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Anthropology of Birth

The Power Dichotomy of Reproduction

                                                               Lily Ostle
                                                Cyborg Anthropology 2006
           
The two certainties of a physical being are life and death.  Both transcendental possibilities are inexorably connected in the minds of women at the moment of birth.  Across time and cultural lines, artistic representations of labor most often involve female helpers for the birthing woman.  The midwife is the modern day incarnation of such depictions.  She focuses on holistic and hands-on methods to aid the birthing woman.  Unfortunately, in our most industrialized and capitalistic nations, the focus at birth is on the financial safety and convenience of the obstetrician in the hospital setting.  The individual obstetrician is most often not to blame for the inappropriate focus during birth; the medical community has set standards for generations concerning the appropriate uses and interventions of technology.  Technology is trusted by the medical community in place of female bodies and female birth attendants.  The current ideological dichotomy concerning birth is made of those who privilege technology’s role in birth and those who privilege women’s role in birth.  Every specific instance of technological intervention has the potential to be considered necessary or unnecessary by cultural standards. 

The cultural standards of the medical community are based on capitalistic standards since hospitals are businesses.  As such, they are run to create the most capital for the perpetuation of the medical community.  The more medical and surgical interventions implemented during a birth, the more money will be appropriated by the hospital.  Medical technology can be life saving when complications arise, but the percentage of crisis situations is disproportionate the actual usage of surgical intervention.  The highest degree of surgical intervention during birth is the Cesarean, which is at an all time high in the United States.  The divide between obstetricians and midwives concerns the appropriate use of technology in birth.  The other cultural standard to consider technology from is the holistic community.  Holistic ideology considers the overall health and well-being of the mother and child as the only factors which should dictate technology’s use during labor.  The basis of holistic thought is finitude, which is the notion that all that is living or considered a resource is limited.  Therefore, there are limits to the use of technology which can be considered healthy for the body, mind and spirit of all humans.  The cultural dichotomy, of medical and holistic beliefs toward technological intervention during birth, stems from the mutually exclusive ideologies of capitalism and finitude.

The obstetrician is the medical community’s active agent in the arena of reproduction.  The American obstetrician is expected to be all things to all women:  a surgical specialist in times of crisis, a compassionate counselor on the daily conditions of pregnancy, and an authority on female diseases (Wagner 2000).  OB/GYNs are the only doctors who are expected to have such a broad field of expertise in the world.  Common protocol in the hospital setting is to not know which obstetrician will physically attend the actual birth.  A woman under obstetrician care will most likely meet with many different doctors throughout her pregnancy, one of whom will deliver her child.  In actuality, the obstetrician is not present during the labor process, all medical interventions he or she deems necessary are actually performed by nurses up until the moment of birth.  Since the majority of training obstetricians experience involves surgical procedures, it is not surprising that such practices are highly valued by both the medical community and the uninformed patient/consumer.  Medical, surgical and technological interventions during labor include the speeding up labor through drug inducement, electronic monitoring of the heart rates of both baby and mother, pharmacologically lessening labor pain, episiotomies, and Cesareans.  In American hospitals, between 50 and 80 percent of births include one or more surgical procedures (Wagner 2000).   The cyborgization of women is forcibly made the norm through medical and surgical interventions unnecessary to the normal physiological process of birth.  The obstetrician believes that these techniques and interventions are necessary to the process of birth in most circumstances. 

The midwife is the holistic community’s birth attendant.  Midwives are autonomous professionals who provide primary maternity care (Wagner 2000).  Midwifery is most likely as old as the human species.   Before medical men entered the realm of birth, women trusted the female authority to attend labor.   The necessity of having birth attendants was and is a result of the vulnerability of the both mother and child during labor.  The original role of midwife could have been a trusted mother who had experience with many births.  Today in the United States, midwives are medically trained and licensed individuals with homeopathic skills for inferring health and progress in pregnancy just as reliable as technology.  With her hands, a midwife can feel the direction a fetus is facing.  Using a tape measure, she can be just as accurate in determining the gestational age of the infant as obstetricians employing high-tech devices. During birth, the midwife is less likely to use technological and surgical procedures universally.  Episiotomy occur between two and 20 percent of the time among independently practicing midwives, this statistic matches up with scientific identification of the actual number of women who need the surgical intervention (Wagner 2000).  Midwives have the option of attending births in all settings, whether at home, a birth center, or a hospital.  Birth centers are non-hospital facilities designed to provide maternity care to women who are at low risk (Lieberman 2004).  At low risk births, midwives have 33 percent fewer deaths among newborn infants than obstetricians (Wagner 2000).  Even so, there is much anti-midwifery legislation and sentiments among the medical community who, not coincidentally, have greater influence based on monetary resources.  The current licensing fee for midwives in Washington State is approximately 1,000 dollars per year, with promises for another increase this congressional session (SMS 2006).  The licensing fee for doctors in Washington State is 310 dollars every two years (WA gov 2006).  Throughout the country the midwife has varying degrees of support.  The largest HMO in New Mexico has more midwives than obstetricians on their full time staff (Wagner 2000).  Outside of the United States, her place is still highly valued in Europe.  The Netherlands provides citizens with complete, free and comprehensive midwife care for pregnant women and the Cesarean rate is less than ten percent (Coates 2004). 

Technology’s role in birth can be statistically measured and predicted based on the mother’s chosen community of birth.  With the high rate of medical intervention associated with hospital birth, the phenomenon of the cascade effect has been identified.  The cascade effect is the tendency for multiple medical interventions to follow the initial one.  An example is the use of Pictocin in low risk births.   Pictocin is a drug used to increase the magnitude of contractions, and is often implemented when birth is not fitting into the linear time restraints of hospitals.  Once Pictocin is introduced into a woman’s body, the intensity of her contractions exceeds her body’s ability to steadily cope with natural pain.  At this point, the suggestion of an epidural block is often made.  The epidural numbs the lower half of the body making the woman bedridden.  As a result, she is no longer able to move between different positions which help the baby negotiate through the pelvis.  Without the help a woman can naturally give to her infant during birth, complications can arise.  One of the most invasive solutions to such complications is the Cesarean.  As of the latest statistical data on Cesareans in 2004, the overall rate was 29.1 percent of all births in the United States (ICAN 2006).  This is the highest rate of Cesareans ever recorded in America, but not world wide.  Currently, Brazil is reporting to have a 90 percent Cesarean rate in private hospitals (Coates 2004).  Women in the United States who are white, middle to upper class, and married with private health insurance have higher surgery rates (Coates 2004).  If these interventions were necessary for high risk women, then the statistics would be reversed.  Nationwide 75 percent of birthing women are low risk, and therefore should not even be considered for the option of Cesarean (SMS 2006).  The World Heath Organization has declared that no region of the world is justified in having a Cesarean rate above ten to 15 percent (Anderson 2005).  Therefore for the 15 to 20 percent of women who unnecessarily receive Cesareans in the United States, the issue becomes one not concerned with life saving techniques but with the loss of power women traditionally maintained over birth and the forced cyborgization of mothers.

The current unprecedented rise in Cesareans is due to the coercion of women by the medical community through inadequate and imbalanced reproductive education.  The unbiased reality is that there are many possible complications resulting from either vaginal or Cesarean birth, with neither one being able to claim the most safety in all circumstances.  The risks of Cesarean include increased maternal death, drop in blood pressure or respiratory complications due to anesthesia, infection of internal organs, accidental cutting of the baby, twice as much blood loss as in vaginal birth, respiratory problems for the baby, longer healing time after the birth, hemorrhage, formation of blood clots, and permanent scars on the uterus.  The only medical reason for having a Cesarean would be actual emergencies, such as a pro-lapsed cord and placentia previa, or the positive STD status of the mother.  Doctors perform this surgery for other reasons, such as, time restraints set by the hospital (1/3 of all Cesareans), for the convenience and efficiency of the doctor’s time (the majority of Cesareans are done during the normal work week and hours), and the choice of elective Cesareans (Epigee 2006).  The popularity of elected Cesareans is one result of imbalanced education of women by the medical community as to the complications which occur more frequently than in vaginal birth. 

The propaganda machine behind elective Cesareans stresses the importance of women having the “choice” to give birth in the most technologically invasive way.  This fallacy simply perpetuates the current systems of medical and technological domination of women. The common reasons for women to chose such a birth are to avoid urinary incontinence, to keep the vagina walls as un-stretched as possible, to have the convenience of knowing when and where the baby will be born, and to follow the general acceptance of technology equaling safety.  According to recent data, there has been a four fold increase in maternal mortality nationwide, which could be attributed to the high rates of Cesareans and epidural blocks which both can result in death (SMS 2000).  Mainstream America is not aware of the dangers and complications of unnecessary Cesareans.  Women hear about Brittany Spears’s elective Cesarean and the perpetuation of prestige and privilege associated with technology persists.  The popular television show Dr. 90210 included an episode about the elective Cesarean birth by the only female plastic surgeon, Dr. Li.  She was interviewed before the surgical procedure and shared her concern about losing control.  For her, the prospect of allowing her body to take control seemed a risk she was not willing to take.  During the actual surgery, her focus and concern was on the size of the incision made in her abdomen.  Being a plastic surgeon, her birth experience makes perfect sense since her job is to perform unnecessary surgeries.  The effect such examples from the media has on American women is to normalize medical definitions of birth and perpetuate the cyborg model of safety. 

Some in the medical community share the sentiment of Robert C. Hock, MD, FACS, FACOG, chairman of obstetrics and gynecology, South Nassau Communities Hospital, Oceanside, N.Y.:

Over the past several years or so, the needs for increased cesarean, from purely medical perspective, have increased dramatically.  These conditions are warranting far more cesareans than were in the past.  About this aspect there is little debate, and the medical community is comfortable with it (Dolan 2005).

 

The unfortunate word choice of “comfortable” by Hock to describe the medical community’s stance on the unnecessary rise of Cesareans, leads one to remember that because of intervention technology the medical community is more comfortable financially.  Hock’s rationalization for the rise in Cesareans is presented with no evidence for its truth.  The only difference between births in the past and births in the present is simply the increase in technological interventions.  Part of the Birth Doula Training curriculum at Seattle Midwifery School is to deconstruct the myth that technology always equates with safety.  For instance, some technological interventions have been shown to be useless in preventing complications and, in some cases, even responsible for such emergencies.  The fetal heart monitor used most often during the 1980s until present is a band that is strapped around the mother’s mid-section.  This device has been shown to limit the amount of oxygen available to the fetus, therefore showing distress when there would be none without the technology.  Often in such circumstances, the birth results in a Cesarean. 

Surgical interventions routinely occur during labor without the permission of the mother; the only way to rectify such invasions of privacy and autonomy within the current system is legal action.  This route only perpetuates the cycle of unnecessary surgical interventions justified with the notion of defensive medicine.  Any deviation from sound medical practice which is a result of the threat of malpractice suits is termed defensive medicine (Anderson 2005).  Fear of malpractice suits and raised insurance premiums has been one of the major explanations by obstetricians for the high rate of Cesareans, since over 70 percent of American obstetricians have been sued one or more times (Wagner 2000).  Specifically, vaginal birth after cesarean (VBAC) has been under the most contention.  Once a Cesarean has been performed on a woman, she will live with a scared uterus.  If she decided to have another child, the risk of uterus rupture increases whether she undergoes another Cesarean or attempts VBAC.  The difference in risk is .2 percent, rupture being one in 2,000 times more likely to occur during VBAC (Koontz 2004).  With this factional difference between the two methods, one would think that the decision for the preferred method of birth would be up to the mother.  Instead, 300 hospitals in the United States have banned VBAC (ICAN 2006).  This statement in all actuality does not mean anything, because it is a violation of patient’s rights to forcefully administer surgery.  Most often, women are very particular about where and how they imagine the birth of their children.  If mothers hear that a particular hospital is adamantly opposing and claiming to ban their preferred method of birth, such women will not risk being subjected to a Cesarean, and simply go someplace else.  Therefore, it is possible that these bans will remain unchallenged by law. 

In response to the common belief represented by Hock above, the International Cesarean Awareness Network was established as a non-profit organization in the early 1980s.  Their mission is to improve maternal-child health by preventing unnecessary Cesareans through education, providing support for Cesarean recovery, and promoting VBAC (ICAN 2006).  The current president is Tonya Jamois who specifically has an answer to Hock’s assertion:

The perception that there is greater medical need for cesarean in women today ignores the reality that vast numbers of cesareans are the result of iatrogenic complications.  Simply put, the obstetric community has been overly zealous in ‘treating’ a normal physiological process and has been triggering many of the medical crises that lead to cesarean surgery.  Greater adherence to evidence-based medicine would drop the national cesarean rate dramatically (Dolan 2005).

 

The notion that birth is a “normal physiological process” is a deconstruction of society’s norm.  The fear intrinsic to facing mortality during labor has been expropriated and manipulated into fear of the “natural” birth unmediated by technology.  Evidence-based medicine tells us that 15 to 20 percent of Cesarean births in the United States are superfluous.  The over medicalization of birth is based on the view of the birthing mother as a patient/consumer.  Additionally, the mother is firmly situated in the role of submissive passive “other” dominated by the condescending medical patriarchal community. 

The transition of power and authority over birth from the birthing woman to other women was the essential technology used through out the majority of human history.  This authority system has existed in often hidden and misunderstood forms ever since science abducted birth.  The female healer has been transformed into the pagan devil-worshipping witch through the Western tradition’s version of history.  It could be possible for equally legitimate forms of knowledge to coexist without formal borders, but most often, one form gains ascendancy and superior legitimacy (Jordan 1997).  The medical view of birth has usurped the authority of the holistic model, only allowing for tension fraught and uneasy fluidity.  Birth is a female ritual which was used in the past to celebrate the creative and procreative power of women.  A ritual is a patterned, repetitive, and symbolic enactment of a cultural belief or value; its primary purpose is transformation (Davis-Floyd 1992).  The birth of a woman’s first child marks the transition into the social role of motherhood.  Cross-culturally, birth is a ritual which societies dictate in order to create culture-bearing mothers who will pass the essential beliefs to the next generation.  Therefore, even though birth has been appropriated by capitalism and patriarchy, it is still an equally potent ritual.  The crucial beliefs birthing women internalize in American hospitals are the wonders of technological progress, the helplessness of the female body, and the dependency on scientific medicine, hence the preservation of the status quo.  Holistic beliefs, internalized during birth without technological intervention, include trust in the processes of the female body, unwavering support of overall health, and empowerment to question the status quo.  There is no question that the holistic community threatens to dispel the ritualistic assertions about the supremacy of technology over the female body made by the medical community.

The holistic community voice is heard through the avenues of alternative medicine, feminist theory, and finitude.  Alternative medicine equates with unneeded and unsubstantiated meddling to the majority of the medical community.  The usefulness of preventative measures available in alternative medicine allow for less technological interference in birth.  A chiropractor can perform the Webster maneuver on a mother if her baby is in breech presentation toward the last weeks of the pregnancy.  This simple and effective repositioning could give back the choice to not have a Cesarean to thousands of women.  Currently, three to four percent of pregnancies are in breech presentation at term, and the medical consensus is planned Cesareans preserve the health of both mother and baby (Hannah 2000).  Feminist theory explores the biases inherent within patriarchal traditions, and the gendered cultural assumptions of Western society (Moore 1998).  Feminism gives women and anthropologists a method to critique the mainstream traditions perpetuated in society through birth.  The social movement most associated with finitude is eco-activism.  The basis for the ecological preservation movements stress the reality of limitations concerning the degree people can destroy the environment without destroying themselves.  Those who belief in limitations in the global sense are likely to make the assertion that there are limitations to how polluted and scared the human body can be in order to survive and thrive. 

The focus on convenience, linear time constraints, and greed surrounding American hospital births can be traced to the economic and social system of capitalism.  The process of appropriating the female ritual moment of birth into a commoditized, medicalized, capitalistic patriarchal celebration of technology took centuries of relentless persistence.  The birth of the professional, scientific male doctor in eighteenth century Europe was the start of this progression.  Scientific medicine dictated that women no longer needed midwives to help deliver babies in anatomically correct positions, now they had “progressed” to delivering infants while laying horizontally and putting unnecessary pressure on essential arteries.  The placement of women on their backs perpetuated the need for more interventions as women lost essential blood flow and cognition.  The power to decide how and where to give birth steadily slipped out of women’s control.  The colonial and patriarchal conquest of the world led to the settling of the Americas, which furthered capitalistic dreams of dominance in the following centuries.  Birth was taken out of its ritualistic life affirming framework; women’s power was usurped through the perpetuation of ignorance concerning the female body by medicine.  Today, Americans do not grow up believing in the life giving abilities of the female body, birth is associated with risks that need to be managed by professional doctors.  The medicalization of birth through the cyborgization of mothers perpetuates the stereotype of labor being a physical ailment in need of surgical treatment.

The power dichotomy of reproduction in the United States comes from the history of patriarchy, colonialism, and capitalism which has tried to stifle the female’s voice of authority.  The question of how to reconcile the two separate ideologies of authority, in order to increase the overall health of mothers and babies, can be asked in structural or individual terms.  To approach the issue structurally is to look for solutions in the top/down model of power.  There has been some research which shows that Cesarean birth rates can be lowered through nonblinded, intradepartmental distribution of individual doctors’ figures and strong physician leadership (Main 1999).  The problem with this model is that women are dependent on doctors to curb their uses of surgical interventions, therefore still giving up the power of choice to them.       Obstetricians continue to have all the power within the medical community’s structure to make the decisions which will then be passed down to the female patients.  To approach the goal of the ultimate health care for birthing women from the individual perspective is to challenge medical authority from the bottom/up.  Since the mother is the individual subject to the medical procedures, she could decide to take the powerful ritual of birth back into her hands.  The obstacle preventing this revolution is that many women have come to the same conclusion, but then been thwarted during the process of labor.  All the ritualistic ways that women are made to feel incompetent and disassociated from their own bodies’ abilities within a hospital work to keep the power structure highly evident and dominant during birth.  Certain aspects of women’s birth plans are routinely ignored without the constant vigilance by the mother or father.  This practice has led to more and more demand for doulas since the initial rise in Cesareans during the 1980s. 
          Doulas are birth educators and coaches whose role is to maintain the advocacy of individual mother’s birth plan and ideology within the hospital context.  The doula has a fluid and flexible role allowing her to participate in births at all settings.  Her ability to bridge the gap between the medical and holistic communities, in order to best serve the birthing woman, is the essential function which can change the way birth is ritualized in the United States.  The result of more women actively deciding the course of their births, as made possible through the support of doulas, is empowerment.  The ability and courage to challenge the status quo is analogous to the ripple effect.  Although the role of motherhood has been downplayed within the Western tradition, mothers have the power to shape the ideological background of their children just as much, if not more, as fathers, educational systems and the media.  The more women become empowered through their birth experiences, the more conscious mainstream America will be to the possibilities outside of capitalistic hegemonic views.  Birth can once again be a ritual reaffirming female authority and finitude, one mother at a time.

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