Tuesday, December 11, 2007

Questioning the uncritical advocacy of "natural" childbirth

Michele Crossley is a professor of health psychology. She was shocked at the way the reality of childbirth diverged from feminist perspectives of what childbirth is supposed to be. Childbirth, Complications and the Illusion of 'Choice' recently published in Feminism and Psychology details her personal experience and her reflections on the relevance of feminist thought to actual childbirth experiences.

Crossley reviews the history of feminist thought about childbirth:
... [F]eminists have argued that the 'medical gaze' pathologizes the birth process, undermining and alienating women’s sense of authority and control over their own bodies, and rendering them dependent on medical professionals. In contrast, some feminists, and midwives, have championed an alternative 'woman-centred, holistic approach to pregnancy and childbirth'. This approach is congruent with a 'wellness' model of care in which the woman feels in control of the pregnancy and labour and in a position to exercise choice and options.

One of the main aims of this article ... is to explore further the whole notion that, contrary to contemporary representations of childbirth as something over which a woman can exercise 'choice' ... this is often not the case at all... A further aim of the article is to explore the tension arising as a result of the discrepancy between expectations and outcomes, and the psychological and emotional consequences this may have for women giving birth.
Crossley discusses her personal experience. She planned a homebirth, but was induced for elevated blood pressure and postdates and eventually delivered by C-section.
... As is clear, my birth plan, obviously influenced by feminist perspectives promoting a 'woman-centred alternative' to medical intervention, manifests a commitment to 'natural childbirth' and minimal medical intervention. Indeed, the very act of writing a birth plan presents an articulation of my desire for self-control and self management with regard to the birthing process. Taking on board the feminist argument that there is a lack of consensus regarding the efficacy of the widespread use of obstetric interventions, it resists almost all of these. For instance, my birth plan clearly shows an explicit resistance to: hospitalization (at least until absolutely necessary), continuous foetal monitoring, medical pain relief, epidural and episiotomy. And yet, reflections on my experience, and the details provided in the transfer and operative reports, show that almost all these procedures were used...
At the time, the author was grateful for the birth of a healthy baby.
It was only later, probably about a year after the birth, that I looked back and began to reflect on the whole birth experience. ... I couldn’t get rid of the underlying feeling that I had 'failed' in some way... I thought my 'failed' attempt at natural childbirth was unique, until I began to talk with the other women in my antenatal group, 50 percent of whom 'admitted' to 'ending up' 'having' a caesarean. This language is in itself revealing – it points to the 'stigma' surrounding medical intervention during childbirth ...

... Why, given my theoretical knowledge of the over-medicalization of childbirth, did I not put up more resistance to the early interventions which, as the feminist literature predicted, simply led to further escalating interventions? ... Why did I not 'fight' ... not to be treated as a medical emergency? Why did I not hold out against 'unnecessary medical procedures'? Why, as proponents of 'woman-centred' birthing practices promote, did I not make sure that the control of my own reproductive health remained within its 'rightful moral domain' – under my own control?

... The very way in which I pose the above questions belies an assumption of a kind of transcendent Sartrean being who is entirely free to choose her own destiny and nature... I truly believed, by preparing and acting in the appropriate manner, that it would be possible to transcend above and beyond the pain and to bring the child forth through 'natural' physical and psychological processes...

In terms of these conditions for making a genuine 'choice', it is clear that I fulfilled the first to the extent that I expressed desires and preferences for a 'natural birth' as manifest in my birth plan. However, the second and third conditions – understanding the situation and the options open to me, and having a means of weighing up possible outcomes – were not fulfilled at all. And this was despite my having read around extensively and armed myself with theoretical knowledge and statistics about the process of birth. Unlike the health professionals who were treating me, I did not have the authority to proclaim whether or not various medical interventions were necessary, or whether my case actually did constitute a medical emergency...
Crossley concludes:
... In an ideal world, women, their partners and midwives would be educated 'for choice' – in a way that would ensure that options are discussed 'openly and honestly', and that decisions are based on 'research evidence, and on sensitive awareness of women’s needs ... ' – in other words, to ensure that the full criteria for making a 'geniune choice' ... are fulfilled. In the context of the current budget-cutting climate of midwifery services, however, such a goal appears rather idealistic.

... [M]y recommendations are therefore rather more pragmatic and limited. I seek instead to critique and challenge the incautious and irresponsible use of the language of 'choice' in promoting maternity services to women. This is because such promotion potentiates a strong sense of disjunction for women between expectations
and eventual outcomes. This is especially the case when ... it becomes clear that medical intervention may be necessary in order to ensure safe delivery. Thus, for instance, if women are to be encouraged to write birth plans, as was the case in my prenatal class, this should be done in a context where 'risks' and the prospect of difficult deliveries are not downplayed. Women, especially first-time mothers, should not be fed a promotional doctrine which leads them to believe that birth is a 'natural process' and that complications and caesarean sections are rare occurrences... Portraying the potential experience of caesarean section in a more positive light could then mean that it is experienced not so much as a failure, but more as a step necessary to deliver one of the most transcendent experiences in the world.


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