Sunday, February 24, 2008

The marketing of homebirth revisited

On the face of it, it seems bewildering that homebirth advocates like to talk about the 1930's. Just yesterday Faith Gibson wrote in the comment section of this blog.
... The Committee on Maternal Welfare (Philadelphia County Medical Society) noted in 1934 that the rate of deaths of infants from birth injuries had increased 62% from 1920 to 1929.

According to a modern day reporter ... "in 1933, the New York Academy of Medicine published a … study of 2,041 maternal deaths in childbirth. At least two-thirds, the investigators found, were preventable..."
Midwifery must be in pretty desperate straits to reach back almost 100 years to criticize obstetrics. Yet this is part of a deliberate campaign to "market" homebirth to the general public. I wrote about this almost 2 years ago, and in light of Gibson's comment, it is worth revisiting.

Craig Thompson, professor of marketing at University of Wisconsin, wrote a fascinating article about the marketing of natural childbirth in the Journal of Consumer Research in September 2005. He described the marketing campaign quite accurately. Many homebirth advocates repeat its tenets almost word for word.

The "technocratic" model of birth:
A critical-reflexive claim ... is that obstetricians are trained in a technocratic model of labor management that has been institutionalized through hospital protocols and technological systems.
"Flaws" in women's bodies.
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.
The "cascade effect":
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.
Professor Thompson believes that most people come to the issue of childbirth with the assumption that modern obstetrics has had tremendous success in making childbirth safer for babies and mothers. Therefore, they are not inclined to believe that returning to "natural" childbirth is safer or better. This is a marketing problem and the homebirth movement has addressed it with a marketing solution. As Prof. Thompson describes the marketing problem:
[Most people believe that] medicalized births would have never gained a cultural foothold if they were so risk laden and ... the medical profession would not support obstetric practices that place laboring women at risk.
He also describes the marketing solution:
... [T]he cultural dominance of medicalized childbirth is explained as the historical artifact of a fin de siecle struggle between midwives and physicians, where the latter group held a decided economic and sociocultural advantage..., 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...

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.
In other words, the homebirth marketing campaign attempts to discredit obstetrics as a profession by appealing to notions of fairness and to cynicism about motives. They don't say that obstetrics hasn't saved millions of women and infants; that would be ridiculous and people would see through that immediately. Instead they say "Look at those evil obstetricians. Those men drove innocent and highly competent women from the business of delivering babies so they could make all the money themselves. Sure obstetricians have all this great technology, but that exists mainly to trick people. Obstetricians invent and even deliberately create emergencies so they can show their technical skill and pretend that they are heroes."

Notice how they attempt to divert attention from the real issue, whether homebirth is as safe as hospital birth. They enlist conscious and unconscious notions about fairness and greediness instead. Homebirth marketing uses two additional tactics:

One of the great virtues of modern medicine, indeed of modern science itself, is that there is a wealth of information and points of view fighting it out in the medical literature and allowing individual doctors and scientists to evaluate data and draw their own conclusions. New data and new points of view are constantly being introduced, forcing doctors to re-evaluate their thinking about medical issues. Dissenting views are allowed, and not supressed. This is a virtue of the medical system, but homebirth advocates point to it as a weakness.
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.
There are always dissident voices in medicine and most of them are wrong, but homebirth marketing doesn't attempt to evaluate whether the dissidents are correct. It tries to leverage conscious and unconscious notions that dissidents are "more enlightened" than others.

Similarly, as new knowledge is acquired, medical practice changes.
During the past 50 yr., many obstetric interventions that were once deemed to enhance the safety of birth or to improve postpartum outcomes—shaving ..; lithotomy position; enemas; ... etc. have all been discarded as ineffective, unnecessary, and in some cases, potentially harmful... The natural childbirth community invokes this historical legacy to argue that many contemporary obstetric interventions are likely to meet a similar fate.
So instead of recognizing the willingness of the medical profession to change as new knowlege becomes available, homebirth advocates express disgust that doctors were wrong in the past and imply (without evidence) that this means that everything they say and do is likely to be wrong.

The beauty of homebirth marketing, like most marketing, is that it is basically unconcerned with the facts about the product. It's all about the perception of the product and the perception of the competing products.

That's why many homebirth advocates are often incapable about making arguments about the actual safety of homebirth. They are often stunned when they are forced to confront the fact that there is no evidence for their beliefs. They have been lulled into making a decision about a safety issue by appeals to their conscious and unconscious beliefs about fairness, greediness, dissidents, power issues between men and women and other irrelevant issues.

The prime example of this is the way homebirth advocates constantly quote medical papers from the 1930's or even the 1800's. They are about as relevant to a discussion of contemporary obstetrical issues as are papers by medieval physicist are to a discussion of Einstein's theory of relativity. It would be laughable except for the fact that they don't seem to realize that they are no longer discussing the facts of childbirth safety, but are instead using marketing tactics to promote a product that otherwise could not compete in the marketplace of ideas.


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