The birth process is an integral and inescapable part of social life (Mishler et al, 1981:232), and the way in which it is managed reflects a great deal about the values, norms, and socially-legitimated distribution of power which characterise a community.
Childbirth, like many other human states and processes, has become increasingly medicalised (Doyal, 1981:234; Helman, 1990:137-138; Zola, 1972:495-496). Western biomedicine perceives the act of childbirth as a clinical crisis (Doyal, 1981:236), and, in this model, knowledge and control of the birth process is legitimately and almost exclusively held by biomedically trained practitioners (Oakley, 1981:202-206).
The biomedical model understands the body as analogous to a machine (Mishler et al, 1981:237; Rothman, 1985:126) and uses highly specialised technology which is often unfamiliar to the majority of patients (see Jordan, 1990:98-99). This contributes to an uneven distribution of knowledge in the biomedicalised birth process (Jordan, 1990:109).
Although the birthing mother should be recognised as a possessor of valuable and relevant knowledge, the social context of Western(ised) society places greater value on the biomedical knowledge held by the physician or other biomedical practitioner managing the birth. The majority of mothers do not have access to this type of knowledge. This leads to an unequal distribution of power between the participants in the birth process (Jordan, 1990:98; Turner, 1987:47, 50).
THE MIDWIFE OBSTETRIC UNITS
Depending on the personal preferences and, more importantly, the financial standing of a South African woman, she can arrange to have her baby delivered in either a state or private maternity health care unit, or in her own home. State maternity units are divided into three levels. To which of these a woman will be referred depends on the potential risks associated with her pregnancy. These are ascertained through the taking of her medical, gynaecological and obstetric history, as well as through observations and examinations during her pregnancy.
The first of these levels consists of the Midwife Obstetric Units (MOUs), which are staffed mainly by nursing sisters who have received midwifery training. Ideally, only 'normal' uncomplicated births are managed here. If a woman's medical history and examinations have shown no indication of a potentially high-risk labour, she will receive her ante-natal care and have her baby delivered at an MOU. Here, the nursing sisters are permitted to administer analgesics, and may also perform episiotomies. If a woman develops problems during labour, an ambulance can take her to the nearest secondary hospital, or, in cases of haemorrhaging, a doctor can prescribe oxytocin over the telephone.
The secondary hospitals are staffed by nursing sisters and doctors. Theatre facilities are available for obstetrical problems. Caesarean sections, tubal ligations and other procedures, like manual deliveries of placentas, can all be performed under general anaesthetic at these hospitals.
High risk cases, i.e. women with diabetes, serious heart disease, or who seem likely to have other major complications, are referred to a tertiary hospital.
This article is based on qualitative research 2 carried out at an MOU in a working class 'coloured area' 3 near Bellville, Cape, and is informed by further research on the experience of the reproductive process at a Cape Town maternity hospital. The MOU is situated alongside the local day hospital, and is staffed by nursing sisters who are assisted by student nurses during the day, and medical students at night.
THE DEVELOPMENT OF THE BIOMEDICAL MODEL OF CHILDBIRTH
In the seventeenth century, Western philosophers began to compare the body with a machine, and childbirth, therefore, came to be seen as a mechanical process. At the same time, technology was being developed in a number of areas, including that of childbirth. 4 Up until this time, births in Western societies had been managed by midwives. These were usually older women who had themselves experienced childbirth, and were often respected and familiar members of the same communities which they served (Mishler et al, 1981:233).
Davis-Floyd contends that Christian theology saw women as being inferior to, and closer to nature than, men (Helman, 1990:147), and that, by an extension of this, men came to be regarded as the custodians of the new technology. Male obstetricians thus came to replace female midwives as the authoritative managers of the birth process. While Christian theology promoted a dichotomous notion of woman / man corresponding to one of nature / culture, the popular move away from supernatural beliefs during the Enlightenment period did not signify a comparable move away from this view. Jordanova argues, instead, that the Enlightenment extended and entrenched this view, with the ability to think scientifically being credited to 'cultural' men, rather than to 'natural' women (Jordanova, 1980:45). The control of technology was probably the crucial factor in obstetricians progressively wresting control from midwives.
An international hegemony of Western science and technology (Pereira, 1993:v) has ensured that the biomedical model of birth management has been exported to, and has attained a position of authority in, most areas of the world. Today, the vast majority of urbanised women have their babies in clinical settings, usually attended by female and/or male biomedical practitioners (e.g. see Gottlieb, 1995:12; Oakley, 1981:204).
The increased medicalisation of the birth process, together with the increased use of technology - which some authors argue is not always necessary (e.g. Jordan, 1990; Oakley, 1981:200) - is widely criticised in the feminist literature for its potential encroachment upon the power and knowledge of women concerning the birth of their children (Doyal, 1981; Helman, 1990; Jordan, 1990; Oakley, 1981; Rothman, 1985).
CHILDBIRTH AS PATHOLOGY
The biomedical frame of reference sees:
"the status of pregnant women as patients and the measurement of successful outcome in terms of biological mortality rates. For mothers, conversely, childbearing is more likely to be seen as a natural biological process; an event that is an integral part of their whole lives and development; an experience to be evaluated in terms of its contribution to happiness in a more general way than mere survival" (Oakley, 1981:203).
The pathological view of childbirth sees the labouring woman as being somehow unhealthy, and is prevalent in the biomedical paradigm. This view can sometimes be insidiously subtle. During the research, John Baungart 5, a medical student at the University of Cape Town, stated that one must remember that "these women," to whom he routinely referred as patients, "are not that sick".
It is important to realise that a pathological view is not always unwarranted. In many pregnancies complications do arise, and biomedical, even surgical, steps become necessary. It cannot be denied that developments in the field of biomedical obstetrics have been strongly correlated with notable reductions in birth-related morbidity and mortality rates (Helman, 1990:146; Lewis Wall, 1995).
It should also be acknowledged that campaigns against biomedical intervention can be as detrimental to childbearing women's freedom of choice as is the system which they seek to remove. Referring to feminist campaigns against the medicalisation of the birth process, Warman and Hawthorne (Fair Lady, 10 February 1993) contend that:
"... freedom from the regime of high-tech labour wards and doctor-controlled childbirth have unwittingly given birth to a new tyranny. No longer may we choose to forego medical intervention and give birth to our children naturally; we now have an obligation to do so."
This, they say, leads to women who require medical intervention experiencing "shock, guilt and disappointment."
Nevertheless, it is a matter for concern when births are routinely viewed as requiring massive medical intervention. This tends to happen in clinical settings. Dr Jean Oaker, a qualified medical doctor and a mother of four, stated that doctors are inclined to have a "mindset of dealing with illness," to which she also referred as a "pathology mode." For this reason, she is quite "pro-midwives." She believes that midwives can have more experience of getting the mother through the whole labour, rather than focusing on the actual delivery, and that they can be more effective in the successful establishment of breastfeeding. These are areas in which someone who views childbirth as an isolated clinical crisis is unlikely to become deeply involved. She stressed her opinion that these midwives must, however, have rigorous training, and a biomedical back-up system for emergencies.
Although she was referring to midwives who assist at home births, one might think that the same could apply to nurse-midwives. According to the nursing sister in charge of the MOU, Sister Lewis, there have been no doctors at the MOU since "before the riots."* As Amanda Greyton, another medical student at the University of Cape Town, noted, the MOUs are community-based. There are no doctors, only nursing sisters, therefore it would be reasonable to assume that they are "very 'woman'-oriented." These nursing sisters, though, have been trained in and identify with the biomedical perspective. The fact that they are women does not necessarily determine their beliefs about and approach towards birth management. It is apparent that biomedically trained nurse-midwives who work in clinical settings subscribe to the same pathological view of childbirth as do doctors (Rothman, 1985:128; see also Gottlieb, 1995: 13).
The notes given to University of Cape Town medical students stress that:
"While the Maternity Service manages close to 30,000 labours per annum, for each mother this is a unique and very special experience" (U.C.T. Department of Obstetrics and Gynaecology, n.d.:146).
A commitment on the part of biomedical practitioners to contribute to the quality of this experience is not always reflected in real-life situations. John stated that medical students are taught that the purpose of biomedical intervention is to decrease both mortality and morbidity rates. According to him, the emphasis on the reduction of morbidity rates is related to a commitment to improving the quality of the birth experience for the mother. What they are taught though, is not always practised. In his own words: "It is practised most of the time, but can sometimes be neglected."
This statement still implies that the norm for birth management is to take the mothers' emotional experiences into account. None of the four mothers interviewed, however, indicated that their labour experiences in clinical institutions had been in any way emotionally satisfying.
As part of the research, I was present at a labour and delivery managed at the MOU. No attempt was made to improve the quality of the emotional birth experience for the mother, Sara Abrahamse. On the contrary, I noted that she was treated very harshly. Just one example of this is that, when she moaned in pain, Sara was brusquely instructed: "Don't make noises,"* and when she wished to say something: "Don't talk, just push!"* Two other mothers related similar experiences. Shariefa Malan, who also gave birth at the MOU, said of the delivery that "there they treated me miserably."* If she made noises they reprimanded her, telling her to "'just sit on the bed and relax' - now where can yourelax with the pains which are shooting over your body?"* Mpho Magibili, who gave birth at another MOU, reported that she had wanted to cry during her labour. The nurse-midwives told her, though, that "you mustn't cry, else all your other babies will be painful."
According to Rothman (1985:126), the biomedical system objectifies birthing women. In these cases, far from attempting to make the birth experience special for the mothers, the nurse-midwives treated the mothers as marginal, or even as a 'hinderance', to the birthing process. There is no reason, not even a biomedical one, why a woman's moans during childbirth should be seen as harmful. Apparently, the noises a birthing woman makes are simply an irritation to these biomedical practitioners, who want to get on with their task of delivering the baby with as little 'interference' from the mother as possible.
"In the minds of some obstetricians, birth seems to be seen as merely the technical problem of getting a living object (the baby) from one tube (the uterus), down another (the birth canal), and then into the hands of the physician." (Helman, 1990:147)
If the woman is seen as simply an object out of which to take a baby, it is possible to ignore her emotional experience and, indeed, to belittle her role in the birth process. This approach, which may be efficient from a biomedical point of view in that it does not increase mortality or narrowly-defined morbidity rates, is not conducive to the care and "general well-being" of the new mother (Lewis and Salo, 1993:61).
When a woman believes that labour has begun because, for example, her membranes have ruptured (waters have broken), her contractions have started, or for some other reason, she goes to the MOU. She is then examined internally by one of the biomedical staff, who measures the dilation of the cervix and decides whether or not labour has started. If, by biomedical criteria, the labour has not yet begun, the woman is usually sent back home and told to return when her contractions are stronger and closer together, or when her waters have broken.
This happened in the case of Sara, a first time mother whose baby was delivered at the MOU. When she arrived, experiencing what she understood to be labour pains, her cervix was only 1cm dilated. She was sent home with two Panados 6 and advised to take a warm bath. The pains became steadily more intense, and she returned to the MOU the following morning. She gave birth that afternoon.
Rather than giving credence to the knowledge of individual women about the sensations they experience, the start of labour is defined in precise and generally applied biomedical terms (Rothman, 1985:123-126). When the two types of knowledge are at odds with one another, even if separated by only a matter of hours:
"the woman's sensations of labour are 'false' and the doctor's definition is true" (Rothman, 1985:125).
The birthing mother is monitored throughout the labour by the measurement of her blood pressure, and her and her foetus' heart rates. When it 'is time', she is taken to the delivery ward where the baby is delivered. After the birth and the delivery of the placenta, mother and baby are examined and observed to see if both are healthy. If the woman is not haemorrhaging heavily and the baby has begun to breastfeed, she is given contraceptive advice and both can be discharged at any time from four hours after the birth. If problems develop, one or both will either remain at the MOU for a longer period, or will be referred to a secondary or tertiary hospital.
MEDICAL TECHNOLOGY AS A MEANS OF CONTROL
"Modern management of labour does not necessarily imply the control of labour with 'high-tech' equipment. It is rather the combination of good medicine and good monitoring - be it clinical or mechanical - allied to the patient's needs and requests" (U.C.T. Department of Obstetrics and Gynaecology, n.d.:140).
Jordan (1990:108) argues, however, that technology plays an important role in the clinical birth context.
Even if unfamiliar technology is not utilised, its very presence in the delivery ward can serve as a means of emphasising the power relations amongst the participants in the birth process. In the delivery ward at the MOU, for instance, the stirrups hang on the wall opposite the bed of the labouring woman, where she can see them clearly.
This is where Sara gave birth to her daughter, attended by biomedically trained nurse-midwives. While in labour, Sara was instructed to open her legs, with her knees raised. She was told to grasp her ankles and pull her legs as far back as she could. When she did not raise her legs sufficiently to satisfy Sister Lewis, the nurse-midwife managing the delivery, she was told that she would be put in the stirrups if she did not obey. Sara lifted her legs. It was clearly a threat, which served to ensure that Sara complied with the wishes of the nurse-midwife. This compliance, as well as making the management of the delivery easier for Sister Lewis, underlined the fact that it was she who was in control.
Amanda, who has completed both her practical and theoretical obstetrical training, said that lying in stirrups (the lithotomy position) is unpleasant for a woman in labour. This is so much so that her legs may be tied to poles because she will often keep pulling them down. Her legs may be quite tightly bound, and they will often start shaking, especially if she is in labour for a long time. The lithotomy position is thus extremely awkward for a woman in labour, and the tilt of the pelvis is also unnatural, as she has to push against gravity. Consequently, Amanda believes that the stirrups should only be used when it is necessary to utilise forceps or to perform an episiotomy. 7
In addition, the use of stirrups constrains the woman in one fixed, symmetrical position. Claire Armstrong, a woman who had had two of her children delivered in a state maternity unit and two at her home attended by a midwife, reported that she had been able to sense if and when walking or shifting her position would relieve pain, as well as which birthing position would be the most comfortable to assume for the actual delivery. The use of stirrups, however, ensures that the birthing woman is unable to change her position in response to the intimate messages which she receives from her body during the labour.
While their use is supposedly not routine, Amanda explained that some nurse-midwives prefer to use stirrups as these provide easier access to and a better view of the vaginal area. This makes the management of the delivery easier for the nurse-midwife.
In a discussion of Davis-Floyd's views on the symbolic impact of high-technology on the participants of the birth process, Helman observes that:
"The baby is removed from the mother, handed to a nurse who inspects, tests, bathes, diapers and wraps the infant, and administers a vitamin K injection and anti-biotic eye drops then - having been 'properly encultured' or 'baptised' into the world of technology, it is handed back to its mother for a short time ... the mother lies surrounded by medical technology ... To the woman 'her entire visual field is conveying one overwhelming perceptual message about our culture's deepest values and beliefs: technology is supreme, and you are utterly dependent on it and on the institutions and individuals who control and dispense it'" (Helman, 1990:148; Davis-Floyd, in Helman, 1990:148 - my emphasis).
NOTES FOR PART ONE:
* Quotes marked in this way have been translated from Afrikaans.
1. I would like, first of all, to express my appreciation and gratitude to the people who willingly participated in the research. Many thanks to Diana Gibson for providing a great deal of support and a very useful critique of a draft of this article. Sincere thanks to Jenny Gardner, Johnny van Schalkwyk and Magriet van Schalkwyk for their helpful suggestions. It should be noted that not all of the suggestions which were received were implemented, and that the views expressed here are not necessarily shared by the people mentioned.
2. Because the sample used was relatively small, it is not advisable to generalise from the experiences described in this article. The experiences of these women and those documented in the literature consulted do, however, provide useful insights into the position of birthing women in the biomedical birth process.
3. Historically, South Africans have been classified as belonging to certain 'races'. The Group Areas Act of 1966 assigned different residential areas to different 'racial groups'. The MOU studied is geographically situated in a residential area historically allocated to those classified as 'coloured'.
4. For example, Chamberlain invented the forceps in the early seventeenth century.
5. All names have been changed in order to protect the identity of those who participated in the study.
6. Paracetamol painkillers, commonly used for headache relief and mild enough to be available without prescription - the recommended dosage for adults is one to two tablets every four hours.
7. Episiotomies, incidently, can, and often are, performed without the use of stirrups. Sara was, in fact, given an episiotomy although she was not put into stirrups.
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