Talk on Politics of Childbirth. December 2, 2002


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Talk on Politics of Childbirth.

December 2, 2002

Birth and how it is accomplished can be seen as the ground on which the conflict between men and women’s rights rests. While birth around the world and throughout history has been the province of women, when men began to get interested and make money from childbirth, we can see this conflict as symbolic of many of the unresolved power issues between the sexes.

  1. My history with this subject: Writing in the mid-seventies on a convention of nurses. The women’s movement and taking control of the birth experience.

  1. As we are covering birth in this class, I decided to explore this area further to learn if there is historically any support for the idea of birth issues being related to the issues of women and women’s issues.

  1. There are supporting arguments for both sides. What follows is a history and information so that you can decide for yourselves; In the workshop after this talk, I will give you some situations to consider from different perspectives so that you can think about this subject and assess the current effect of politics on birth.

The history of Childbirth

    • Historically, midwives were the ones who assisted in birth. Illustrations #1, Lying-In.

    • Pictures of midwives, birthing stools used Illustration #2

    • It was thought that babies kicked their way out of the womb. Woodcut from first birthing manual in 1545 and revised a number of times until 1626. Illustration #3.

Surgeons (men) were called in for emergencies—often having to take apart the baby to save the mother’s life. This procedure was called craniotomy. Surgeons were often very aggressive with women, cutting women to expand the birth canal and performing cesareans. Since women often died, these techniques were abandoned. They were able to announce that a woman might die, if she had a misshapen pelvis, but could not really help in any other way. Illustration #4

The invention of forceps, by 1695 by Chamberlan was kept a family kept a secret for over a century, but finally the secret leaked out. Some male midwives used these forceps in the earliest stages of delivery, before the baby was in the birth canal, with deadly results.
In Paris, there were established school/hospitals where in wards for poor women, doctors learned and trained. New techniques included measuring the pelvis and getting a sense if the baby would be able to fit through the birth canal. (the “touch” of the attendant.). These ideas were based on the notion that the body was a machine, and the womb would expel the fetus. This began a new “science” of midwifery, and magic, and religious incantations were no longer seen as necessary. While they understood birth better, they did not really have better techniques in aiding birth. Illustration #8

Rise of male-midwives: First birth manual—by a man to instruct female midwives 1545 and revised a number of times, to 1626. Illustration p.16. Women in the colonies often did well in childbirth, they were stronger, healthier, more well-fed than their counterparts in England. After 1750, male doctors returned from training in Europe to practice medicine in America. They often used the obstetrics they had learned to get their practices started and found themselves in conflict with midwives. Childbirth was redefined: medicine vs. “granny and superstitious” midwives

Forceps were often used by male midwives in the earlier stages of labor, before the head was down in the birth canal, often causing damage to both mother and baby. There was little or no training of those who used these instruments—especially in England.. Women did not use the instruments, either because they could not get them, did not want them, or were not strong enough to use them. Because they were not shaped as the mother’s body, the person using them had to be very strong. A few cases of midwives having instruments show that they used them rarely in their careers.

Illustration #5 of a male midwife who dressed as a woman. He was later burned at the stake.

Illustration #6 of the modesty used by male midwives—woman giving birth is fully clothed, and cannot see what he is doing.
#7 Quote from a new medically trained obstetrician. He didn’t have a clue.
Hospitals were established for women giving birth, but were rampant with childbirth fever. Many women still continued to give birth at home and slowly midwifery began to make a comeback. Midwife-assisted births had better outcomes and almost no evidence of the childbed fever rampant in hospitals. Some hospitals even employed midwives at one end of the hospital to care for the poor and less wealthy patients and doctors at the other end to deliver the babies of wealthy clients. Even here, the midwives' outcomes were better and incidence of childbed fever was much lower. Wealthier women who could afford the doctors often pleaded to be delivered by the midwives to avoid the death in the medical wards.

In 1847, Dr. Ignaz Semmelweiss instituted rules in his ward that physicians must wash between patients. He was convinced that the infections were being spread by the doctors and that the reasons midwives had better outcomes was directly related to their practices of cleanliness. This practice dramatically decreased the incidence of childbed fever, but most of his contemporaries ridiculed his research and continued to practice as they always had.

By the end of the 1800's many doctors were finally beginning to accept the research of Dr. Semmelweiss and others. Washing standards and protocols were instituted across Europe and American, but many women continued to favor delivering at home to a hospital delivery.

The death of women proved to be the result of attendants not washing their hands after dissecting cadavers or between helping at different births.

By mid-1800’s there was serious competition between male midwives and doctors and classic midwives who competed to deliver at births. Gradually, women midwives disappeared from and doctors won the contest. According to Wertz and Wertz, one of the reasons that midwives disappeared is that they never organized, developed leadership or training requirements. It came to be seen, especially by upper and middle class women, as more up to date to have a doctor rather than a midwife. A doctor’s reputation was based on the social standing of his patients, and they wanted the rich ones. However, the doctors were trained in established medical schools, and midwife schools, and both left much to be desired. Women midwives often fought against interference with the birth process.

Women were not allowed to have medical training.

A woman who bucked the social trends and did apply to medical school was at first rejected and then, when allowed in the next year, forced out by her fellow male students. They wrote: “We object to having the company of any female forced upon us who is disposed to unsex herself and to sacrifice her modesty by appearing with men in the medical lecture room where no woman of any true delicacy should be found.” P. 59 The difficulty women had getting into medical schools inspired the opening of medical schools for women—New England Medical College founded in 1848 by Samuel Gregory and the Quakers began one in 1850.

Early gynecologists were seen by the medical historian Barker-Benfield, as “ruthless and ambitious.” While traditional histories extol the glories of medical surgeries, he describes them as developed with “ulterior motives.” Surgeries, which allowed the removal of all parts of women, were attempts to retaliate against and control women, who, under the impetus of the Industrial Revolution, were increasingly entering the work force and stimulating the growth of the women’s rights movement. Rather than humanitarian concerns, Barker-Benfield argues, “hostility toward women and competition among men were the conditions for the rise of gynecology.” (Scully p.39)

For men to convince women that they were needed in childbirth, they had to begin to convince women that childbirth was “a pathological state requiring the intervention of obstetricians and their instruments and surgical techniques.” (p.28 Scully) Normal childbirth was now unusual, and complicated birth was seen as the norm.

In 1847, Dr. Ignaz Semmelweiss instituted rules in his ward that physicians must wash between patients. He was convinced that the infections were being spread by the doctors and that the reasons midwives had better outcomes was directly related to their practices of cleanliness. This practice dramatically decreased the incidence of childbed fever, but most of his contemporaries ridiculed his research and continued to practice as they always had.

By the end of the 1800's many doctors were finally beginning to accept the research of Dr. Semmelweiss and others. Washing standards and protocols were instituted across Europe and American, but many women continued to favor delivering at home to a hospital delivery.

Even though the need to wash was known, many doctors did not follow such rules. Women continued to die in hospitals. In the 1900’s many poor women, and then others who could afford them, were taken to hospitals to give birth. The women often died as a result of childbed fever. I have heard stories about wealthy women begging to give birth at home and not go to the hospital where so many died.

The issue of pain in childbirth was an interesting question. It appeared that women who were “uncivilized” had less pain than other women. There were stories of Native Americans who gave birth easily, and some women who gave birth in their sleep. Fashionable women of the mid 1800’s wore corsets tightly cinching their waists. Pale, sickly, weak women were seen to be gentile, and strong healthy women were seen as coarse and vulgar. Also in another source was a biblical reference to Hebrew slave women have no pain in childbirth compared to the Egyptian women who had to do nothing for themselves, and suffered terribly in childbirth.

Chloroform was introduced for women in labor around 1860. Despite the fact that these chloroformed women were unable to care for their babies for several days while they recovered from the effects of the gas, a growing number of women saw the use of anesthetic to be a boon. Mothers were unable to care for their infants, resulting in the beginnings of nurseries for newborns

Also in the mid-1800’s was the development of the speculum by Dr. Marion Sims, who is seen as the father of gynecology, but operated on slave women who had developed a condition known as vesicovaginal fisutula, which meant that after childbirth, women were not able to control their urine. It made the slaves useless, and he performed many operations on these women, without the use of anesthesia. While he caused these women enormous pain, he did figure out how to fix the problem.

In 1940, Twilight Sleep was introduced. This heavy dose of narcotics and amnesiacs completely incapacitated laboring women and caused women to loose control. Many were literally strapped to their beds to keep them from injuring themselves. Recovery was a long process because of the drugs and breastfeeding was more impossible than before. Fathers, unable to help, were not needed at all. Twilight sleep was also difficult on the babies were born sleepy and unable to respond or suck. Breathing was difficult and babies had to be watched carefully to insure that they didn't stop breathing. Many were force-fed in those first days after birth because they would not or could not suck effectively due to the drugs in their systems. My brother almost died after my mother gave birth in twilight sleep. Interestingly, I always heard this story about the fabulous doctor who saved my brother, not about the doctor who almost killed him with so many drugs given to my mother.

In the 1940’s, In 1944, Dr. Grantley Dick-Reed wrote Childbirth Without Fear. He studied midwives with laboring women and learned how these women assisted laboring women to give birth without medication using relaxation techniques. He also studied the fear-pain cycle and discovered that women who were not afraid of childbirth had less pain and fewer problems.

In 1953, Dr. Fernand Lamaze published his findings about labor and delivery in Russia. His philosophy substituted scientism for faith and introduced self-hypnotism as a method of coping. His "prepared childbirth classes" were accepted by many hospitals because the instructors taught couples to accommodate hospital practices instead of listening to their own bodies. His work did, however, open the door to childbirth education classes –fathers had a role in birth helping their wives.

Not many years later, Dr. Robert Bradley introduced his philosophy of husband-coached childbirth in a book by the same name..

1970’s feminism and childbirth. During the 70’s and later there was a rise in women who wanted to have natural childbirth. Women began having babies with midwife assistance in their homes. The response of hospitals was to make birthing units that were as much like home as possible. Some hospitals allow midwives in take care of women for the first stages of labor. However, there continues to be much use of ultrasound, fetal monitors, epidurals and these all contribute to a high rate of cesarean sections. While the rate has reduced somewhat, it is over 20%. Interestingly, the statistics show that 90% of births are normal.

Some other issues where politics and birth intersect.

1. Contraceptives. Still condemned by some religions and in some countries. What are the politics involved?
2. Money to other countries dependent on abortions. Bush is holding back money to assist in health care if any of that money is used for abortions. We have not yet seen the toll this will take on women’s health care world wide.
3. High rate of death for Black women in the US. The death rate for Black women in poverty in this country is high. Poverty, lack of prenatal care, adequate nutrition, access to hospitals and doctors. How can policies affect this situation? What policies can you suggest?
What is done today:

  • Induction: Babies who doctors think are late may be induced to prevent harm to the baby. Simplest way to induce is to puncture the membranes. Early puncturing—in the first stages of labor, result in contractions pressing directly on the walls of the birth canal against the fetal skull. “Tracings from fetal heart monitors have shown that as each contraction increases this pressure, a marked decrease in blood to the baby (and oxygen to its brain) occurs in cases of early ruptures, but is rarely seen in cases where the mother’s membranes are still intact.

Workshop on Politics of Birth

December 2, 2002
Dividing into groups of four or five, discuss the following questions after reading the appropriate sections. We will reconvene to hear some suggestions and findings that your groups come up with.

1. From Reading Birth and Death by Jo Murphy-Lawless, 1998.

“In enforcing its account obstetrics has usurped any sense of agency on the part of the birthing woman. In effect the science tells women, “You can escape death if you follow us. But you must hand over to us your role as the central player in childbirth.” Examining the history of obstetric thinking has led me to conclude that we need to interrogate the obstetric demand that it should remain the single arbiter about childbirth management because—it contends—its practices have brought to an end danger in childbirth for the vast majority of women and their babies in the West. This demand with its accompanying rationale is, I believe, at the heart of our dilemma with obstetric science. We should be demand in of obstetrics that it acknowledge the limits of its actions, that it has been but one element, and one with contradictory effects, in a complex picture of the changing lives of women in the modern period.”

“Obstetrics argues that its power to determine what ought to be done in childbirth is founded on its authority as a form of scientific rationality and it is not amenable to accepting as expert any voice from outside that community (and dismisses the dissident voice within.)
“Women see the issue of obstetric power differently and question what we experience as an overt exercise of power, one that is often expressed in distinction irrational practices and language. This irrational response emerges pretty rapidly whenever we query obstetrics and it always turns on the same issue, the risk of death in childbirth whether for woman or baby.
“I think we need to recognize and maintain our awareness of our proximity to death in the sense that there are never guaranteed outcomes. If we reclaim the awareness that there are no guaranteed outcomes, we can deal critically with obstetrics strategies of risk, its categories of normalcy.”

  1. Do you think that this assessment of obstetrics is correct? Are women forced to give up their “agency” in exchange for a promised death-free birth?

  2. In your discussion on this question, consider the different points of view of doctor, midwife, hospital CEO, woman, husband, baby, and insurance company.

  3. Do you think that women have been diminished as a result of the attitude of obstetrics as described in these selections? Is the author rallying women?

2. From Lying-in, by Wertz and Wertz, p.57.

The following statement is from a pamphlet by an unknown author, 1820 published in Boston. “They (women) have not that power of action, or that active power of mind, which is essential to the practice of a surgeon. They have less power of restraining and governing the natural tendencies to sympathy and are more disposed to yield to the expression of acute sensibility…where they become the principal agents, the feelings of sympathy are too powerful for the cool exercise of judgment.”

Doctors had to eliminate midwives to develop their larger practices. Midwives were attacked as unfit for a number of reasons, but did not respond as a group. They never mobilized in any way, never developed any kind of certification process, as men were doing. The defenders suggested that the natural way to have a child was with midwives in attendance, and the introduction of men into the field had not improved things for women—in fact, had made things worse. The argument against midwives was that they were ignorant and that “women who presumed to supervise births had overreached their proper position in life.” (p.56) No “true” woman would want to gain the skills and knowledge necessary to overcome what they didn’t know about deliveries. Also, women who learned the skills necessary to be a surgeon would no longer be a “lady.”

Question: What was really behind the rise of men involved in birthing concerns—was it only that they were interested in helping women have babies, or are there other reasons? Does this kind of statement reveal something else about childbirth? What are the politics involved here?

3. From: Maternal Mortality in the United States: WHERE ARE THE DOCTORS ? by Marsden Wagner, MD, MSPH

“The reason the maternal mortality fell in the US this century was because of the advent of antibiotics and blood transfusion more than anything else. There is simply no scientific evidence to prove the falling mortality was because birth was moved into the hospital.(1) The evidence does show that as long as there is a system in place to transport women in labor to a facility within 30 minutes where there are antibiotics, blood transfusion and cesarean section capacity, there should be very little maternal mortality.

Maternal mortality is quite different from perinatal mortality and infant mortality. The latter two are much influenced by socioeconomic factors while maternal mortality is much more directly a function of the quality of the health care available. If midwives (traditional, direct entry, or nurse-midwives) are trained to know the signs of serious complications and have the means of transport, there is no need for a doctor at the site of primary care of pregnant and birthing women who have had no complications. But at the site of the place where the woman is transported, there is need for a doctor who has surgical skills and, ideally, obstetrical skills, to manage the complications.

There are at least two reasons why the US is 16th in the world in maternal mortality and both reasons have to do with access to quality care. First, the large numbers of women without health insurance in the US have to jump through so many hoops to get care that there is likely to be delays in receiving the care and this can be a disaster. Furthermore, the women receiving publicly funded care go to hospitals which are overcrowded and with overworked doctors without sufficient training (ie interns and residents). The delays and crowding and lack of skill of doctors all can lead to maternal mortality.

The second reason the US does poorly in maternal mortality is a huge irony. US doctors scream that women need to be in hospital at the time of birth and yet the doctors who need to treat them are NOT in the hospital but in their offices doing prenatal checkups and postnatal checkups on healthy women. So when the woman who is in the hospital (or transported to the hospital) needs urgent attention for developing complications, the obstetrician is not there and must be called and may come too late.

In every industrialized country in Europe (including the countries with the world's lowest maternal mortality rates), obstetricians are hospital based specialists who remain in the hospital and are there to jump in and treat the complications. Meanwhile it is the midwives who are out in the community giving the prenatal checkups and postnatal checkups to women without complications. It cannot be overemphasized that this lack of access of American women to immediate obstetrical attention in the hospital, for whatever reason, is a fundamental difference between maternity care in the US and the rest of the world and is the reason for the poor US maternal mortality. Put differently, the countries which do better than the US in maternal mortality all have universal health care coverage for pregnant and birthing women (without any hoops to jump through) and all have hospital based obstetricians ready to care for these women.”

Question: Given this statement, what can we do through policy changes that would improve the rates of childbirth in these populations in the US?

4. From Immaculate Deception: p. 98

”Part of the doctor’s heroic infallibility is rooted in the premise that our technology can save us from all risks of the natural process of birth. Well, suppose it can; suppose for a moment that all American hospitals can somehow perfect all technological interference to the extent that all pregnant women could be provided with a risk-free birth, either by means of routine Cesarean or by a combination of medical interventions in vaginal birth. What would be the consequence to the average pregnant woman?

Questions: If it were possible for all births to come out well if women completely gave themselves up in the process, would it be worth it? What are women gaining? Giving up? What politics are involved here?
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2002-2003 -> Russia: empires and enduring legacies


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