—safety, necessity, effectiveness—commonly unproved in any truly scientific way ( 15–25). Obstetric practice imposes a cascade of interventions on labors that would usually progress at a natural, harmonious rate in less coercive circumstances ( 26). Hospitals, modeled on factories organized around the clock, have rules, schedules, and routines of their own that interfere with the unique flow of each woman's labor.
Reinforcing Obstetric Ideology and Practice
It is vitally important for readers to ask whether these two ideologies can coexist or must inevitably clash. Because obstetrics dominates maternity care, authors of childbirth advice books feel compelled to become engaged with its narrowly focused ideology. It dictates the priorities to be addressed and tolerates little deviation, obliging writers to justify their more woman-centered point of view to their readers as if an obstetric eye and mind were hovering on the horizon. It requires them to use the words and categories of the system they criticize, even as they try to help readers strategize against conventional medical practice. Such books are less about the wonder, joy, and challenge of having babies than about coping with the atmosphere, tests, and routines of a medical establishment that might be amenable to their needs and desires, but would most likely oppose them. Although each book contains a great deal of information and pearls of wisdom, the authors' language, tone, content, and organization of material often run counter to their aims. Informing women does not necessarily mean empowering them. Echoing obstetric ideology, either by countering it or condoning it implicitly through the wording and organization of their books, many authors offer mixed, confusing, and negative messages.
It is imperative (and sobering) to reflect on the language used in most advice books. No sooner do authors mention women's strengths, abilities, complex emotions, worries, and wishes, than they engage in medical talk of “low- and high-risk pregnancies,”“safety,”“difficulty,”“problems,”“false labor,”“normal labor,”“pain control,” and “outcome.” Descriptions of pregnancy are entangled with lists of prenatal diagnostic tests, and discussions of labor with all the things that might go wrong, so that a woman cannot easily read how an uninterrupted pregnancy might flow and flower, how labor enabled to run its course might intensify, ebb, and reintensify as her baby emerges into the outside world. Women are compelled to look outward instead of being encouraged to focus on their deeply felt experiences, to believe in their intuition and ability to deal with the intensity, the pain, and the exhilaration of labor contractions. Although the well-intentioned authors of these books want to help women cope with a complicated obstetric system, their information only goes so far. Entering the obstetric system itself serves to reinforce apprehension and fear. Most childbearing women today, like their doctors, do not believe that they can give birth without a great deal of pharmacologic and technological help.
I have chosen several books to illustrate how authors combine positive and negative elements, and how the negative is emphasized. One book begins with “a normal pregnant woman is healthy, not ill,” introducing the idea of illness right from the start—why place it there? It continues, “While pregnancies are usually monitored by doctors or midwives to make sure things are proceeding normally, that does not mean something is likely to go wrong” ( 27, p 7). Another introduction, entitled “Obstetric Management: What's Wrong With This Picture?,” states that “things have gone terribly wrong with maternity care in this country.” It lists cesarean sections, fetal monitoring, epidurals, and episiotomies in the first two pages ( 28). Chapter Five in another current book is called “Tests, Technology and Other Interventions That Happen on the Way to Birth” ( 29).
Note also the organization of information. A book's table of contents, and the internal chapters' subject headings reveal an author's instructional itinerary. For instance, most authors place descriptions of obstetricians and family practitioners before midwives, hospitals before birthing centers and homes. Ordered according to the most common practices, this predictable line-up gives readers the message that midwives come last, even while midwifery is being described as desirable and the appropriate care for most women.
A popular book ( 30) begins with “What Women Want.” This book contains important insights about women and birth. It is refreshing to hear women's voices, enlightening to read about the studies that support their desires, and heartening to see in a second tiny chapter, “The Pleasure Principle,” that childbearing has something to do with sexuality and sensual enjoyment. But all too soon the book veers off in another direction. “If You Don't Know Your Options, You Don't Have Any” has a punitive ring (and what about all those women who do not read childbirth advice books and who have no way of learning about options—are they doomed to be “done to”?). Midwives, mentioned a few times, disappear as the next four chapters describe obstetricians' practices in great detail. Only at the very end do we read about childbirth support groups and how to have a “normal” vaginal birth. Although the authors' laudable aim is to warn readers that obstetricians acquire a set of priorities, beliefs, and mechanisms for survival during training and practice that conflict with a woman's desire to take (or share) responsibility, dwelling on obstetrics at such great length in the middle of the book reinforces the power of the medical establishment.
It can be confusing to choose among the plethora of ideas and suggestions. In a list of pros and cons describing epidurals, in one book the elimination of pain is a “pro.” Five pages later one reads that “the pain … of normal labor ha(s) value for both you and your baby … pain guides you … Your body responds to labor pain by secreting adrenalines and endorphins” ( 28, p 138). Hog many viewpoints are represented here? Is pain good or undesirable?
A Difficult If Not Impossible Mandate for Women
All caregivers have seen or heard about indignities suffered by women in labor. In an effort to prevent such occurrences, educators and authors advise women to learn about their strengths and capabilities while zeroing in on the coercive aspects of physician-dominated care—offering options to a woman is only useful if her choices will be honored. They exhort women to “negotiate” and “fight” for that “natural” birth while simultaneously listing the tests and interventions to be circumvented, if possible, somehow (one book lists 22 prenatal interview topics). Too often, the struggle must take place in the midst of labor, even when “birth plans” have been drawn up. Women are urged to wield their amazing ability to give birth in the very atmosphere that stifles and mutes childbearing in all its depth and dimensions. When a woman is fighting for or against, she is not free to attend to herself. Nor, despite the information she absorbs, can she ever foresee all of the possibilities that may arise. Encouraged to develop offensive or defensive strategies, or a combination of both, mothers find themselves in the insupportable position of having to depend on the people they are strategizing against. A woman seeking a “natural” birth feels tense, because she is under assault, having to prove herself, to produce a perfect experience out of the choices she has made. Often she has to give up her autonomy bit by bit. No wonder that she gives in to the imperatives of the medical machine. No wonder that, her thoughts teeming with “should haves,” she blames herself when she “fails.”
Only women who live in an area offering many kinds of practitioners, who are not bound by regulations of their health maintenance organizations or by restrictive insurance policies, who have time and money to look around, who have a supportive community around them, or who have the ability and luck to identify and live out their desires for autonomy may have their babies the way they want. Few childbearing women in the United States enjoy those opportunities. Our society is structured to remove childbirth from the context of women's everyday lives, and to deny most of them easily accessible alternatives to medicalized childbirth.
Concentrating on childbearing has always led me to ask deeper questions: how do women acquire knowledge? What do they want, and why? Is it possible, reasonable, or kind to expect them to think through alternatives in advance, negotiate, become active, assertive, and persistent, when, in a different “climate,” they would not need to do all that?
Why educate one side of the equation, women, when obstetricians, health maintenance organizations, and drug and insurance companies are not basically affected? Is it any mystery at all why so many obstetricians discount midwifery care, even though it has been proved appropriate, fulfilling, and cost-effective for most childbearing women?
How do advances such as birthing rooms, birth centers, nurse-midwifery services, doula support, and rooming-in influence conventional obstetric care? How is it possible to be responsible to the majority of women who do not read books, watch videos, or access the Internet? Many economic, social, and ideological forces prevent access to whole-woman care; what initiatives and organizations have improved maternity care policy (locally or nationally) in ways that make a difference? What constraints and fears make practitioners and educators hesitant or unable to go “too far” in their critique of the existing system? How can they address these issues, both in their daily lives and in yearly conferences?
I echo Armstrong and Feldman's lament about how strange it is for those who believe birth to be about love, kindness, and dignity to find themselves on the outside, how incomprehensible that they are called radicals and reformers, and how absurd that they must lobby, organize, and negotiate to get others to notice that birth has a human dimension ( 31, p 236).
We do not woo women into giving birth. We do not trail our fingertips in the beds we've made up, anticipating their coming. We do not bake their favorite bread, pick flowers, hurry down the path to greet them, settle down with them … We do not touch them, rejoice in them, admire them, laugh with them or stand by them. We do not treat them as if they were all our daughters, whom we have adored and who are taking up major work. We have chosen to show little love.
Pregnancy and childbirth technologies are proliferating wildly. Because they make up an integral part of medical training and hospital “furniture,” physicians and nurses will continue to believe in them and to use them regardless of their risks and benefits to women and newborns, and of their physical, emotional, and spiritual effects on mothers. Media, including television, magazines, films, and even the Internet will always reflect the dominant attitude toward birth. Mothers with new babies, describing encounters with and submission to obstetric procedures, are weaving their birth stories into our culture, alarming younger women, inclining them toward medicalized births, increasing their reliance on interventions. It is indeed a vicious circle.
Maternity care professionals may risk jobs or licenses if they protest this state of affairs. They may be labeled as extremists, or, if they work outside the prevailing system, lack credibility and power. It can be counterproductive to confront, much less try and halt the medical juggernaut. Any attempts to change the system must take into account both the vested interests of drug and equipment industries and technologically slanted medical education.
Fruitful dialogs will be likely only when people can change their point of view. Change is possible ( 32,33). Further reforms will be achieved only by combining massive grassroots organization with widespread medical leadership. Wise women and men—the many mothers, midwives, educators, compassionate maternity care professionals, and advocates for childbirth reform—must continue to imagine what could be.
In fact, I have not yet addressed the most pressing issues for childbearing women. The undue emphasis on technology, testing, and intervention diverts attention and resources from creating preventive strategies that would enable the vast majority of women in the United States to give birth well. Efforts should be concentrated instead on dispelling poverty and ignorance, providing sex and parenting education to teens, providing safe and dependable contraception, eliminating environmental hazards, making good food available to all, and developing a wide and varied network of social supports for women and families.
Childbirth educators and authors throughout this century have been crucially important in bringing to light women's desires for humane childbirth practices and comprehensive maternity care, and identifying the indignities of the obstetric system ( 34,35). They owe everyone the fruits of their knowledge and experience by carrying their combined analysis of conventional obstetrics to its logical end—envisioning and working toward a woman-centered, midwifery-based maternity care system.
I wish to give special thanks to Judy Luce and Diony Young, and also to Barbara O'Sullivan.