Thursday, June 15, 2006

Miwifery and "natural" birth

There is a fascinating article in this month's Medical Anthropology Quarterly about midwifery in Canada and the definition of "natural" birth. This article confirms my assertion that "normal" or "natural" birth is merely a social construction.

The article by Margaret MacDonald, a medical anthropologist at York University is Gender Expections: Natural Bodies and Natural Births in the New Midwifery in Canada. The article requires payment to read, but the complete abstract in available on AnthroSource.

According to Dr. MacDonald:

The ideal of a natural birth has been used as a successful rhetorical strategy in scholarly and popular feminist works on childbirth to counter and critique the predominant biomedical or "technocratic" model of the pregnant and birthing body as inherently problematic and potentially dangerous to the fetus... However, my key finding in this ethnographic study, ... is that natural birth is being redefined by the personal, political, and pragmatic choices of midwives and their clients... [T]he construction ... of natural birth in contemporary midwifery both reflects and promotes a fundamental shift away from essentialized understandings as it makes room for biomedical technology and hospital spaces...
MacDonald examines the "natural history of natural birth":

Midwives and their supporters too have often appealed to the authority of nature as the basis for their work. …[N]atural birth is an idiom for what midwives clinically refer to as normal birth and … carries a kind of cultural weight that goes beyond this latter term. Specifically, the promotion … of natural birth within contemporary midwifery posits women as naturally capable and strong, their bodies perfectly designed to carry a fetus and give birth successfully …

In contrast:
[The] medicalization thesis holds that obstetric medicine developed its tools … for the control and manipulation of what was purported to be the inherently defective, and therefore dangerous, process of birth… Although strategically useful, both feminist scholarship and ethnographic material on childbirth reveal a problematic tendency to search for authentic origins as if to chart the natural history of natural birth for the reeducation of modern women.
Indeed:

[T]he nostalgic desire for birth as a natural event that take place in the home … is problematic… [I]t is perhaps time to rethink our attachments to such a notion.
So:

When asked directly about natural birth, midwives … respond in predictable ways: “It means drug free”; “It means no interventions”; “It means nonmedicalized, the opposite of a hospital birth.” When probed, however, the question of what constitutes natural birth begins to reveal some interesting and unexpected dimensions.
For example:

Midwives do use technology during prenatal care and during delivery … They use handheld ultrasound devices … to listen to fetal heartbeats. They order ultrasounds … They carry oxygen for both mother and baby … as well as oxytocin injections.
Ultimately:

Despite the clear acknowledgement from midwives that natural birth is a slippery concept, it is still such a powerful concept that what midwives … work for is often articulated in its terms. In many ways, the idea of natural birth stands for midwifery itself, and for a particular set of gender expectations … [M]idwifery’s discursive framework for the body posits a new west of social and cultural meanings and expectations for gender …
In other words, "natural" or "normal" birth is an arbitrary social construction. As such, it may have relevance for the women who accept it, but it is not universal and it should not be lauded as the best way to have a baby.

See original comments here

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18 Old Comments:

I had a big, long comment under another post about this, but now I can't find it. (It might not have gone thorugh.)

First off: why do you care that "natural" is a euphemism for "less invasive"? Do you believe people are using it in a dangerous way? I mean, what is your real point? What are the implications of this?

Short answer: for me "natural" means "as natural as possible" and using less invasisve measures to steer my body back to normal if my birth deviates from what is considered normal or safe. I view it as a full spectrum with highly intervened, technilogical birth at one end, and a wild birth of an "uncivilized" (uninfluenced by society)woman at the other. I don't want either of those options.

I think it's a lot more natural -- or less invasive -- to place a warmed up rice sock on the mom's back or massage her or help her to moan to release tension than to dope her up or sitck a needle in her spine. It's a lot more natural to help a woman move around for malpresentation (yes, that is often effective) than forceps or vacuum.

And you're right. This is all rhetoric and completely beside the point if you ask me.

By Anonymous Anonymous, at 10:44 AM  

"why do you care that "natural" is a euphemism for "less invasive"?"

Why? Because I think "natural" birth is used as a cudgel for some women (the RCM, for example) to beat other women over the head.

It is an arbitrary definition that includes what advocates want and excludes what they don't want.

They have every right to adopt social and cultural constructs about birth that they wish to adopt. However, it is important for everyone to understand that their views are arbitrary and tell us nothing about what type of birth is better than any other.

Sometimes, people become so imbued with their own value system that they forget that it is not a universal expression of truth for everyone everywhere.

By Blogger Amy Tuteur, MD, at 10:51 AM  

Sometimes, people become so imbued with their own value system that they forget that it is not a universal expression of truth for everyone everywhere.

Nah. Being first a mother who had babies in hospitals and homes, then a medical assistant in an OB/GYN-CNM office, then a midwife you become acutely aware of the differences in birth-speak.

By Anonymous clever ID, at 10:58 AM  

It's too bad you don't read the magazines of the opposition. The current issue of Midwifery Today addresses much of what you're saying.

For example, from an article by Holly Scholles (a CPM who, incidentally, has two Masters degrees in Anthropology):

...I suggest we eliminate the notion of "normal birth" as in "midwives are specialists in normal birth" or "midwives assist women with normal birth." "Normal" is such a vague word and has been used against us to constrain our practice and our independence.

Wow! Midwives are bothered by the term, too. The author's motion:

I would suggest we reconceptualize midwives as experts in vaginal birth, because that is what we are.

Interesting idea. What do you think, Amy?

I started to get worried here, because I dislike this natural/surgical polarization and don't believe it's that black-and-white:

We are not interested in assisting with abdominal birth - that is the province of obstetricians, the surgical specialists. But if a baby cam come out of a yoni, we know how to help.

But she clarifies herself to my satisfaction:

This doesn't mean that we must assist every vaginal delivery.

In other words, midwives are not for every woman or for every birth. But they certainly have a place in the field of childbirth.

I agree that the notion that because it's natural it's good, is highly problematic. Lots of people overuse the appeal to nature, and it drives me crazy, because it is essentially baseless. What we are talking about is really personal preference, and there is no real ground for argument there, it's all opinion.

But I'm not sure that the "natural is good" logic truly is a fundamental part of the unmedicated birth movement (no longer using the term "natural" here) the way you claim it is.

"Natural" is an oversimplified way of saying "leave me alone! No drugs, no routine whatevers - I want to do this myself!" (with the understanding that if there are complications, intervention is necessary - I don't want to sound like a loony person who advocates birthing through a prolapsed cord or something - whew, I'm defensive! Where'd I learn that??).

So what word would YOU use to describe that approach to birth? Agreeing that 'natural' is perhaps not the best choice (and that "normal" is questionable as well), what word should we use?

By Anonymous wasting my breath, at 12:23 PM  

I’m still wondering where the movement of natural-birth advocates or midwifery activists, who are beating women over the head, lives. I mean, of course I know there are home and natural birth extremists, but I’d argue there are more women who have never heard of a midwife (and who think homebirth extinct) than there are women who have been made to feel badly by such a group. I think Amy, in personal experience or bias, is overstating this point. I don’t think it’s actually relevant at all to the subjects being discussed, except to explain the bias.

I agree with a lot of what Dr. McDonald wrote in the excerpted piece, and am quite interested to read more. Of course midwifery, and “alternative birth” families, have a culture all their own. Who doesn’t have a culture all their own? I love reading anthropological insight on pregnancy, birthing, motherhood, midwifery, and so on, and also highly recommend Sheila Kitzinger to everyone.

As you’ve said, Amy, natural childbirth is the default. Birthing upright, without limitations on mobility, with privacy or close female support, without intervention, without time limits, without pharmaceutical pain relief, is how most women in the world have ever birthed (and continue to do so). And of course the movement away from that is much more of a ‘social construction’ than the “natural birth movement, or alternative birth movement” of the past generation.

I still argue we need to differentiate the phrases natural birth from normal birth. For me, suffice to say that ‘natural birth’ means without pharmaceutical pain relief, and normal birth means something like ‘spontaneous labor and birth without artificial facilitation of the process”. I absolutely think that a woman, who rests in a bed, in the hospital, on monitors and pushes her baby out without augmentation has a normal birth. I don’t think simple pain relief excludes her from having a normal birth, either. She can still move and cope and feel and react to labor. I DO think an epidural is not a normal birth – as a woman essentially becomes a passive container of a fetus rather than an active birth giver. I do think that vacuums and forceps exclude normal birth, as they are externally facilitated births. Do I think that, say, back massage or squatting excludes normal birth? No. It’s not because these are somehow more “natural”, and of course they are a means of facilitation of birth, but they do not take away from the basic normalcy of a woman giving spontaneous birth through her own powers. If you are going to argue that squatting is as artificial as forceps, Amy, don’t even bother as it’s ludicrous.

Anyway, I’m sure my assumptions and opinions in the paragraph above would give Dr. McDonald and other birth anthropologists a lot of food for fodder; rightly so. I think my only objection to the thread is the final comment by Amy at the bottom: As such, it may have relevance for the women who accept it, but it is not universal and it should not be lauded as the best way to have a baby. . There is no judgment in the essay before it, only in Amy’s attempt to use it to prove her biased point. And I think it goes back to the problem of Amy’s perception of natural birth advocates “beating women over the head” and nothing else.

Amy admits again and again that Obstetricians want their clients to have uncomplicated births. Of course they don’t want 28% of women to have c/sections, and another 15% or so to have vacuum-assisted deliveries, and 40% or so to need pitocin in labor – they want normal birth too. I don’t think it’s even arguable that a normal, spontaneous birth is healthier. Of course it’s laudable as the best way to have a baby. So where’s the problem? Where's the relevance to homebirth or to midwifery?

By Anonymous maribeth, CNM, at 2:44 PM  

When investigating a potential OB, I called the office and asked for the C sections rates, and the natural birth rates. She had to go ask, and call me back.

When she called back, she informed me the C section rate was 22%. I asked about natural births, and she said 78%.

This told me that they were not doing any natural births. And did not have a clue what the natural birth process is.

Natural birth means doing as nature intends. No IV, no pit, no AROM, no bright lights, and no official policies.

By Blogger stockingup99, at 3:02 PM  

Dr. McDonald writes

I argue that the construction, negotiation, and experience of natural birth in contemporary midwifery both reflects and promotes a fundamental shift away from essentialized understandings as it makes room for biomedical technology and hospital spaces, underpinned by the midwifery logics of caring and choice . Natural birth in this context also carries important cultural messages—gender expectations—that posit women as persons and bodies as naturally competent and knowing .

That is really lovely, and true. I am so interested to read more of her work.

By Anonymous maribeth, CNM, at 3:12 PM  

Wasting my breath:

"I would suggest we reconceptualize midwives as experts in vaginal birth, because that is what we are.

Interesting idea. What do you think, Amy?"

My particular concern is that no one elevates one form of birth above another as "better", "more natural" or "more normal".

That's why I found the whole RCM proposal so interesting. A group of midwives got together and said:

1. Our way of birth is better.
2. As a society, we need to put as many obstacles as possible in the way of women who want to give birth any way but our way.

I think the underlying problem is the essentially competitive nature of both the homebirth movement and the natural childbirth movement. They don't appear to be content with their own choices. They NEED to have those choices validated by other women. So they create a definition of "natural" or "normal" birth that suits them. Then they announce that their way is best, and everyone else, in consequence, is "un-natural" or "ab-normal" with all the negative connotations that implies.

Midwives are not experts in vaginal birth. Virtually everything that is known about caring for laboring women and unborn babies was identified or discovered by obstetricians. Midwives copy them. However, midwives are experts in supporting women who believe that natural birth is a priority.

By Blogger Amy Tuteur, MD, at 3:30 PM  

If midwives are not experts at vaginal birth, why can they help women achieve such a higher percentage of vaginal birth (including hospital CNMs under the same protocols as OBs?).

Amy, I believe you defined normal birth as 'a healthy baby born to a healthy mother' or similarly. You don't think normal birth is "better"?

By Anonymous maribeth, CNM, at 3:36 PM  

Stockingup99:

"Natural birth means doing as nature intends. No IV, no pit, no AROM, no bright lights, and no official policies."

Nature doesn't "intend" anything. We are products of evolution.

Dr. MacDonald's article addresses your point of view specifically:

"Although strategically useful, both feminist scholarship and ethnographic material on childbirth reveal a problematic tendency to search for authentic origins as if to chart the natural history of natural birth for the reeducation of modern women."

What MacDonald seems to be saying is that it is wrong for midwives to rely on an idealized history of natural childbirth that probably never existed. She also acknowledges the fact that such an idealized version of natural birth is a strategic tool in an ideological battle with others who disagree.

And:

"[T]he construction ... of natural birth in contemporary midwifery both reflects and promotes a fundamental shift away from essentialized understandings as it makes room for biomedical technology and hospital spaces..."

In other words, "natural birth" no longer means birth as it occured in nature. It means birth as defined by midwives to incorporate the medical technology that midwives feel like incorporating.

By Blogger Amy Tuteur, MD, at 3:40 PM  

Virtually everything that is known about caring for laboring women and unborn babies was identified or discovered by obstetricians. Midwives copy them.

SO WHAT?! Obstetricians, blah, blah, blah. Their previous work -- because you stole it too, unless of course you discovered some great thing we haven't learned yet but I think not since your career was short and sweet-- allows midwives to be the experts in "basic", "normal", "natural", "vaginal", whatEVER you want to call it, birth.

By Anonymous clever ID, at 3:59 PM  

so I am just trying to see who it is you think is being marginalized here? In your estimate how many medicated birth occur in the United States?
If I want professional support like a doua, or breastfeeding advice- does my insurance pay does medicaid pay? do they pay for rental of an electric breast pump if my child has to say in the hospital? In America I will most likely have to pay for this kind of help out of pocket. and you as an OB where is your protection of the normal in birth and postpartum? how are you assisting or protecting me? In fact why should I even need to hire a doula why aren't you my support , why isn't the hospital my support? You have spent a ton of time here pushing the primary way things are done here and some how claim you and others are being bullied.... I just don't see it what I see is I am the one being bullied and scoffed at because I do not want drugs or surgery.

By Anonymous Anonymous, at 7:02 PM  

"I just don't see it what I see is I am the one being bullied and scoffed at because I do not want drugs or surgery."

Well, I suggest that you read through the hundreds of comments on this blog, and you will see what I mean. There seems to be an overwhelming need to declare one way of birth the best.

By Blogger Amy Tuteur, MD, at 7:05 PM  

here is the full intro to the article---

In this article, I examine the meaning of natural bodies and natural births in contemporary midwifery in Canada and explore the impact of these central concepts on the embodied experiences of pregnant and birthing women. The ideal of a natural birth has been used as a successful rhetorical strategy in scholarly and popular feminist works on childbirth to counter and critique the predominant biomedical or "technocratic" model of the pregnant and birthing body as inherently problematic and potentially dangerous to the fetus. Contemporary Canadian midwifery—which only as recently as 1994 made a historic transition from a grassroots social movement to a full profession within the public health care system—continues to work discursively through the idiom of nature to affect women's knowledge and experience of their bodies and selves in pregnancy and birth. However, my key finding in this ethnographic study, which focused primarily on midwifery in the province of Ontario in the years following professionalization, is that natural birth is being redefined by the personal, political, and pragmatic choices of midwives and their clients. I argue that the construction, negotiation, and experience of natural birth in contemporary midwifery both reflects and promotes a fundamental shift away from essentialized understandings as it makes room for biomedical technology and hospital spaces, underpinned by the midwifery logics of caring and choice. Natural birth in this context also carries important cultural messages—gender expectations—that posit women as persons and bodies as naturally competent and knowing.

By Anonymous Anonymous, at 7:13 PM  

Amy wrote
"1. Our way of birth is better.
2. As a society, we need to put as many obstacles as possible in the way of women who want to give birth any way but our way."
and
"Well, I suggest that you read through the hundreds of comments on this blog, and you will see what I mean. There seems to be an overwhelming need to declare one way of birth the best."

I say to you why do I need to hire someone out of pocket to protect me at a birth in the hospital and you say this to me?
So a woman who may have to pay out of pocket for a type of pain relief in labor you are mad about- but you think it is not your job and you don't care that I will have to pay out of pocket for they type of "pain relief and protection" I want in a hospital-- do you not see that this is exactly the same thing?
there are more obstacles in a hospital birth to having a natural, no surgery no drug birth than there are protections. I should not have to pay out of pocket for what should be mine automatically just like the drugs you are fighting for that do cost money.

By Anonymous Anonymous, at 10:36 PM  

Amy said:"Midwives are not experts in vaginal birth. Virtually everything that is known about caring for laboring women and unborn babies was identified or discovered by obstetricians. Midwives copy them."

This is an astonishing assertion. What is your source? The very word "obstetrics" is from the Latin word for midwife and its root obstare - to stand in front of: [L.obstetricius,fr. obstetrix, -icis, a midwife, fr. obstare to stand before]
And the practice of midwifery as science has deep, respectable roots: in 1671 Jane Sharpe wrote The Midwives Book, or the Whole Art of Midwifery Discovered; in Germany, Justine Siegemund wrote Die Chur-Brandenburgisclze Hoff-We/femuller in 1689; and even earlier, in France, Louise Bourgeois in 1626 wrote her Observations sur la sterilit et maladies des femmes.

Marie Boivin was denied entrance to medical school because she was female and received her degree as a midwife in Paris in 1800. Her first book, Mémorial de l'art des accouchements ("About the Art of Childbirth"), was a case textbook for midwives.It used was illustrated with "more than a hundred precise drawings that showed the various possible positions of the fetus in the womb. Accompanying text detailed the symptoms to be aware of and course of action to take for each. Boivin originally had not considered her illustrations suitable for publication (she considered them too shockingly blunt for the general public), but François Chaussier, the directing physician at the Maternité, insisted that they be included. Because no such work had been written in Europe since 1688, there was great need for Boivin's book. It was hugely popular and was translated into German and Italian."

"From 1811 until her death, Boivin directed several hospitals and maternity wards in Paris, and she also continued to write prolifically about obstetrics and gynecology. She continued her work and study as a gynecologist and became the leading expert in France about pathologies of women's reproductive organs... In 1818, she wrote her own book on uterine hemorrhaging, which was a history of the thought and treatment on the subject from antiquity until the early 19th century. Finally, in 1827, she published an important work on the hydatiform mole, a condition of abnormal pregnancy in which the fetus degenerates into a mass of cysts. The work was called Nouvelle recherches dur l'origine, la nature et le traitement de la mole vesiculaire ou grossesse hydatique."

You were saying about midwives copying?
(info on Boivin is from International Encyclopedia of Women Scientists)

By Blogger midwifemom, at 4:44 AM  

Midwife mom:

"You were saying about midwives copying?"

Yes, and I am still saying it.

The easiest way to demonstrate this is to ask you to make a list of all the things that midwives have discovered about normal labor and delivery. Then we could compare it to a similar list for obstetricians.

Alternatively, you could look at Williams' Obstetrics (1325 pages) and pick out the midwife described or discovered facts from there. The rest would, of course, be attributable to obstetricians.

It makes no sense for you to even challenge my assertion, because it damages your credibility.

It also goes back to an issue that we have been discussing for awhile. Why do some midwives feel the need to inflate their qualifications above what they really are? Everyone knows that no midwife can practice safely without obstetrician back up. That tells you a lot about the relative relationship between the two professions.

Why do homebirth advocates feel the need to elevate their opinions above everyone else's? Furthermore, why do they feel the need to publicize the fact that they think they are smarter and better than everyone else, when there is simply no evidence to justify it.

Why do they continue to define themselves by what they are opposed to, instead of what they stand for?

By Blogger Amy Tuteur, MD, at 7:07 AM  

"Alternatively, you could look at Williams' Obstetrics (1325 pages) and pick out the midwife described or discovered facts from there. The rest would, of course, be attributable to obstetricians."

Tell me what things have been attributed to women or women's discoveries? you are now playing out some very old sexism , in America women's right to vote was not allowed until 1920 so not even a hundred years.... for a very long period of time women were barely allowed to obtain higher education of any kind or to even read or write in a time before that- and much of what women did or have done- be it home making , child care , building, bartering or birth were not written down or payed much attention to other than by their own family or community- how did I learn to be with women- I learned it from how my mother and grandmothers- acted and also by what has been expected of me socially-- I am old enough to have had to wear dresses until I was 17 years old- if you wore shorts or pants to school you would have been kicked out- a restaurant would not serve you, if you were in town the police may even stop to see what you were up to. Just because something was written down by physicians or written down does not mean that they discovered everything - or it could even mean that they discovered something for themselves an ah-ha moment but could still be something midwives may have known. All I would have to do is have a baby or 2 in hospitals that treated me very badly to contrast this to how the old mothers acted --- things that I have learned that are not in Williams- how about feeling a baby's heart beat with the palm of my hand- should have had enough sense to feel this myself to begin with but how I learned it was from an old granny midwife who had learned it from an old southern granny who had done over 1000 births before she was forcibly retired having only lost 1 preterm baby and no mothers - or how about putting a pair of you DH dirty pants around your neck- something that smells strongly of him. Or that there were people who could cure thrush by breathing into a baby's mouth - well now lactobacillus studies are catching up to some old technology. How to feed someone in labor, how to tell when someone is not well- by using my senses. How to listen , actively listen. How to look at a breathing, pink, nursing baby and know that it is well and fine. How to be patient. How to massage a pregnant woman a postpartum mom and baby, how to be a sobada. How about to not suction every baby that babies sneeze and cough - and that suctioning can cause the nose to swell. How about paying enough attention to a laboring woman to wait until she is done with a contraction before I speak to her and expect an answer-- you know something that should be common sense- like how many questions do you ask a man carrying a refrigerator? I didn't need to read somewhere about that. That mom is a radiant warmer- that cords can be cut after the placenta is born. That when a woman says her bottom hurts and she won't sit I don't make her sit- that hot water is soothing - that you can lift a belly with a reboso or a sheet or duct tape and a irritable uterus will stop being irritable- I could make a long list-- even longer--
An example not midwifery but somewhat related you know patents are not suppose to be granted for things that are in common use- well when paper diapers first came out they did not have tape closers on them- and women started using tape to close diapers pretty soon you have Pampers with sticky tape on them

By Anonymous Anonymous, at 8:20 AM