Childbirth embodiment: problematic aspects of current understandings
Address for correspondence: Denis J. Walsh, 366 Hinckley Road, Leicester, LE3 0TN
The experience of childbirth is one of the most corporeal of the human condition. Against a backdrop of profound change in the milieu of birthing over the past 30 years, especially in the developed world, a number of discourses now compete for the status of the safest, most fulfilling birth experience. Supporters of biomedical and ‘natural’ approaches make their respective claims to those, with obstetricians broadly aligning their professional interests with the former and midwives with the latter. There is mounting evidence that childbearing women’s experiences of birth are often shaped in the uneasy space between the two. Within sociological discourse in health, embodiment is a dominant theme but, to date, research has concentrated mainly on new reproductive technologies, and there is a dearth of recent research and theorising around the act of parturition itself. This paper argues that because of this, there has been a polarising tendency in current discourses which is having a largely negative impact on women, professionals and the maternity services. A call is made for an integration of traditional childbirth embodiment theories, mediated through compassionate, relationally focused maternity care, especially when labour complications develop.
Extensive engagement with the sociological concept of embodiment in research and scholarship around childbirth would seem axiomatic. The experience is so ‘carnal’, so grounded in the ‘corpus’ that one would expect academic scholarship in maternity care to prioritise its research. However, for a variety of reasons, this is not the case and this paper’s contention is that the omission has had negative consequences for consumers and professionals alike. In particular, the arena of childbirth has been colonised by contrasting approaches to the body that stifle the realisation of humane maternity care. These approaches emanate from an impoverished concept of embodiment which urgently needs to be superseded as we move into a postmodern age.
This paper discusses theories of embodiment and how they have been applied to childbirth, before exploring their rather vexed intersection with agency, especially when birth complications arise. An attempt is then made to synthesise the strands, and, using ‘relationality’ as a conduit, develop an approach that might maximise agency within a more fluid interpretation of embodiment.
Contemporary childbirth is dominated by a variety of discourses – medicalisation, natural childbirth, androcentric models, woman-centred models and risk (Walsh 2007a). These tend to be most explicit at a theoretical level in academic papers and books (Davis-Floyd 2001, Martin 1987, Fahy and Hastie 2008, Reiger and Dempsey 2006). In practice, their edges are more blurred (van Teijlingen 2005), though almost universal hospital birth (95% in the United Kingdom, Health Commission 2008) arguably reflects the ubiquity of risk and medicalisation. There is evidence now from Canada (Reime et al. 2004), Italy (Monari et al. 2008) and Australia (Turner et al. 2008) that the beliefs of obstetricians and midwives differ regarding what constitutes a desirable birth. Midwives work across a range of settings and there is emerging evidence that even though they may be caring for low-risk women, they adapt their practices according to the context (Hunter 2003). These vagaries in attitudes and practices may be problematic for child-bearing women because they could result in pigeon-holing their experiences according to clinician preference.
Evidence that all is not well in maternity services is replete in the literature. There is ambivalence and debate in a number of areas, including the gains and losses attributed to medicalisation of childbirth (Johanson et al. 2002) and the relative merits of childbirth technologies (Williams 2006). The area of pain is highly conflicted (Lally et al. 2008, Leap and Anderson 2008) and finally there is the considerable body of literature on professional territorialism, particularly between obstetrics and midwifery (Witz 1992, Donnison 1988). Against the backdrop of these tensions, there is significant research detailing women’s experience of post-traumatic stress syndrome in birth (Ryding et al. 1998,Ayres et al. 2006,Creedy 2000) and of the relative new diagnostic category of tocophobia (morbid fear of labour) (Wax et al. 2004, Hofberg and Ward 2004). Additional papers tell of midwifery disillusionment with practice (Curtis et al. 2003) and decreasing appeal of obstetrics as a specialty (Royal College of Obstetricians and Gynaecologists 2006).
The literature review objective was to identify all published papers that had engaged with the notion of embodiment in relation specifically to giving birth. Ten health and social science databases were searched for dates from 1990 until August 2008. Search terms were ‘embodiment’, ‘body’, ‘childbirth’ and ‘birth experience’. These were searched for using Boolean operators and truncations and then results combined to narrow the field. Relevant papers were then scrutinised and ‘berrypicking’ (Bates 1989) enabled further books and book chapters to be indentified. When papers on new reproductive technologies were excluded, only five childbirth papers were identified that used the term ‘embodiment’ in the context of giving birth or the experience of birth. However, numerous research papers using phenomenological method adopting the term ‘lived experience’ were included in the review. Wider sociological literature on embodiment helped flesh out the evolution of theorising the concept.
Embodiment in sociology
Embodiment is a relatively new concept in sociological studies but in the last 20 years there has been a burgeoning of interest and hence increased attention paid to it (Nettleton 2006). At a lay level of understanding, it has to do with the nature of physical experience as mediated through the body, though theorising has explored both the body’s shaping of experience and the social world, and being shaped by it in return. Shilling (2003), in particular, traces the development in the field of body studies, explicating in depth these two approaches of naturalism and social constructionism. Gabe et al. (2004) add to these the phenomenological approaches which grew out of a reaction to the mind/body dualism of the Enlightenment. Phenomenology highlights the totality of lived experience, emanating from the connections between physical, psychological and social dimensions. In addition, critical perspectives to embodiment have been foregrounded by Foucault (1973), Bourdieu (1986) and feminist writers like de Beauvoir (1974) and Martin (1987). These argue that vested interests and social conditions seek to secure jurisdiction over the body and regulate its behaviour. Within this complex mix, a tension between personal agency and social structure is played out. The childbirth literature at both policy and practice level, and in academic theorising, reflects this agency/structure tension with the former framing this as informed choice and notions of control (Department of Health 2006, Kirkham 2004, Green 1999) and the latter as autonomy and compliance (Shaw 2002, Crossley 2007, Tanassi 2004).
The principal embodiment theories are elucidated in more detail below.
The natural body
Shilling (2003) summarises this position as holding ‘that the capabilities and constraints of human bodies define individuals and generate the social, political and economic relations which characterise… patterns of living’ (2003: 37). Thus the body becomes the source of social relations and human behaviours. For much of the last 200 years, because gender has been conflated with sex, the naturalistic position has had a largely negative impact on women in childbirth. Male anatomy and physiology was, until the last 30 years, the template for normality (Lawrence and Bendixen 1992) with female physiology viewed pessimistically and suspiciously. Legacies of this can be seen in the prefix ‘hystero’ meaning womb but also aligned with madness and the view that women’s bodies in childbirth were anarchic and unpredictable if left to their own devices (Briggs 2000). Arguably, the justification for the medicalisation of childbirth, in part, lay with the belief that female physiology was flawed (Martin 1987). The Enlightenment period reinforced this by promoting the separation between mind and body (Cartesian dualism –Davis and Walker 2008) with the body becoming the object of dissection and examination. One effect of this was that the understanding of childbirth became reductionist with women’s bodies analogous to a machine (Garcia et al. 1990). Its susceptibility to breakdown is reflected in diagnostic terms like ‘failure to progress’ and ‘incompetent cervix’ (Hunter 2006).
Thus, the natural body strand of embodiment resulted in an essentialist view that the female body was defective, and encouraged the introduction of various drugs and obstetric procedures to regulate and control labour and birth. However, since the 1970s, there has been a feminist backlash against patriarchal views of the female body and the medicalisation of birth (Oakley 1984) with some feminists endorsing an essentialism at the other end of the spectrum, reifying natural birth (Kaplan and Rogers 1990, Daly 1984). Consumer groups (Beech and Phipps 2008), midwives (England and Horowitz 2007) and some researchers (Davis-Floyd and Sargent 1997, Walsh 2006a) appear to align themselves with this position. Annandale and Clark (1996) and Michie and Cahn (1996) apply the line of argument of post-structuralist feminists, critiquing both the natural childbirth discourse as replacing one hegemonic discourse with another and the simplistic conflating of midwifery with woman-centred approaches. The belief that birth should be natural also resurrects gendered constructs previously critiqued as problematic for women who like home as the appropriate private, domestic domain for birth and intuition/nurture as inherently female traits (Beckett 2005).
Essentialist positioning implies both an objectivist epistemology and ontology that is exclusionary and marginalising to other perspectives (Dyson and Brown 2006). If the view is held that knowledge is ‘out there’, reflecting an ‘always true’ reality, then dichotomous thinking follows, because what is real is either empirically verifiable or not. There is little room for equivocation or uncertainty (Downe and McCourt 2008). Proponents have a tendency to take up contrasting views that birth should either be medicalised or natural, childbirth physiology is inherently faulty or trustworthy, hospital birth is safer than home birth and so on. This creates ambivalence and uncertainty when birth does not conform to prior expectations, sometimes resulting in profound disappointment and distress for women (Thomson 2007). It also aids and abets a polarising of childbirth professionals behind their respective philosophies (Blaaka 2008), causing conflict and occupational stress as Lydon’s (2008) study of birth centres in the USA revealed.
The socially constructed body
The view that bodies are circumscribed and bounded by external social effects arose in the 20th century. Post-modernist thinkers began to question grand narratives of the Enlightenment like scientific explanations and political ideologies, deconstructing their truth claims to reveal the centrality of language and discourse in constructing an authoritative version of reality (Fox 1993). Foucault (1973) had a seminal influence over this period and he, more than any other theorist, is credited with the promotion of a socially constructed understanding of embodiment (Nettleton 2006). For Foucault, various discourses produced subjectivities in bodies that regulated behaviour and experience. These effects he researched in institutional settings such as prisons where the controlling power of surveillance (‘the gaze’) produced conformity and docility in prisoners. Post-structuralist theorists like Arney (1982) have applied Foucault analysis to obstetrics to explain the medicalising and regulating of women’s bodies in labour. Feminist midwife researchers have alluded to other discourses in maternity care like a professional/client orthodoxy that inscribes a compliant ‘patient role’ on women (Kirkham 1989) and institutionalisation that endorses hierarchical positioning of staff and stereotyping of service users in busy delivery suites (Hunt and Symonds 1995).
Though social constructionism has been an important counterbalance to biological essentialism, it has struggled to address the carnal characteristics and expressions of the body. In fact as Shilling (2003) comments, the corporality of the body ‘goes missing’ behind a series of discourses that actually can only be comprehended and articulated by the mind. Even at this level, there is a debate about the ability of the individual to resist the inscriptive power of discourse so the key agency/structure tension remains unresolved.
There is no doubt though that social constructionism has added a missing dimension to embodiment that begins to posit the body as being acted on by external forces that impinge on behaviour and experience. In particular, it has introduced a critical dimension to theorising which has been picked up by other thinkers in the last 30 years including Bourdieu’s (1986) concept of physical capital enacted through socio-economic disparities.
Phenomenology and the lived experience of the body
If the body fades to the background under the power of discourse, it has a habit of reasserting its presence through the senses (Shilling 2003). Some body sensations, like pain, completely dominate consciousness and any embodiment theory that does not address sensorium will be found wanting. Merleau-Ponty (1962), the existential phenomenologist, did precisely this with his phenomenology of perception. He viewed perception and consciousness as intrinsically linked to the body. One cannot exist without the other. Central to this idea was intentionality – the way of the body being and acting in the world which was the sum of bodily experience, physicality and emotions. In this sense, a corrector is being introduced to the dominance of discourse because an individual shapes the world, albeit at a micro-level by the embodied experience of interacting with it (practical engagement). The perspective also begins to rehabilitate agency alongside structure.
Such an approach challenges the reductionism of medicalisation because bodies are so much more than the sum of their individual parts. This approach has found strong resonance with the nursing and midwifery professions. Phenomenological research into chronic illness (Lawler 1991, Iaquinta and Larrabee 2004, Person and Hallberg 2004) and to a lesser extent pregnancy and childbirth (Berg and Dahlberg 1998, Lai and Levy 2002) has grown exponentially over the last 20 years. The visceral physicality of the labour experience is unusual in foregrounding both external and internal bodily processes. Pain is an almost universal manifestation of this but, uniquely, does not generally represent pathology. For these reasons its lived experience forms a personal narrative for women that remains vivid over many years (Simkin 1991).
Embodiment understood in this way may underplay the influence of social structures but eschews any essentialism by emphasising the constructing of knowledge (meaning) by individuals as they interact with their environment. It also opens up the possibility of experientially derived knowledge sources alongside scientific knowledge. Abel and Browner (1998) suggest this is of two varieties – embodied (that which is gleaned from one’s own experience of body change or illness) and empathic (that which is gleaned from comparing one’s own account with others with a similar experience). Most women’s narratives of childbirth are saturated with this kind of knowledge (Shaw 2002, Akrich and Pasveer 2004), demonstrating a synthesis with or resistance to medical knowledge.
Childbirth and its susceptibility to binaries
These differing perspectives on embodiment can both enrich and obfuscate understandings of childbirth embodiment. The tensions they throw up for maternity services reflect the tensions in the wider literature regarding embodiment, and can be expressed as dualities: nature/culture, mind/body, agency/structure, essentialist/contingent. Before exploring ways that a reconstructed concept of embodiment could resolve these dualisms, the crises that currently afflict maternity services will be further elaborated on.
In July 2008, Channel 5 in the UK showed a documentary on freebirthing. It told the stories of three women who chose labour and birth without the attendance of any childbirth professionals. The notoriety of the programme resulted in the Royal College of Obstetricians and Gynaecologists (2008) issuing a statement condemning the practice. Freebirthing is a clandestine activity and there are no figures available as to its prevalence. Turton (2007) concludes that there are three groups of women who choose this option – those who wish to avoid medical intervention, those who believe their own body knowledge and hence self-care is superior to medical knowledge and professional care, and those who have been previously traumatised by their birth experiences and want to avoid a similar experience next time. These perspectives suggest a strong belief in a natural embodiment subjectivity, positing these women at one end of a nature/culture continuum. Theirs is a powerful expression of agency, transcending a mind/body split and probably anti-essentialist in the sense of not universalising their experience to all other women. Though they are on the fringe, they pose a challenge to maternity services that purports to be woman-centred.
A much larger group of women, though still small in percentage of overall births (with the notable exception of the Netherlands), choose a home birth attended by a midwife. Though government policy in many Western countries is less hostile to home birth than in the past, overall numbers of women choosing home birth have only marginally increased. The reversal in the ratio of home to hospital birth since the 1960s has been widely debated in the United Kingdom (Tew 1998, Mori et al. 2008) and the discourses at work here represent an alliance of biological essentialism (understood as faulty female physiology requiring hospitalisation) and culture (risk discourse). They also privilege the mind over the body (safety over lived experience). Women’s dissatisfaction internationally with options for place of birth has been shown to be related to the marginalisation of home birth (Hirst 2005, Hildingsson et al. 2003) and comparisons between low risk women birthing at home or in hospital continue to show higher rates of intervention in the latter group (Fullerton et al. 2006).
Intervention rates in labour and birth in the Western world are inexorably rising. Some years ago a review of caesarean section rates was carried out in the UK (Thomas and Paranjothy 2001) and its conclusions revealed a reductionist focus on pathology only. Only tacit acknowledgement was given in the report to psychosocial determinants of the problem. Yet, one of the unequivocal findings over the last 30 years in relation to caesarean rates is that providing women with a labour support companion reduces the rate (Hodnett et al. 2006). Additionally, there is an extensive body of research that shows labour and birth interventions are reduced by continuity of care models (Waldenstrom and Turnbull 1998) and midwifery-led models/birth centres (Hatem et al. 2008, Walsh and Downe 2004). All of these findings indicate that labour outcomes are seminally influenced by psychosocial factors and, therefore, an approach to care that endorses a mind/body split as if appropriate medical management of emerging pathology is all that matters, will be inadequate. The reductionism of the scientific method, exemplified in randomised controlled trials, promotes an essentialism in the application of knowledge and can blind stakeholders to the complexities of maternity care. The body of work just mentioned illustrates the contingent and contextual nature of childbirth.
Agency and complicated birth
Though complications of childbirth are multi-factorial in origin, everyone would agree that some labours develop pathology and require appropriate intervention. What is of grave concern for maternity services, apart from the physical morbidity and increased costs of intervention, is the considerable psychosocial sequelae attached to complicated labours and births. Lobel and DeLuca’s (2007) systematic review of this in relation to caesarean section makes for sobering reading, with long-term negative impact on self, baby and parenting. This augmented an earlier meta analysis by DiMatteo et al. (1996) with little change in outcomes over that eleven year period. There is a growing body of work by midwifery researchers regarding the psychological stress of prolonged labour (Kjaergaard et al. 2007,Nystedt et al. 2006), detailing disembodiment as a traumatising effect.
Women’s experiences of birth trauma recount common themes of poor communication and diminished agency as well as insensitive care, lacking in compassion (Beck 2006). Often their experiences are exacerbated by feelings of disappointment and guilt. Kjaergaard et al’s (2007) thoughtful paper captures the nuances of evolving trauma as women traverse through trying to balance a natural and medical delivery, and losing and regaining control. Their dichotomised thinking regarding natural and medical birth contributed to their ambivalence and distress. This kind of thinking as already stated is found in professional approaches to birth as well (Monari et al. 2008) with evidence of dysfunction and at the midwifery/obstetric interface (Davis-Floyd 2003, Blaaka et al. 2006, Lankshear et al. 2005). Both service user and maternity care professionals are suffering under the burden of quasi-essentialist and polarising versions of good and bad births. That makes the findings of Kjaergaard et al. (2007) and Nystedt et al. (2006) all the more demanding because they both highlight the role of the midwife in nurturing the woman through labour complications. This role requires her to maintain ongoing support, optimise information-sharing as clinical events unfold, and help the woman adjust to a different outcome than she was expecting.
For these key interventions to work well, the midwife needs to be free to stay as the woman’s birth companion while other staff facilitate the new interventions required. However, midwives’ narratives tell another story of being caught by competing demands from the medical staff and the woman (Lydon, 2008). This occurs because the instrumental needs of the institution take precedence over the interpersonal needs of the client (Walsh 2006a). In relation to assisting women to adjust their expectations when clinical events do not go to plan, childbirth professionals need to construct intervention not as medical rescue (Grol and Grimshaw 2003) but as collaborative team work. Decision making throughout should be consultative and inclusive. Then agency and a sense of control over events are more likely to be retained by the mother.
For obstetricians and midwives to understand ‘team’ as including the woman, even when their own skills are directly facilitating the birth, they may have to soften their professional personas and alter some of their institutionalised behaviours. A rather dramatic illustration of this was Callender’s (2007) website containing paintings of her experience of caesarean section. In one of her pictures, her newborn baby has been placed on the edge of a golf course fairway. She remarks underneath the painting that the surgeon and anaesthetist were discussing golf during the procedure so she painted the picture as a mark of protest to them disrespecting the event. As Flint (1987) stated 20 years ago, assisted vaginal births and caesarean births should be treated with the same reverence as normal births. It is still one of the most significant days in a woman’s life and, though the operating theatre is familiar territory to hospital staff, it is foreign and frightening for most childbearing women. There is a dearth of maternity care literature detailing positive examples of teamwork or multidisciplinary collaboration in partnership with women. The Ontario Women’s Health Council’s (2006) document remains one of the few published examples where teamwork contributes to a lowering of caesarean section rates. The teamwork was characterised by mutual respect for differing but complementary roles and shared commitment to normalising birth.
In relation to reframing caesarean birth as not necessarily a disappointing outcome, the following anecdote is instructive. It is a midwife’s recollection of woman’s perspective on her planned home birth. The woman had constructed this storyline about the unpredictable nature of birth. She saw preparing for her birth as analogous to climbing a mountain she had never climbed before. Her plan was, along with a companion, to take the A route which was direct and challenging but nevertheless the most straightforward (home birth). Success clearly was dependent on fine weather and her feeling well on the day. However, if weather conditions changed during the assent or she was struggling for other reasons then, she would change course (transfer to hospital), bring in reinforcements and be helped to the summit via the B route (obstetricians, hospital technologies/interventions). Either way she got to the top and the achievement was hers to savour. Callister (2004) reminds us of the power of the birth story in integrating positive and negative events into our life narrative and it may be that this way of framing, on the face of it, a disappointing outcome would facilitate this process. Every woman could be introduced to this type of narrative in advance of labour so that she can remain flexible if the need arises and all childbirth professionals could work within this framing as occasions arise. This still requires sensitive and respectful communication and decision making in labour, and attention to the environmental ambience in operating theatres but, if these areas could be addressed, birth trauma narratives may diminish.
Ethical positioning and ‘relationality’
So far no mention has been made of an ethical position, fleshing out the meaning of humane maternity care. To do this, the branch of ethical theory known as virtue ethics will be utilised and, in particular, Tong’s (1998) elucidation of feminist virtue ethics. Virtue ethics concentrates on character and character traits, rather than the formal moral rules/imperatives of deontological approaches or the outcome’s focus of consequentialism. Feminist virtue ethics emphasises the primacy of relationships in directing ethical behaviour. These relationships are characterised by equality, mutuality and respect. What flows from these encounters are caring, kindness and compassion, eschewing power and manipulation. Many of these themes already exist in the midwifery literature (Kirkham 2000), often clustering around the notion of ‘presence’ (Pembroke and Pembroke 2008) and have been summarised recently by Hunter et al. (2008). ‘Relationality’ may best capture the web of connection and reciprocity that this extensive body of literature refers to.
Virtue ethics has been criticised for not emphasising enough an end point or purpose to ethical behaviour and traditionally has espoused the Aristotelian idea of ‘eudaimonia’ (Duvall and Dotson 1998), meaning happiness or human flourishing. A similar idea has been forwarded by Downe and McCourt (2008) in relation to maternity care – salutogenesis or wellbeing. This appears to privilege healthy outcomes only, and for this reason, Kennedy’s (2006) concept of optimality, defined as the best possible outcome with the minimal number of interventions, is more applicable because it covers all eventualities, including those that arise from childbirth complications.
Humane care from this perspective then means empathic and kind care, predicated on relationships of equality, openness and trust. This needs to be sustained throughout the labour and birth experience and especially when complications arise.
Synthesising the strands of embodiment
This section attempts to map an understanding of embodiment that engages with the best of the various strands without lapsing into essentialism.
With reference to childbirth, at first glance, the naturalistic view has a heady appeal. After all, despite its fallibility, it has been extremely successful at reproducing humankind over millions of years. It is reasonable therefore to start from a position which maintains that physiology is purposeful and sufficient in the main. From an anthropological and evolutionary perspective, it can generally be trusted to ‘deliver’. Some women will develop complications that require appropriate medical and technical intervention, but these should be the exception. Epistemologically, taking this standpoint is akin to Rose’s (1994)‘constrained essentialism’. This reference point leaves open for the moment the question of the appropriateness of elective intervention in the absence of complications.
Our knowledge base around childbirth physiology has increased significantly over the last 20 years and now provides a strong platform to endorse the above starting point. The pessimism attached to prior, androcentric readings of the female reproductive system has already been alluded to and in the present the focus of most of the research in childbirth remains on pathology. A cursory glance at the Cochrane Library for Pregnancy and Childbirth where the vast majority of systematic reviews target medical interventions confirms this fact. In addition, midwifery authors have highlighted the relative dearth of research into the physiology of childbirth in non-hospital settings (Downe 2000, Walsh 2007b).
Despite these limitations, there is quite a thorough understanding of the hormonal interactions in labour which are mediated through a merger of emotional factors (stress hormones) and physical factors (labour initiating/stimulating hormones) (Buckley 2004). This understanding makes it difficult to sustain mind/body dualism in childbirth. In addition, these hormonal exchanges facilitate the release of endorphins, the natural pain-relieving agents in the body (Odent 2001). Odent has suggested that the marriage of hormones is sensitive to environmental conditions and draws heavily on animal studies to support a proposition that the birth environment should not be disturbed. Walsh (2006b) has argued that environmental and emotional ambience is assessed by women birthing in birth centres and that this resonates with mammalian nesting practices which are themselves grounded in safety. These arguments tend to essentialism and, though they may make a persuasive case for constructing places of birth that reflect these features, they should remain relative rather than absolute claims.
Other physiological evidence, especially around the use of upright posture (Gupta et al. 2006) non-directed pushing in the second stage of labour (Bosomworth and Bettany-Saltikov 2006) and leaving the cord intact after birth (Mercer 2001), has a substantial empirical base.
Whilst adopting a position of trust in the birth physiology to work well, this has to be tempered with flexibility if pathology ensues. One of the difficulties for childbearing women and childbirth professionals is the equivocal nature of the space between physiology and pathology. Arguably, this space is as much socially constructed as identifiable as an objective transition between the normal and abnormal (Davis-Floyd 2003). Walsh (2007a) illustrated this in a paper about the clinical judgement of a birth centre midwife regarding a woman’s transfer to hospital. The area is highly conflicted as the variations in risk criteria for booking at home and birth centres across the UK illustrate (Campbell 1999). In this space are not only uncertain research findings about what constitutes potential morbidity (Tracy 2006) but a risk discourse enacted through practitioners and health institutions (Klein 2005, Lankshear et al. 2005). Managing this space is done best where there is trust between midwives and obstetricians and where robust clinical governance procedures are in place. Both midwives and obstetricians need to be reflexive about their birth philosophies and presuppositions, and their professional roles for there to be a constructive interface between them. Arguably, this will require training and facilitation, though Giddens (1992) holds that a reflexive posture is a characteristic of human subjectivity in high modernity.
Reflexivity extends to being able to identify the dominant discourses that socially inscribe current maternity care provision. Some of these have been mooted already – medicalisation, institutionalisation, bureaucratisation and risk. The discourse impinging on the professional/client relationship could be added to these. Writing about this in the context of the midwife/woman relationship, Walsh (2007a) utilised Fox’s notions of ‘vigil of care’ versus ‘care as gift’ (Fox 1999). The former disciplines and regulates the care encounter while the latter is open-ended, reciprocal and altruistic. The ‘vigil of care’ would be more likely to offer informed consent (bounded autonomy) rather than informed choice (true agency) (Thachuk 2007) which would flow from ‘care as gift’. There are obvious links here with the concept of relationality.
It is probably unrealistic to assume that childbirth professionals will gain exposure to social constructionism and critical discourse by reading sociology journals, as sadly health research findings from different research paradigms rarely cross journal genres. However, these topics are beginning to make their way into undergraduate medical and midwifery training (Meakin 2004).
There has been significant progress made over recent years in clinical research in moving this beyond the mind/body duality. Most research now requires mixed methods that value patient experience alongside testing interventions. It has been acknowledged by major grant holders that health and illness are complex rather than linear phenomena (Craig et al. 2008, Ross et al. 2005) and this is especially true of childbirth. Research methods from both quantitative and qualitative paradigms are now commonly utilised in major grants in response to this awareness (Behague 2007). Advances in the neurosciences, especially neuropsychology (Kim 1979) and neuroimmunology (Oakley 2004), support an integrationist understanding of human behaviour and, as already mentioned, the extensive repository of research on relational aspects of labour and birth paints a convincing picture of the links between psychosocial factors and clinical outcomes.
These reflections resonate with recent papers by Davis and Walker (2008) and Reiger and Dempsey (2006). Davis and Walker suggest that post-modernist, feminist thought can hold together the tension between biology and culture by adopting the metaphor of the Mobius strip, the mathematical artefact with only one side and one boundary. The strip is created by taking a paper band and giving it a half-twist, and then joining the ends of the band together to form a loop. Davis and Walker posit that it can demonstrate the way in which a women’s body in labour is presented and lived by the subject (the inside out – emotions, hormones combine to regulate physiological and anatomical processes) while at the same time social inscriptions (birth setting, societal and professional attitudes) produce effects on the interior of the body (outside in). This figuratively collapses boundaries between the natural and social body, leaving the childbirth milieu free for the multiplicity and fluidity of women’s experiences.
Agency and embodiment
Davis and Walker’s (2008) insights suggest the possibility of greater emancipation for childbearing women but their arguments remain unconvincing as a route to agenic birth. This is because they fail to recognise the pervasive power of some current dominant childbirth discourses like medicalisation, risk and institutional birth. In relation to this, Reiger and Dempsey (2006) make the important point that because of what we now know from advances in neuropsychology, a risk discourse can stimulate the emotion of fear which can have real somatic effects. In other words, a social construction of childbirth can become embodied, internalised and enacted by individual women. Stressing the ‘performativity’ and active ‘doing’ of labour, they develop the notion of agency by making links to other performance-oriented experiences in sport and the arts. Research in these areas could inform women and childbirth professionals’ approach to building agency, especially in relation to handling pain.
Beckett (2005), in a parallel argument, suggests that unreflective endorsement of women’s preferences for whatever birth they desire, can ignore the embedded social relations that shapes those choices – for example that choices may be based on inadequate information, ‘as well as subtle and not-so-subtle invocations of women’s obligation to make...sacrifices on behalf of their sexual partners or children-to-be’ (2005: 269). Here the author is referring to notions that vaginal birth may deleteriously affect one’s sex life or that choices might have to be made between the woman’s preferences and the needs of her baby.
Finally, Akrich and Pasveer (2004) introduce the idea that it is alienation, not embodiment (or disembodiment) which impacts on agency in birth. They problematise agency in the sense of embracing embodiment. In their research, some women dissociated from their corpus experience of pain, either through psychological techniques or through having an epidural. This apparent disembodiment was perceived as positive while the experience of alienation was not. Alienation occurred when women were ‘frozen’, unable to appropriate a subjective embodiment, in one case because the pain of home birth was smothering and in another because the epidural obliterated the labour. This serves to illustrate that the lived experience of labour is unique to each woman. Agency, rather like the layered concept of control in childbirth (Green 1999), can mean embracing embodiment’s physicality which paradoxically can be a letting go/giving in to the body’s primal power (Anderson 2000) or dissociating (disembodiment) as a way of coping with labour pain. Both of these maintain a subjectivity but alienation does not. Alienation negates any agency and the woman is left in limbo until she can ground herself again with some meaningful embodied subjectivity.
It may be that this experience of alienation is at the kernel of birth trauma narratives. During these times, achieving a grounding may be crucially linked to interpersonal connection with a childbirth carer or companion. Hence, the primacy of this role as hinted at in so much of the phenomenological research of labour experience (Thomson 2007, Nystedt et al. 2006, Berg 2005). In its simplest form this may require ongoing communication, kindness and empathy only, with additional clinical skills of secondary importance.
This journey through the literature on childbirth embodiment reveals tensions and ambiguity. Though childbirth has never been safer in the Western world, many of those involved in its milieu are discontents for a range of reasons, as outlined in the body of this paper. Because of this, the paper concludes that the current strands in childbirth embodiment theory are impoverished and inadequate. What is required is a balance between naturalist and socially constructed positions that values the integrity of childbirth physiology for birthing for the majority of women, whilst acknowledging that prominent discourses in society attempt to construct childbirth in line with their own value system. Both positions have essentialist tendencies (Shilling 2003). Negotiating this terrain is the lived experience of women in labour who have to balance their expectations with varying degrees of uncertainty as labour events unfold. Theirs is an experience beyond traditional mind/body dualism. Each will realise embodiment in their own way, through embracing the physiology or inviting intervention, but all will welcome and benefit from trusted companions accompanying them in relationships of respect and empathy. For a smaller number, this relationality might be the difference between alienation and trauma and embodiment and agency. It is at those times that reflexive professionals (Giddens 1992) have so much more to offer than just their clinical skills.