Tuesday, October 30, 2007

Knock on wood and trust birth

Why did I put the phrases "knock on wood" and "trust birth" together? Both are prime examples of magical thinking, and magical thinking is integral to homebirth advocacy. Magical thinking does not mean believing in magic. It means believing that thoughts and actions have the power to affect unconnected events. It is obvious that knocking on wood has no power to prevent bad events of any kind; it is also obvious that trusting birth has no power to affect the occurance of complications or to prevent undesired outcomes of pregnancy or childbirth. Yet people persist in knocking on wood and homebirth advocates persist in exhorting women to trust birth.

In a fascinating and thought provoking dissertation, Yannick St. James explores the role of magical thinking in consumer coping, specifically in the context of attempting to lose weight. Her analysis strikingly resembles the role of magical thinking in coping with childbirth among homebirth, and (to a lesser extent) natural childbirth advocates. In this post we will look at the meaning of magical thinking, and in a future post, the specific manifestations of magical thinking within homebirth and natural childbirth advocacy.

St. James begins with a definition of magical thinking:
... [M]agical thinking ... involves imparting moral meaning to a situation, reifying and externalizing one's control over the situation, attempting to symbolically influence this powerful, mystical entity that is vested with control, and interpreting scientific symbols as objective signs from this entity. ... [M]agical thinking [is] a resource that expands the realm of the possible to help consumers cope with the moral responsibility for a domain over which they experience limited agency.
She expands further on this definition:
Magical thinking is defined here as creating or invoking 'extraordinary' connections - symbolic relationships founded on a belief or intuition in the presence of mystical forces in the world - in order to understand, predict, or influence events… Research suggests that, when faced with situations of uncertainty, loss, absence of control, or inability to attain a desired outcome – ... people often engage in magical thinking by creating and using meaning-based connections to understand and influence situation outcomes. The concept of magical thinking turns our attention to the role of mystical forces in consumer coping; meaning-making then involves creating and invoking symbolic relationships in which these mystical forces provide ways to understand and influence stressful events.
Childbirth is a paradigmatic situation of uncertainty, potential loss, absence of control or inability to attain a desired outcome. No one, not the mother nor the providers, can control the process or perfectly predict the outcome. The potential always exists for a devastating loss, either the death or the permanent intellectual impairment of the baby.

In the face of this uncertainty, the vast majority of people have turned to science and technology to limit the occurance of death and disability. Science, specifically modern obstetrics, has been spectacularly successful in reducing the risk of neonatal and maternal mortality. Prenatal care, improved anesthesia, more C-sections, blood banking and use of antibiotics save literally tens of thousands of lives every year. As St. James notes, integral to the practice of science is the impact of "chance, probability and randomness". This is, in fact, what statistics tell us. Complications WILL occur; we can predict the probability of complications, but their occurance is essentially random. For example, obstetricians realize that some women attempting VBAC WILL sustain a ruptured uterus, and some women who go postdates WILL end up with a stillborn baby. Because these events are random, every woman MUST be treated as if these tragic outcomes might occur.

There are a small number of women who either reject science, or (more commonly) add a magical thinking component onto their scientific understanding. Magical thinking involves:

"a participative worldview in which there is no boundary between humans and nature or between the objective and subjective. Through creative persuasion, consumers participate in the creation of reality by appealing to mysterious forces residing in nature… Specifically, magical thinking proposes that consumer agency is enacted within the construction of a world inhabited by mysterious forces that can be persuaded to bring forth desired ends."

Imbuing events with "sacred cultural categories and cultural principles."

"Creating and invoking extraordinary symbolic relationships to understand, predict, or influence events."

A rejection of the scientific concepts of chance, probability and randomness in favor of "luck, faith and destiny". Hence the extraordinary fatalism in the face of neonatal death. Instead of understanding that probability tells us that certain complications will occur and therefore we should take steps to prevent them or treat them, magical thinking asserts that the death was destined to happen anyway and nothing could have prevented it.

As St. James comments:
Whereas scientific thinking seeks to empirically validate or invalidate possibilities to classify them as reality or fantasy, magical thinking creates and maintains ambiguity around what is possible in order to provide meaning and sustain hope in the context of stressful situations.
The fundamental point is that magical thinking within the context of homebirth and natural childbirth advocacy provides a way to manage the uncertainty and fear associated with pregnancy and childbirth. Homebirth and natural childbirth advocates insist that mysterious forces such as "trust" and subjective perceptions such as "intuition" can prevent, diagnose or manage complications of childbirth to insure the desired outcomes of a healthy baby and a vaginal delivery.


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