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Pregnancy & Birth

Recommended Books and Films About Childbearing

continued...

A pregnant women would likely be confused by the sentence above, and ask herself what the word "natural" really means. Bombarded with descriptions of conflict and with information about "technological" births, she has little chance to learn about alternatives. Well before she gets to the chapter about choosing a practitioner she is told to communicate with her doctor (always "he") (35), and to "find a doctor whose...attitudes fit easily with your own." (93) Midwives are not seriously mentioned until Chapter 10 "Finding Your Birth Assistant" (119). Nurse-midwives are contrasted with "non-medical" midwives (11), a biased and inaccurate distinction. Nurse-midwives would not necessarily like to be called "medical" practitioners, and independent midwives would not appreciate this cursory, implicitly negative description.

In a discussion of birthplace options the high-tech medical hospital comes first, followed by family-centered hospitals, birthing rooms within hospitals, midwifery services within hospitals and finally "More controversial options" (189) -- controversial to whom? -- which include out-of hospital birthplaces. An out-of-hospital birth is described at one point as "a less desirable setting" (180) immediately following an uneven discussion of the comparative advantages and disadvantages of home and hospital births. This ranking of possibilities could have been written by an enthusiastic advocate of the present obstetrical system.

Feldman uses terms "high-risk" (97) and "normal" (21) as if health professionals and childbearing women both agreed upon their definition: "Of course, high-risk patients are screened out" (180). Alternatives, couched in cautious terms, are presented less knowledgeably and less vigorously than the descriptions and critiques of medical tests and technologies.

The author constantly refers to the "qualified childbirth expert" (2, 13, 15, 47, 49, 85, 95), most often the doctor, and only occasionally the midwife or childbirth activist. "Expert" in fact is never defined; it seems to mean those in power rather than the women themselves who go through pregnancy, labor, and birth. Once again, this point of view is common in our society, and implies that only the experts know what's best for women. The author's reliance upon "experts" reinforces the attitude of "learned helplessness" she decries. (15)

A Good Birth, A Safe Birth and Sense & Sensibility

A Good Birth, A Safe Birth (AGB) by Diana Korte and Roberta Scaer (1984, revised 1992) and Sense and Sensibility in Childbirth (S&S) by Judith Herzfeld (1987), exemplify this subversion. Intelligently and compassionately written, both present childbearing as occurring in a social and emotional matrix, not as a purely medical event. Both books emphasize women's ability to labor and give birth naturally, with empathetic, knowledgeable labor support, in a calm, unhurried setting with minimal intervention. Both state strongly that what is best for mothers is best and safest for their babies, and that a growing amount of research validates women's wishes for as natural a birth as possible. AGB makes a point of relating women's experiences and desires, explicitly set down in the form of responses to questionnaires the authors sent out. They bring out the particularly female aspects of childbearing, and make the connection made between sexuality and childbearing. AGB talks about the similarity between sexual arousal and pregnancy, the facilitating role of the hormone oxytocin, a woman's extreme vulnerability and openness during pregnancy and birth, the importance of touch during labor, and the erotic quality of breastfeeding. S&S speaks of similarities between childbirth and lovemaking -- "unusual muscular strength, restricted sensory perception, rhythmic contractions of the uterus...and sudden return of awareness and emotional reaction of deep satisfaction at completion." Birth reaches fruition more readily if a woman can lose herself in it. It can be painful and frustrating to be self-conscious, to resist, or to have a partner (or a birth attendant) insensitive to her needs.

AGB then analyzes the existing obstetrical system. After describing the inappropriateness of crisis-oriented care for normal birthing, the authors then abruptly bid women to knock on hospital doors. By not carrying their analysis to its logical conclusion -- the desirability of restructuring care for childbearing women -- they do readers the disservice of describing two realities that cannot by definition exist in the same place at the same time.

This confusion occurs most strikingly at the heart of both books -- the search for the "perfect" doctor, almost always "he." AGB lists the rigors of obstetrical training, the time pressures on interns and residents in obstetrics, the emphasis on surgery, the disposition to use "new toys" -- techniques and technologies -- and the fact that residents practice upon low-income women who have neither the education nor support to state what they really want and need. What's more, the authors state "Asking an obstetrician to 'sit on his hands' and wait for nature to take its course goes against his beliefs, training and experience...they want to practice medicine in the style to which they have become accustomed. And that style definitely affects the care an obstetrician gives you" (74). In the U.S., doctors fear malpractice suits and thus practice defensive medicine, performing most available tests and procedures just "in case" something goes wrong. Insurance companies reinforce doctors' urge to intervene by reimbursing these costly procedures. The authors point out that in some areas a surplus of obstetricians leads these same physicians to attempt to eliminate the competition represented by family practitioners and midwives.

After listing all these facts one would expect the authors to advise readers to seek out the midwives and family practitioners experienced in normal birth whose skills they have carefully described and praised. Instead they tell us: "There is a doctor for you." S&S calls him "a guardian angel." (100?) AGB, less romantic, more contemporary, calls him "Dr. Right" (81). "Because nearly all of you will choose a physician, we call your birth attendant Dr. Right. For most of you, he (sic) is an obstetrician. For others, a family practitioner, or, for a few, an osteopath. If your search is for a midwife, you can still follow the same process" (83).

Note the main assumption and the ordering of practitioners. "Dr. Right" has been defined as right for you because you have chosen him? After listing a series of interview questions to ask prospective doctors, the authors, in discussing HMOs and group practices, go on to say: "In spite of knowing your obstetrician may not be there, you may still decide that (he) is Dr. Right." Absence as perfection? They continue: "...tell him that you would like to meet all the doctors who might cover for him when your baby is born...there may be literally a dozen or more doctors who might be on call..." (91). A dozen! Even if Dr. Right exists, Dr. Wrong will be attending most births! Women may indeed have to believe in Dr. Right so much because they truly want a birth attendant who will be sensitive to their needs; and so they deceive themselves into settling for less than they deserve, despite the veneer of rational choice.

S&S follows a similar pattern. Herzfeld discusses economic and institutional realities in a chapter entitled "In the Interests of All Concerned" -- the malpractice threat, the pressure on doctors to adhere to standard practice and not alienate other doctors, anesthesiologists and nurses. She points out that hospitals must protect their financial interests, using equipment and services to capacity. "In our fee-for-service system, every IV placed, every pill dispensed, and every (fetal) monitor brings extra income into the hospital," as does each administration of anesthesia. In teaching hospitals, "...it is the obligation of the maternity unit to provide (learning) opportunities to residents in ob/gyn and ob/gyn anesthesiology...Although patients may have the right to refuse the care of a resident...they are discouraged from doing so." Nurses may perceive family members, friends and "labor coaches" present during labor as interfering with what they see as their duty. Hospital routines set up for efficiency and for the benefit of its staff are not flexible enough to accommodate the fluctuating rhythms of individual women's labors.

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