Thursday, June 01, 2006

The Marketing of Natural Childbirth

From a fascinating article about the marketing of natural childbirth from Craig Thompson, professor of marketing at University of Wisconsin, published in the Journal of Consumer Research in September 2005.

Evidentally this marketing campaign is quite effective. Many homebirth advocates repeat the marketing campaign almost word for word.

"A critical-reflexive claim that finds common expression in the natural childbirth literature is that obstetricians are trained in a technocratic model of labor management that has been institutionalized through hospital protocols and technological systems (Davis-Floyd and Davis 1997; Jordan 1997). This technocratic model is condemned for treating pregnancy and labor as a mechanistic process in which the woman’s body is fraught with treacherous design flaws that necessitate the administration of corrective technologies. As a result, women are routinely subjected to the unintended consequences of a cascade effect, whereby one technological intervention creates a problem that must be managed by yet another. The driving cautionary tale, oft repeated in the natural childbirth literature, is that the labor process can be so disrupted by this escalating series of technological interventions that a C-section becomes medically necessary (Mc- Cutcheon 1996).

The natural childbirth model, as articulated through pedagogical literature, Web sites, birth classes, and various social forums, espouses a conversion rhetoric that presumes consumers will initially be skeptical toward the counterintuitive idea that home births are safer than hospital births. Advocates of natural childbirth seek to inculcate reflexive doubt by countering two commonsense objections to their unorthodox construction of risk: (1) medicalized births would have never gained a cultural foothold if they were so risk laden and (2) the medical profession would not support obstetric practices that place laboring women at risk. In regard to the first objection, the cultural dominance of medicalized childbirth is explained as the historical artifact of a fin de sie`cle struggle between midwives and physicians, where the latter group held a decided economic and sociocultural advantage. As this critical narrative goes, the medical profession leveraged its emerging economic-political clout and cultural affinities toward ideals of scientific progress and technological control to displace midwives (both socially and legally) as the authoritative source of childbirth knowledge. In the United States, the middle classes were especially receptive to the medicalization of childbirth, which promised a safer and less painful labor and also symbolized a newfound consumer power to purchase a more desirable birth experience (Leavitt 1986; Pollock 1999).

Through this cultural shift, the obstetric profession also imposed medical preferences for heroic, technological interventions on the birth process. Childbirth reformers interpret these innovations—such as forceps deliveries—as unnecessary intrusions whose primary function was enabling physicians to display technical skill. This scandalous reading of birth technologies is buttressed by the fact that several prominent childbirth reformers, such as Grantly Dick-Read and Robert Bradley (founder of the Bradley method of natural childbirth), were physicians who advocated a return to a more natural, less technologically mediated approach. Furthermore, research studies within the medical community provide very mixed results on the question of whether medical technologies lead to overall improved birth outcomes (Goer 1995; Kitzinger 2001; Wagner 1997). The natural childbirth literature emphasizes this internal dissension in the medical profession and portrays these dissident voices as the enlightened parties who are breaking ranks with an entrenched dogma.

This natural childbirth literature also challenges the medicalized model of childbirth through another kind of historical appeal. During the past 50 yr., many obstetric interventions that were once deemed to enhance the safety of birth or to improve postpartum outcomes—shaving of the women’s pubic region; mandatory intravenous drips; the onthe- back, lithotomy position; enemas; hand strapping of the laboring women; and the 12 hr. monitoring of newborns in a nursery—have all been discarded as ineffective, unnecessary, and in some cases, potentially harmful (Goer 1995; Tew 1995). The natural childbirth community invokes this historical legacy to argue that many contemporary obstetric interventions are likely to meet a similar fate (Gaskin 2002; Kitzinger 2001)."

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25 Old Comments:

Having given birth without medication and with a doula for at least one of your own births, would you say you fell for the natural childbirth marketing pitch? Doulas are the newest product on the natural childbirth market. Sign up for 'em at Babies R Us along with your Avent Isis breast pump, and sling baby carrier. If you don't feel like you bought the pitch, why not? Why bother with the doula and natural, er normal, childbirth?

I didn't know about any of this stuff you quote the first time I had a baby "naturally". I didn't have internet access until after that baby was born (hospital, btw) and relied on the new OB standard, "What to Expect When You're Expecting" for most of my information. I'm definitely a mainstream gal but somehow without the influence of the natural childbirth legions I managed to make my own decisions without much concern about the technocracy of hospitals.

ps: Did you see that Sheila Kitzinger is publishing a book on Birth Trauma? (thought you might like to know that in light of the poo-poo on traumatic childbirth thread) Oh and I wonder why on your site you list as a link? Do you take any of that seriously?

By Anonymous Anonymous, at 12:52 AM  

The "marketing campaign" is not about choosing natural childbirth, it is about claiming that natural childbirth is safer.

There are many reasons to choose natural childbirth, but claiming that it is better for the baby is not one of them.

I am quite impressed by the number of people who have accepted this campaign without questioning whether any of it is true.

By Blogger Amy Tuteur, MD, at 7:34 AM  

Throughout this blog, I've been struck by how dismissive you are of midwives. You attribute the apparent success of homebirths to the fact that childbirth would go perfectly normally most of the time, and the only thing a midwife has to do is catch the baby before it hits the floor. We agree on this point. However you infer that that is all midwives know how to do, and if anything comes up, they transfer. I agree with you that midwives level of training can be all over the board, and that a few unsafe midwives are in practice. I think the CPM certification is a step forward in ensuring a body of knowledge that all midwives acquire before practicing on their own. A good next step would be for all the states to decide on one method of regulating midwives.

One thing I think you fail to recognize is the two distinct bodies of knowledge, two circles are often used to represent this. The two circles are side by side, and overlap in the middle. One circle represents obstetrics and it's related specialties in the hospital. The other represents out of hospital midwifery. You are standing in one circle, and from your viewpoint midwives knowledge is squashed up against one side of your circle. You are not aware of the second circle. Out of hospital midwives are at least always aware of the second circle, aware that someone else out there has something they may be limited in, and they know where to seek help when they need it. Your viewpoint is understandable, but is one of the reasons this 'debate' keeps running into a brick wall. We can't continue the conversation past this point until we can both recognize the other's existence. The blog forum doesn't support a 'debate' anyway, it's too lopsided.

An example from my personal experience is of watching two external versions. The first version I saw was a hospital one, where two big men worked to turn a transverse baby. They pried, and sweated, and applied a great deal of force for no more than 5 minutes before it was very clear it would not be successful. The second version I saw took place out of hospital. The midwife applied oil liberally to the woman's belly, and gave a delightful, relaxing massage while also turning a breech baby. It took an hour, and no force of any kind was ever applied. The baby was turned and the mother was totally relaxed and felt pampered. We know that because of hormonal communication between mother and baby, that the baby was also relaxed and happy. The two procedures carry the same name, external version, but were so different that you can't put them in the same group. The first was clearly dangerous and needed to be in a hospital where a C could be carried out immediately in case of abruption or cord compression. The second held no danger to either mother or child. The success rate for either obviously depends on practitioner experience, time available, costs, etc.

Supporters of home births tend to be academics, as your Marketing thread shows, not private practitioners. I think that is why women who homebirth tend to be educated, they understand the paradigm and it appeals to them. (the other section of the population who use midwives are from other cultures, where the midwife historically cares for normal birth at home, they don't need to analyze it, it's the natural, comfortable choice)

The body of knowledge midwives hold encompasses different areas than obstetrics. You can't practice obstetrics in the home, it isn't safe. It may be impossible to practice midwifery in the hospital for the above reasons of time, costs, strange environment, etc. You have argued that midwives learned all their stuff from doctors and science. I disagree. I agree that much of the stuff OBs and midwives both practice was discovered with science, and needs to be continually re-evaluated as knowledge in the area grows. (this fits in perfectly with your latest thread) But midwives have knowledge of, and good success with techniques that OBs don't have the resources to learn or apply, such as the rebozo method of turning a posterior or asynclitic baby which might save a C-section. Obstetrics and Midwifery are both valuable, and we need both of them to work together for the health and safety of women and children.

By Anonymous Anonymous, at 9:00 AM  

Just because the midwife administered a delightful massage does not mean that there was no danger of the cord prolapsing, etc.
Just because the mother is happy does not mean that the baby is not in distress.
I can't believe I have to point this out.

By Anonymous Joanna, at 9:13 AM  

I think it is logical and correct to say that the fewer interventions (like routine cervical checks, water breaking, routine epidurals, pitocin drips, episiotomies) reduce risk and C-sections. No physician would deny it. It is a measurable and provable statistic.
Also on the cost model, if indigent women were given doulas rather than epidurals out the gate it would reduce the overhead and crushing expendentures that hospitals are serving. Doulas are not new. They do provide a service that is valuable to patients and physicians. And unless the goal is to keep a patient subdued, what difference does it make how the patient is comforted as long as they submit to regular fetal monitoring and blood pressure checks?

By Anonymous Anonymous, at 9:28 AM  

People seem to be missing the point of this post. The point is that there is has been a concerted campaign to discredit hospital birth and that this campaign is based on false information.

The above comments actually prove the point that homebirth advocates have swallowed the false information hook line and sinker.

By Blogger Amy Tuteur, MD, at 10:00 AM  

Could you point out the false-hoods?

By Anonymous Anonymous, at 10:03 AM  

"and that this campaign is based on false information."

Where does what you posted show that the campaign is based on false information?

I don't doubt there is more of a concerted "marketing campaign" of late. The monopolistic laws which shut out midwives have been falling like dominoes throughout the US, thanks in part to some good ol' fashioned marketing. Just because there is a marketing campaign doesn't mean it is based on false information. Have you heard the term "social marketing"? Anti-drug campaigns, breast cancer awareness campaigns, etc., all rely on marketing. Just because someone "markets" an idea doesn't mean its false!

By Blogger Mama Liberty, at 10:14 AM  

I am quite impressed by the number of people who have accepted this campaign without questioning whether any of it is true.

Now, what is really impressive is the scores of women who question obstetrics without investigation of truth. I know that was me the first time! If my OB team was saying it, I had no reason not to believe it, likewise what my CNM (also hospital based) had to say.

Thanks for skipping the questions I asked you, especially after seeing how persistent you are in getting your questions answered. This blog really isn't too interactive and with only one obstetrician partipating, it's definitely flat.

Anonymous 12:52

By Anonymous Anonymous, at 10:49 AM  

Amy, can you consider disallowing "anonymous" postings?

People can still retain complete anonymity (just choose "other" call yourself hombrthgrrll117 or something, no need to use your real name) but it would make the threads and responses about 500 times easier to follow.

Sailorman (posting as "Mr. Anonymousman" to show how simple it is)

By Anonymous Mr. Anonymousman, at 10:59 AM  

Just because someone doesn't agree with you, Amy, doesn't mean that they haven't looked into all the information available on the subject.

Since less than 1% of women have OOH births, I really don't believe that women are believing some marketing campaign without investigating it themselves.

By Anonymous homebirther, at 11:24 AM  

"rebozo method of turning a posterior or asynclitic baby which might save a C-section."

Here are a few other suggestions from midwives that I got when I googled the rebozo method:

Read the exchange. It is a good example of what midwifery today is. This is what is being marketed as better than OBs.

I'm sorry if I'm not convinced.

By Anonymous Amka, at 12:12 PM  

Thanks Joanna for pointing out an omission I made.
Both versions were conducted in the absence of labor, at around 36-37 weeks. (no PROM= no prolapse) Both FHTs were monitored, and no distress was detected in either. Both versions were 'teaching versions' as in there were students present to learn how to conduct one from the instructor doing the version, and I was not a student at either but a bystander.

The hormone communication I refer to is Michel Odent's work, you can look it up.

Not that the outcome of either has any bearing on the point of my post, but the hospital version ended in an elective C later that evening, and the OOH version ended at term with the uneventful home birth of a vertex baby.

Anonymous 900

By Anonymous Anonymous, at 2:24 PM  

Amy what over the counter medicines should pregnant women take on a regular basis?
the NASIDS recent research is making me nervous

What foods are safe to eat and unsafe to eat?
i was trying to eat healthier not so many skipped meals or fast food but now I need to be careful about salads and cheese and????

Is it safe to have sex? what if I can feel some uterine tightening when this happens?
go in and be monitored at out patient....
the problem isn't just natural child birth advocates- everyone has tons of cautious advice to give a pregnant mom- we are barraged with advice-- when the use of drugs are considered unsafe in pregnancy unless really necessary, if I no longer can even eat without worrying it is the wrong thing or have a satisfying relationship with my husband- without going to triage then why wouldn't natural birth be though of in that stream of things- avoid drugs except for in labor-- how logical does that seem?
and yet you are arguing with midwives who have a very very small consumer group and the consumers of obstetrics are-beating down the doors to get the safest birth for their babies the C-Section!!!!!!! You folks have over promoted yourselves... way out done any "marketing" strategies set forth...
you know we are women and consumers of your craft... you are the ones who should be answering our questions and be responsive to our needs- why do you think that if I want an unmedicated non-surgery event that there is something wrong with me?

By Anonymous Anonymous, at 2:36 PM  

That was an example "the medical profession leveraged its emerging economic-political clout and cultural affinities toward ideals of scientific progress and technological control to displace midwives "

Actually, doctors are notoriously non-activist and it has only in very recent years been that you ever see an advertisement by doctors. It has historically been concidered unprofessional.

When I was researching homebirth, I tried to find the 'other side of the argument' - that of OBs, and I couldn't. There were a number of midwives denouncing doctors, and a number of parenting websites giving out information on birthing choices, including articles written by doctors, but no doctors denouncing midwives. There was a birthing center here where I lived that I tried to learn more about, but they didn't answer the phone and weren't in during their described office hours. There were a few turnovers of people on their website. The 'vibe' for lack of a better word, that I got from the establishment wasn't feeling very good.

I finally saw them towards the end of my pregnancy at a local health and safety fair. The doubt I'd had was well confirmed: these were women angry at an establishment. They definately had a self righteous attitude.

By Anonymous Amka, at 3:23 PM  

ask your ob provider
in the 1980's you have the head of the California AMA saying some very interesting things..
and I guess you have not been in a senate or congressional office in a while nor read many things including the medicaid payment info where the docs tried to get CNMs excluded from receiving payment

after the 1930's they had though they had gotten rid of the "midwife" problem--

By Anonymous Anonymous, at 4:44 PM  

" Amka said...
Here are a few other suggestions from midwives that I got when I googled the rebozo method:
method=TopicQuote&TOPIC_ID=5407&FORUM_ID=18Read the exchange. It is a good example of what midwifery today is."

Oh. My. God.

Are they serious? It's such an odd list--SOME of the things seem nice and, well, reality-based. But some seem utterly laughable. And (surprise!) nobody seems to distinguish between them.


My favorite on how to cure OP has to be this one, by FAR:

"talk to baby about turning without making the baby feel guilty"

What has science been missing?

Apparently the fetus can understand your explanation, AND control his actions to turn in your belly in response to your spoken request.

But the end part is the best of all: If your feels guilty, s/he will somehow thwart you. From GUILT!!!

I mean damn, this is a FETUS. It hardly has cognition yet at all. It hasn't started to breathe. It has never seen light. It has never tasted food. Its brain won't "do" language for a while yet.

Yet somehow if you are not careful, it will

1) understand your speech;
2) give some relevance to the TONE and PHRASING of your request;
3) Process your request against the tone of (former?) requests;
4) Decide that it doesn't like your tone and/or phrasing; and
5) Refuse to move (as if it could) just to piss you off, because you tried to make it feel guilty.


By Blogger sailorman, at 5:52 PM  

Hey, sailorman, just FYI - lots of info lately about fetal tastebuds and amniotic fluid flavored by mom's recent diet. Very interesting! I do believe babies have active lives en utero, though I agree with you that the guilt idea is absurd.

As for the original post - yes, I agree with it all! Great post Amy. I likewise agree that, as the 1% of families who choose OOH birth are (as we have agreed) highly educated, it's not marketing that sells it, but personal investigation and informed choice in believing in the safety of homebirth for healthy, low risk women with a qualified birth attendant.

By Anonymous maribeth, CNM, at 9:01 PM  

I mean damn, this is a FETUS. It hardly has cognition yet at all. It hasn't started to breathe. It has never seen light. It has never tasted food. Its brain won't "do" language for a while yet.

Dear Sailorman, certainly the baby you are waiting on is more than a lump of cells in the womb waiting for you to mold it into a successful statistic! Even Amy links to Birth Psychology, the site for the Association for Pre- & Perinatal Psychology & Health on her vanity site (so it must be good!)! Why not read about Life Before Birth... it's very fascinating.

By Anonymous Anonymous, at 9:37 PM  

Maribeth said:

"lots of info lately about fetal tastebuds and amniotic fluid flavored by mom's recent diet. Very interesting! I do believe babies have active lives en utero, though I agree with you that the guilt idea is absurd."

That IS cool. My mom always joked that the reason I love hot dogs was because it was one of the few things she could eat while pregnant. Now that makes me wonder...

By Anonymous Amka, at 12:51 AM  

Yes, I have taken numerous courses in fetal neurodevelopment and I'm well aware it's not just a "lump of cells." As usual in my posts, the reason you can know I don't think that is because I don't SAY that.

Though to be honest, a prebirth fetus is debatably closer to an instinct-only lump than it is to an intelligent individual who is aware of its surroundings, in control of its movements, and capable of feeling guilt.

By Blogger sailorman, at 11:19 AM  

you don't need to be in control of your movements to be aware of your surroundings, Sailor. You know that.

By Anonymous Anonymous, at 3:28 PM  

"you don't need to be in control of your movements to be aware of your surroundings, Sailor. You know that. "

Yes, I know that, which is why I didn't SAY that.


I confess I was sort of hoping for a lot of people to say "that's crazy!" and "I am shocked the other midwives in the forum didn't contradict her!" and "I am truly amazed she was learning that in a so-called midwifery class, what a shame!" and "yes, while midwifery has many good and scientifically-based aspects, there will always be some fringe people who make us look bad."

Maribeth acknowleged it was ridiculous (thanks, MB) but it is actually funny how almost nobody else here jumped on that train--people would much rather argue about what I'm (not) typing.

I fervently hope that everyone here would--in real life--have said something. Wouldn't you?

By Blogger sailorman, at 4:28 PM  

I agree that a pre-birth baby can't feel guilt. I didn't bother saying how silly that was, because Amy wants us to stick to topic, and that one is far far FAR off topic. People repeating how silly fetal guilt is just clogs up the list.

By Anonymous Anonymous, at 5:50 PM  

let me see - every time I say anything about a topic that is within the realm of midwifery but not what you or amy want to talk about--- what happens?

By Anonymous Anonymous, at 12:22 AM