By Barbara Katz Rothman, PhD
Today, I am delighted to share with you an essay on risk written by sociologist and author Barbara Katz Rothman, PhD. There has been much discussion and debate on two papers just published in the Journal of Midwifery and Women’s Health, using the MANA Stats V2.0 data from the Midwives Alliance of North American. You can find these two papers and a research review by Judith Lothian published on January 30th on Science & Sensibility. – Sharon Muza, Community Manager, Science & Sensibility.
We live in what Social Scientists called a ‘Risk Society.”[i] If you simply google “risk and birth,” you get over 402 million ‘hits.’ So no question, birth is understood as having risks, creating risks, being risky business indeed. But not the riskiest of businesses – Google “risk and food,” and you get almost twice as many hits – over 746 million. That doesn’t feel right somehow – pregnancy and birth are always and everywhere in our world understood as risky; food not so much. I nibble some snacks as I write, sip some tea – are you worrying for me? Wishing me luck with that? Thinking about the odds of food poisoning? Insecticide exposure? the long term risks of diabetes, joint pain, heart troubles, cancers that might be flowing forth from the snack choices I am making?
And what about those snack choices? Do they not carry much of the same moral weight that pregnancy choices make — if I tell you it’s green tea and carrots, or if I tell you it’s a honey chai latte and multigrain crackers with organic almond butter, or if I tell you it’s a Nestle Iced Tea and Oreo cookies – do I not create different images of myself as a risk-taking or risk-sparing person, even as a more or less ‘good’ and responsible person? These are of course the arguments that Risk-society thinkers have been addressing: the risks we perceive and the risks we take are judged, by ourselves and by others.
In birth, few choices have been as freighted with the language of risk and responsibility as that of home birth.
The irony here is that birth moved into the hospital with all of the data showing us that move increased risk; and all of the research we have now still shows us that hospitals present unique and particular risks for birth. Birth moved into the hospital long before the era of Risk – that move was done in the era of Science. The same science that covered our kitchens in white laboratory-style paint and tiles, that replaced local baking with packaged white bread made out of mass-milled white flour, that created industrialized systems to raise cheap meat at whatever costs to health of humans or animals, that moved fruits and vegetables from fresh to canned – that same science that created the industrial diet of the turn of the century, created the industrial birth.
When I wanted a home birth almost forty years ago, I knew nothing of midwifery. I just assumed that obstetricians had the necessary knowledge and skills to deliver babies (and yes, I called it ‘deliver’) and that those skills could be used in my bedroom as well as in a ‘delivery room.’ Over the course of my scholarly work in the years following, I learned how wrong that was. Home birth involves a set of skills, practices and competencies that people trained in hospital birth most often never have learned. Thus the MANA data is not merely a comparison of place: What we are seeing in this data set is a study of midwifery-led care, or as Ronnie Lichtman has called it[ii], midwifery-guided birth, birth in settings where midwives and the women they are guiding have control over practice.
MANA’s data and these articles are showing us that the United States, for all of its problems, is not exceptional: Fully autonomous, informed midwifery care provides better birth outcomes than does care under Obstetrical management. Obstetrics and Gynecology is a surgical specialty, magnificently equipped to manage particular illnesses and crises, but neither the discipline nor the hospital settings it has developed for its practice are appropriate for normal, physiologic birth.
Research on women who choose home birth, as well as midwives who provide it, show that their concerns go beyond the risks of what is often called the ‘cascade of interventions’ that follows medical management, leading as it so often does to cesarean section. In addition to the well-documented iatrogenic risks, they address risks of the hospital itself, what are called when looking at infections, ‘nosocomial’ risks. They were concerned with errors that are made when people are managed in what is essentially a factory-like setting: risks of overcrowding; risks of exposure to others and exposure of self.[iii]
Hospital-industrialized births demand standardized care. Consider something as mundane and yet intrusive as the vaginal exam. Medical guidelines, the medical story, is that such exams are necessary to determine labor and its stages. That of course is absurd. Do you really think that an experienced midwife, someone who has attended hundreds or thousands of births cannot tell if a labor is established without a vaginal exam? What a midwife needs that exam for is to document, not to establish the labor. Those exams are not only intimate and intrusive, but for women with histories of sexual abuse especially, can be experienced as traumatic.[iv] For all women, raised with ideas of bodily privacy, integrity and what used to be called ‘modesty,’ such exams at a moment of vulnerable transition are problematic. Done for reasons of institutional management and control, they are one more interruption and create risks of their own. Particularly in hospital settings, vaginal exams are one more occasion for the introduction of nosocomial infection.
Managing the management thus becomes necessary in hospital settings: – midwives use the vaginal exam to create the story that will be most in the woman’s best interests, and occasionally in the midwives’ own best interest. Midwives are thoughtful about when they measure because, for example, they are hesitant to start the clock too early. In such care, what midwives are trying to minimize is not the risks of a prolonged labor, but the risks of intervening in a labor medically defined as prolonged.
It is reasonable to talk about how recent this language of ‘risk’ is in pregnancy and in birth – but the language of danger, that which we are in risk of, has long been an accepted part of birth. Calling it “Risk” is adding the numbers – sure there are dangers, but precisely what are the odds? That there are dangers in pregnancy and in birth, and that they can be avoided or overcome, this is not news. Dangers, disasters even, could happen in the best and healthiest of pregnancies and births. The difference perhaps is that now there is no such thing as a healthy pregnancy and birth. There still is an understanding of such a thing as a ‘healthy meal” and even a “healthy diet,’ but no longer, it seems to me, a healthy pregnancy – the best you can hope for is a low risk pregnancy.
It is not that midwives do not have understandings of danger and knowledge about ways to avoid danger, including the dangers of prolonged labors. That is precisely what midwifery has been throughout time and across place: the development of a body of knowledge and skilled craftsmanship to navigate the dangers of childbirth. All of that knowledge was discounted with medicalization.
Scientific or ‘Medical’ knowledge is accepted as real and authoritative; other knowledge is reduced to ‘intuition’ or ‘spiritual knowing,’ made all but laughable. But when a baker adds a bit more flour because the dough is sticky, is that ‘intuition’? Or is that knowledge based on craft, skill, deep knowledge of the hands? When a violin-maker rejects a piece of wood in favor of one lying next to it that looks just the same to me or to you, is that ‘intuition’? Or experience, skill and craft? And when a leading neurosurgeon examines a dozen stroke patients who all present pretty much the same way on all of their tests and feels hopeful about some and concerned for others, is that ‘intuition’? Or knowledge based on experience, using a range of senses and information that may not be captured in the tests?
In hospital settings, midwives do not have the authority to use their knowledge fully in the woman’s best interests. And therein lie the risks.
And finally, it would be helpful to put these risks in context. If safety were our real concern, if saving the lives of babies and of mothers were the driving force, then there are a number of changes we would make immediately. We would require helmets for people in cars, something we know would save lives each week. We would lower the speed limit in urban areas, and end driveway parking in suburbs. To suggest such things makes one look crazy – crazier than suggesting home birth. But it most assuredly would protect children. If saving babies were our concern, we would invest in public housing, and in the food system. These are large scale changes that would save far more people than anything that happens in those few hours of late labor to early neonatal period, the 24 or so hours of hospitalization that is now being debated.
Clearly something more or other than saving babies is at stake.
[i] Beck, U. (1992). Risk society: Towards a new modernity (Vol. 17). Sage.
[ii] Lichtman, R. (2013). Midwives Don’t Deliver or Catch: A Humble Vocabulary Suggestion. Journal of Midwifery & Women’s Health.
[iv] Adult manifestations of childhood sexual abuse. Committee Opinion No. 498, American College of Obstetricians and Gynecologists. Obstet Gynecol 2011: 118:392-5.
About Barbara Katz Rothman
Barbara Katz Rothman, PhD, is Professor of Sociology, Public Health, Disability Studies and Women’s Studies at the City University of New York, and on the faculty of the Masters in Health and Society at the Charite in Berlin, the University of Plymouth in the UK, and the International Midwifery Preparation Program at Ryerson University in Toronto Canada. Her books include In Labor: Women and Power in the Birthplace, The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood, Recreating Motherhood, The Book of Life: A Personal and Ethical Guide to Race, Normality and the Human Gene Study, Weaving A Family: Untangling Race and Adoption and Laboring On: Birth in Transition in the United States. Dr. Katz Rothman is the proud recipient of an award for “Midwifing the Movement” from the Midwives Alliance of North America.