Transformations: Gender, Reproduction, and Contemporary Society

1. Transformations: Gender, Reproduction, and Contemporary Society Week 9: Giving Birth to Children and Mothers Dr. Maria do Mar Pereira m.d.m.pereira@warwick.ac.uk

2. Structure of the Lecture • The Medicalisation of Childbirth • Women’s Experiences of Birth • Homebirth – a Debate • Midwifes at Work and the Crisis of Midwifery • International Perspectives

3. Returning to Medicalisation… Much like pregnancy, childbirth has undergone a process of medicalisation in modern Europe. • 17th and 18th centuries  key turning point: • Cartesian conceptualisation of the body as a machine in need of regulation • expansion of the monopoly and authority of medicine, through • the creation of boundaries around experts • the discrediting of other practitioners (‘wise women’, midwives) • invention and routinisation of new surgical instruments 19th century forceps

4. Feminist Critique of Medicalisation • These were gendered processes, which were grounded on, and gave rise to, unequal relations of power. • women were barred from these new professions (first female doctor in the UK: 1858) • women’sknowledge & advicebecameincreasinglydisqualifiedanddismissed as ‘oldwives’ tales’

5. Professionalisation and Gendered Exclusion Obstetrical examination (1822 engraving) 3 midwives attending to a pregnant woman (16th century woodcut)

6. The Face of Birth (2013) http://www.youtube.com/watch?v=GpARnr353Rk

7. Feminist Critique of Medicalisation • These were gendered processes, which were grounded on, and gave rise to, unequal relations of power. • women were barred from these new professions (first female doctor in the UK: 1858) • women’s knowledge & advice becameincreasingly disqualified and dismissed as ‘old wives’ tales’ • symbolically and materially, childbirthstructuredin linewith(male) doctor’s gaze, ratherthanpregnant woman’sexperience • materially: e.g. in Western countries, women are oftenexpected to deliver in thepositionswhich are mostconvenient for the medical practitionersassistingthem (ratherthanthosemostsuited to aidingthemechanicsoflabourandminimisingdiscomfort for thewoman) • symbolically: e.g. Emily Martin’sstudyofmetaphorsofchildbirth

8. Medical Metaphors of Women’s Bodies • ‘the womb and the uterus were spoken of “as though they formed a mechanical pump that in particular instances was more or less adequate to expel the foetus”’ (Martin, 1992, p. 54) • Birth as factory production: ‘the uterus is held to a reasonable “progress”, a certain “pace” and not allowed to stop and start with its natural rhythm’ (Martin, 1992, p. 59)

9. Regulating the ‘Machine’ • Discourse of time and motion • Emphasis on efficiency, predictability, productivity • Deviation = intervention e.g. the Friedman curve

10. Feminist Critique of Medicalisation • These were gendered processes, which were grounded on, and gave rise to, unequal relations of power. • women were barred from these new professions (first female doctor in the UK: 1858) • women’s knowledge & advice became increasin-gly disqualified and dismissed as ‘old wives’ tales’ • symbolically and materially, childbirth became structured in line with the (male) doctor’s gaze, rather than the pregnant woman’s experience • medicalisation facilitated large-scalesocial (andbiological) control of women  hence, a key part of second-wave feminist mobili-sing was a critique of medical practice and discourse

11. ‘Climates of Confidence or Doubt' ‘Pregnancyandchildbirth are normal, healthy processes for mostwomen, thevastmajorityofwhomhavehealthypregnanciesand babies. Butwhenwasthelast time yousaw a newspaperarticletitled “3,5 MillionAmericanWomenHad Normal LaborsandHealthy Babies thisYear” or a TV episodethatshowed a healthywomangivingbirth to a healthynewborn, without a senseofemergencyorheroicrescue? Themedia’spreference for portrayingemergencysituations, anddoctorssaving babies, sendsthemessagethatbirthisfraughtwithdanger. Otherfactors (…) alsocontribute to the popular perceptionthatchildbirthisanunbearablypainful, riskyprocess to be “managed” in a hospital with use ofmanytests, drugsandprocedures. In suchanenvironment, the high-tech medical carethatisessential for a smallproportionofwomenand babies hasbecomethenorm for almosteveryone. Some advocates for childbearingwomendescribethis as a “climateofdoubt” thatincreaseswomen’sanxietyandfear. In contract, a climateofconfidencefocusesonour bodies’ capacity to givebirth. Such a climatereinforceswomen’sstrengthsandabilitiesand minimizes fear.’ (Our Bodies, Ourselves – PregnancyandChildbirth, 2008, pp. 7-8)

12. Childbirth as a Cultural Event ‘A society's definition of birth is fundamental; it allows those belonging to the culture to develop a set of internally consistent and mutually dependent birth practices. (…) Birth practices tend to be highly (…) ritualized (and may even be invested with a sense of moral requiredness) within any given system. Whatever the nature of a particular birthing system may be, its practitioners will tend to see it as the best way, and perhaps the only way, to bring a child into the world.(…) In the United States birth is predominantly viewed as a medical event and a pregnant woman is accordingly treated as a patient. As such she is expected to fulfill the role of "sick person" (Parsons, 1951): she is considered relatively helpless and exempt to some extent from her normal responsibilities for herself, and she is required to seek technically competent help from medical personnel for treatment of her "condition". In Sweden birth is considered an intensely fulfilling personal experience. The Dutch regard birth as a natural event. The Maya Indians similarly view birth as a difficult but normal part of family life.’ Lozoff, B. et al (1988), ‘Childbirth in Cross-Cultural Perspective’, Marriage and Family Review, 12:3/4, pp. 35-60.

13. The Homebirth Debate Hospital birth Homebirth vs.

14. The Rise of Hospital Births • 1920s: 80% of UK births at home • 1991: 1% of UK births at home • 2006: 2.6% of UK births at home Cahill (2001) ‘The last four decades have witnessed a largely consistent and persuasive argument from the obstetric establishment that the hospital is the best and safest place to be born’.

15. Women’s Experiences of Childbirth (I) ‘The main trauma for me was all the intervention: being induced, having my waters broken for me and being examined all the time… my labour didn’t progress well because I didn’t dilate enough. In the end they had to use both forceps and a ventouse suction cup to get Amelie out, which was frightening and stressing… Staff were too busy to explain what they were doing and why. I didn’t know what was happening or going to happen, and I didn’t like that lack of control.’ (Guardian, 15 November 2010)

16. Women’s Experiences of Childbirth (II) ‘I had a highly medicated birth--pitocin to induce contractions because my water was leaking, then Stadol for the pain… and then (hooray!) the epidural. And episiotomy. Lots of medical intervention. And it was actually a pretty great experience because the people around me were sensitive to my needs and desires and cared for me in the way that I personally needed. My nurse was fantastic--very nurturing and reassuring. At all times I felt like I had control of the situation…’ http://mommyphd.blogspot.com/2006/10/positive-birth-experience-can-happen.html

17. Control and Decision-Making • Control – over one’s body and over ‘risky’ and unpredictable natural processes – as a key element of understandings and experiences of pregnancy: • Fox and Worts (1999): A sense of control is crucial to women having a positive experience of birth – even with intervention • Fox and Worts (1999): Technology as both empowering and disempowering • Lupton and Schmied (2013): to understand one’s sense of control we must consider the nature of the embodied experience of childbirth

18. The Politics of Medicalisation • Martin examines how the micro-politics of medicalised childbirth, and particularly how women resist medicalisation: • Similar to strategies used by workers • Covert resistance • ‘Go-slow’ • Remove equipment • Stay on the move • Childbirth is shaped by broader structures of power: e.g. experiences and degree of autonomy allowed in childbirth are differentiated by ‘race’ and class

19. Woman-centred vs. Institution-centred Midwifery Hunter (2004) argues that the practice of midwifery in the UK is fraught with conflicts. • Conflict between teaching and practise of midwifery • ‘With woman’ vs ‘With Institution’ • Authoritative knowledge about childbirth is with the system of production and not with the women

20. Childbirth and Midwifery Policies in the UK • 1993: Department of Health report Changing Childbirth • 1997: Audit Commission report First Class Delivery: Making it Better for Mothers and Babies • 2007: Department of Health guidance: Maternity matters: choice, access and continuity of care in a safe service • 2008: Healthcare Commission report Towards Better Births: A review of maternity services in England • £330 million extra funding over 3 years from 2008 • David Cameron accused of breaking pre-election promise to recruit an additional 3000 midwives

21. Is there a Crisis in Midwifery? • Midwives leaving the profession, leaving training • Exodus related to inability to provide continuity of care leading to poor job satisfaction • Walters: midwives are ‘popping in and out of three or four labour rooms and filling out endless forms while women yell for them’ (The Guardian, 2003). • Recruitment has increased but birth-rate has also increased • Royal College of Midwives: 66% of midwifery heads report insufficient staff (November 2009) • 12% of midwifery posts unfilled in south-east • Rise of doulas

22. Campaigns for Continuity of Care • Independent Midwives UK: www.independentmidwives.org.uk • Community Midwifery Model • Association of Radical Midwives (ARM): www.midwifery.org.uk/ • Taking midwifery ‘back to the roots’ • Re-skilling midwives • Association for Improvements in Maternity Services (AIMS): www.aims.org.uk • Pressure group • Offers advice to women

23. The Future…who knows? • The death of midwifery? • The implementation of one-to-one midwifery care across the country? • Further development of the ‘conveyor belt’ birthing unit to cut costs? • Continued contestation over ‘control’ in childbirth?

24. ‘Dying to have a baby’: International Perspectives • Chance of dying in childbirth: • Niger: 1 in 7 • Sweden: 1 in 29,800 (Save the Children, 2006) • More than 340 000 women die in pregnancy or childbirth annually around the globe • Many deaths are from treatable conditions such as high blood pressure • 15 million women endure injuries, infection and disabilities in pregnancy and childbirth

25. The bottom 10 countries: Afghanistan Central African Republic Malawi Chad Sierra Leone Lesotho Cote d’Ivoire East Timor Guinea Liberia Source: The Lancet, 12 April 2010

26. For Seminars, you must read: Fox, Bonnie and Diana Worts (1999) ‘Revisiting the Critique of Medicalized Childbirth: A Contribution to the Sociology of Birth’, Gender and Society, Vol. 13, No. 3, pp. 326-346 Hunter, Billie (2004) ‘Conflicting ideologies as a source of emotion work in Midwifery’, Midwifery, Vol. 20, No. 3, pp. 261-272 Martin, Emily (2001) The Woman in the Body, Boston: Beacon Press, Ch. 4 ‘Medical Metaphors of Women’s Bodies: Birth’, pp. 54-70. Lupton, Deborah and Virginia Schmied (2013) ‘Splitting bodies/selves: women’s concepts of embodiment at the moment of birth’, Sociology of Health & Illness, Vol. 35, No. 6, pp. 828–841 AND PLUS OR