Friday, February 09, 2007


Fatalism is persistent and rather suprising theme in homebirth advocacy. Feelings of fatalism about health reflect the idea that "bad things are going to happen" regardless of measures we take, and often imply that it doesn't make sense to undertake certain healthcare measures because "if it's going to happen, it's going to happen". I'd like to make four specific points about fatalism toward childbirth that is often found in homebirth advocacy:

1. Fatalism is a religious and philosophical orientation. It is not a medical viewpoint.

2. Fatalism among healthcare providers can compromise the quality of care that patients receive.

3. Fatalism in homebirth advocacy is rather suprising considering the cult of personal responsibility that homebirth advocacy assumes and encourages.

4. Fatalism is an excuse designed to avoid responsibility for poor clinical decisions.

In order to get a better idea of what fatalism in healthcare means, it will be helpful to look at non-controversial issues in healthcare first. There is quite a bit of literature in healthcare sociology about fatalism and cancer. For example, everyone knows that smoking causes lung cancer, but fatalism leads many smokers to continue smoking anyway. They reason that if they are "meant to get cancer" they are going to get cancer and there's nothing they can do to prevent that. Why give up something they enjoy (smoking), when they have very little control over their health? So fatalism leads some people to continue dangerous health behaviors since they don't believe that they will make a difference.

Fatalism also affects the willingness of people to get screening tests for various conditions. The Pap smear for cervical cancer screening is one of the most successful screening tests ever found. Yet there are still many women who deliberately avoid routine Pap smears either because of a fatalistic view that "if they are meant to get cancer, they will get it" or a fatalistic view that it is pointless to know about the existence of cancer since getting cancer means that you will surely die of it anyway. So fatalism leads people to continue dangerous healthcare behaviors and to avoid potentially beneficial healthcare behaviors.

Fatalism is not a medical view. Doctors work under the premise that healthcare problems are identifiable, treatable, possibly even preventable, unless there is specific information to indicate otherwise. Fatalism is a religious/philosophical view of the world. Individual religions and philosophies encourage fatalism to a greater or less extent. It is certainly the right of any person to adopt whatever philosophy he or she chooses. However, we should note that a fatalistic philosophy about healthcare often does not reflect the reality of healthcare. Stopping smoking can and usually does have a big impact on cancer risk. Routine Pap smears have dramatically reduced the incidence of advanced cervical cancer and improved the life expectancy of women who do get cervical cancer.

Fatalism is often a component of homebirth advocacy, both on the part of lay people and on the part of providers. Almost every week, a lay homebirth advocates will make a statement similar to the following:
First of all, Amy, babies (and mothers) die. It's a fact of life. You will never have 100% survival rate. So what's acceptable? Knowing that there was nothing that could have been done or that if you had have done something, you may well have ended up with a baby that was so damaged, it would have been better off dead. For others, it's knowing that it's God's Will. You are arguing against religious and personal freedom by saying that we should treat all women the same.
Fatalism extends to homebirth midwives and this attitude can effect the information and care that they give to patients. As Weitz and Sullivan write in Licensed Lay Midwifery and the Medical Model of Childbirth:
Religious and philosophical beliefs also influence the degree of medical intervention that each midwife feels is appropriate. During the course of the interviews, three midwives expressed fatalistic attitudes toward childbearing... One midwife stated:

'Basically one of the things I object to about the medical profession is their one hundred per cent rule, their unwillingness to accept the fact that sometimes people are just supposed to die or babies are just supposed to die or that there is a place for less than perfect and less than one hundred per cent .'

Two other midwives expressed 'providential' attitudes towards the dangers of childbearing, believing that if 'bad" things occur during a birth, perhaps they are meant to serve some purpose which we cannot know at the time... [One midwife]described with equanimity her own childbirth experience, in which she bled afterwards until near death. She did not obtain medical assistance because she believed that God had a reason for her troubles. As this example demonstrates, when midwives hold fatalistic or providential beliefs, the potential for medical intervention is limited."
This finding is consistent with the results of other studies that show that when providers have a fatalistic attitude, they often do not mention, or withhold, information about behaviors and treatments that objectively have been shown to be effective.

The fact that fatalism appears to be part of homebirth advocacy is suprising in some ways because homebirth advocacy aggressively promotes the notion that patients have much more control over health outcomes than they objectively do. Eating right, taking herbal supplements and avoiding childbirth interventions are emphasized as the keys to good childbirth outcomes. Therefore, at first glance, fatalism seems incompatible with homebirth advocacy. I believe that this apparent inconsistency serves an important psychological purpose. By invoking both personal responsiblity for health and fatalism, homebirth advocates are trying to have their cake and eat it, too. Esssentially, they claim credit for good outcomes which they fervently believe are the result of homebirth advocacy, and they disavow bad outcomes which they fervently claim are beyond their control.

Simply put, fatalism is used in homebirth advocacy as an excuse. Homebirth advocates are quick to ascribe good outcomes to their choices and their actions, and bad outcomes to forces beyond their control. Homebirth midwives are quick to ascribe good outcomes to their own clinical skills (when it requires no skill at all to have a good outcome in an uncomplicated pregnancy and birth) and shed responsibility for bad outcomes by claiming that "it was meant to happen". Fatalism in homebirth advocacy serves a psychological function. It protects advocates from the psychologically difficult task of confronting and acknowledging the evidence that homebirth increases the risk of neonatal death.


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