Wednesday, February 28, 2007

"Natural" childbirth and utopian theory

I came across a fascinating article in the journal Social Theory and Health that discusses the utopian vision of "natural" childbirth. The article is Utopian Theory and the Discourse of Natural Birth by Frost et al (Social Theory & Health, 2006, 4, 299–318). The authors specifically reject the use of the term "normal birth":
"The term 'natural' birth is sometimes used interchangeably with 'normal' birth, which ... belies the normalcy of intervention, at least in the developed world. For this reason, we avoid the use of the term normal birth, but suggest that natural birth can be summarized as a birth which 'starts, progresses and concludes spontaneously' and is one where 'the woman does not have anaesthesia or
I have pointed out in the past that "natural childbirth" is fundamentally about refusing pain medication and episiotomy.

They review the theoretical underpinnings of the "natural" childbirth movement:
The contemporary discourse around natural birth is closely associated with feminist theorizing which directly challenges the medicalization of birth. Whereas the 'first wave' feminists of the early 20th century had welcomed medical interventions as alleviating the pain and risks associated with childbirth, as the century unfolded 'second wave' critics began to view medical intervention as a pathologization of reproduction... At their extreme, the proponents of natural birth present a highly romanticized view of natural birth perhaps best encapsulated in Kitzinger's description of birth as 'powerfully erotic the most intensely sexual feeling a woman ever experiences, as strong as orgasm, even more compelling than orgasm' ...

... Meanwhile the popular media has provided support for the natural birth discourse by lambasting the very small percentage of women who choose caesarean, labelled ‘Too Posh To Push’ and highlighting the small number of women who die as a result of operative delivery ...
Things are changing, though:
The more recent 'third wave' feminist position has taken issue with the valorization of 'natural' birth and the inherent assumption that medicalized birth is bad ...

Indeed, the foregrounding of the natural birth discourse has itself come to been seen as contributing to a woman’s sense of failure – where natural birth is not 'achieved' and medical assistance is seen as 'giving in' or 'relinquishing control'. A further impact of the natural birth discourse ... in championing 'the view of women as simple, instinctive, close to nature' ... makes it difficult for some women to accept interventions. As Wolf points out 'one of the unintended consequences of the natural birth movement is that it can lead women to feel like failures when they cannot manage birth so effortlessly, and it can also leave them unprepared when faced with the real drawn out, painful battle that childbirth can be'.
The authors point out that this is only an issue in first world countries. In most of the world, the inherent dangers of pregnancy and childbirth are more pressing concerns.
Of course much of the debate and research has taken place in the developed world. It is worth remembering that while maternal mortality in the developed world has decreased ... some 515,000 women die annually as a result of pregnancy and childbirth, 98% of them in 'resource-poor countries' where natural birth can be dangerous.
The authors move on to a critique of the views of "natural" childbirth advocates:
Utopian theory allows exploration of this notion that ‘every mother dreams of a natural birth’ and the consequences of the persistence of this ideal in the face of rising rates of interventionist birth. For Sargisson the ‘dark side’ of the ecofeminist project is its prescription: natural is better...
On birth plans:
One way in which the natural birth discourse becomes embedded in these women’s accounts is via the ‘birth plan’. Many of the women were encouraged to write a birth plan, detailing their expectations and preferences for management of their labour, often as part of ante-natal care process. These birth plans were partly informed by health professionals – the community midwifes and antenatal educators – although, typically not the professionals who were subsequently responsible for the delivery. ... [T]he birth plan reinforces the natural birth ideal.
Finally, the authors recommend reevaluating the ideal of "natural" childbirth to more accurately reflect the range of experiences and desires of all women:
Utopian theorizing provides a way of reconsidering the birth experience. The link between motherhood and ideas about purity and the 'natural' have a long tradition in the feminist utopian novel... However, more recently some feminists have acknowledged that some technology may be liberating for women – both in terms of releasing them from domestic drudgery and, for example, in providing real choice in childbirth...

We were struck by the way that the pervasiveness of the natural birth discourse prohibited meaningful discussion of, and preparation for, operative delivery. Women’s choices and preferences are symbolized in the construction of a birth plan which as Shaw notes, creates a paradox. The birth plan is located within a community midwifery model of care, which accentuates the natural birth ideal, yet many women (over half those giving birth in the UK) will experience a delivery that is outwith this ideal because it entails medical or surgical intervention.

...[W]e suggest that ways of talking about and 'doing' delivery need to incorporate ... a range of perspectives ... so that a range of birth experiences could be incorporated into birth discourses. Such discourses would recognize that alongside an ideal of natural birth there exist other possible experiences which encompass not only the difficult births described here, but also more extreme dystopias that some of the women allude to in their talk about ‘it could have been worse’.

... Rather than setting up a single idealized natural birth that encourages many women to feel that they have failed, utopian theorizing could open up a discussion that would prepare women for different birth experiences and provide the basis for informed decision-making. ... [W]e recognize that utopian thinking is context bound: it is not possible to return to a less litigious society, nor to ignore the possibility (and sometimes necessity) of medical interventions in birth. Nonetheless it should be possible to prepare women for a range of birth experiences which synthesize and build upon [a range of perspectives] to encompass heterotopia. This does not mean that women have to accept interventionist birth or suppress desires for a natural birth. Rather that they could be informed about the types of interventions that may occur In much the same way that the transition to motherhood is viewed as a process rather than an and/or situation the natural/interventionist birth dichotomy could be overcome.

The natural birth discourse although powerful and enduring does not reflect the typical experience of birthing mothers in the developed world. Yet this discourse maintains a polarity between 'natural' as good, and ‘intervention’ as bad. Utopian thinking, which captures the continuum of birth experiences would allow us to move forward.

...In our analysis we suggest the extent to which discourses fix boundaries (around that which is ‘natural’ and ‘other) is unhelpful to women and their carers, whereas heterotopias have the potential to promote fluidity and move the debate forward to a discussion of genuinely utopian births.

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