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Normal birth and its meaning: a discussion paper

25 February, 2013

Normal birth and its meaning: a discussion paper

Using Foucault’s (1976) concept of power and knowledge, this paper aims to explore how growth of authoritative knowledge and dominant discourse associated with medicine – in particular obstetrics – in the 20th century has transformed society’s view concerning ‘normal birth’. Evidence Based Midwifery: March 2013


Claire Clews MSc, PGDip, BSc, RM.

Senior midwifery lecturer, School of Health, University of Northampton, Boughton Green Road, Northampton NN2 7AL England. Email: claire.clews@northampton.ac.uk


The author would like to thank Dr Mary Dobson, principal lecturer lead for postgraduate provision at the School of Health, University of Northampton, for her guidance.

Abstract
Background. The importance of working in partnership with women to engender true ‘choice’ may be challenging for many midwives, but there is a need to confront those who promote authoritative knowledge within their own organisations if the profession is going to reclaim the fragile construct of normal birth as a physiological and social process in the future.

Aim
. Using Foucault’s (1976) concept of power and knowledge, this paper aims to explore how growth of authoritative knowledge and dominant discourse associated with medicine – in particular obstetrics – in the 20th century has transformed society’s view concerning ‘normal birth’. Discussion is placed within the context of recent NICE guidelines published in 2011, which afford women the choice of CS birth in the absence of clinical need.

Key objectives
. To understand how the use of authoritative knowledge and dominant discourse in obstetrics has influenced society’s view concerning the concept of ‘normal birth’.

Findings
. It is recognised as that which Foucault (1976) identified as the singular concept of power and knowledge has influenced society’s vision of ‘normal birth’ in the present day. Increasing medicalisation and pathologising of childbirth has led to the current practice of birth by CS in the absence of clinical need, as a genuine alternative birth choice available to all women in the UK.

Implications
. Midwives need to be mindful of how within the domain of present day maternity services in society, authoritative knowledge and dominant discourse surrounding ‘normal birth’, can influence women in their decision-making.

Key words: Women, normal birth, medicalisation, dominant discourse, caesarean section, evidence-based midwifery

Introduction
This paper will focus its discussion on the key issues of birth, knowledge and women’s choice. The structure of the paper is embedded within a discourse framework to maximise attention on the multiplicity of factors that influence perceptions about childbirth. Recognising at the outset that the author is a midwife, it is acknowledged that there is the potential for a conflict of interests, as a practitioner rooted in the perspective that childbirth is inherently a physiological process. However, the intention is to stimulate discussion and debate and by focusing on the evidence from the literature, it is hoped that the reader will be able to gain a deeper insight into the key issues that dominate modern thinking in this area.

The early 20th century witnessed an emerging dichotomy, which altered society’s view of ‘normal birth’. This changed the concept of ‘normal birth’ from that of a physiological and social process taking place within the home, to the dominant policy of the present day, which sees birth as a largely medicalised process within the UK. This century witnessed the prominence of a persuasive campaign of ‘safety’ by the medical establishment, which contributed to figures that by 1980 showed that less than 1% of births occurred in the home (Tew, 1995). Supported by the political milieu of post-war Britain, and with the establishment of the NHS, this singular policy was embraced by society, leading to maternity care that became more and more fragmented (Henley-Einion, 2003). It was a policy that pathologised childbirth (Flint, 1986) as a process that required technological management within a hospital setting (Towler and Bramall, 1986). Such medicalisation can be contextualised within feminist and social theory by considering the societal influences surrounding knowledge and power, which, historically, have afforded privilege to the increasingly dominant discourse of obstetrics. In turn this led to the marginalisation of discourse surrounding normal birth, midwifery knowledge and women’s intuitive knowledge (Hewer et al, 2009). Later in the 20th century, there was largely unquestioning and wide placed subscription to the findings of publications, such as The Peel report (DH, 1970), which recommended all births take place in a hospital setting, aligning it to one which equated to safety, overtly implying that midwifery care in the community was inherent with risk (Cahill, 2001). This message of ‘safety’, as a component of patriarchal control, coerced women to accept medical control over their bodies for the greater good; that of a healthy newborn. It was not until over two decades later that the report of the expert maternity committee in 1992 afforded women a voice and recognised that the overwhelming majority would welcome an alternative to medical birth in hospital (DH, 1993). Although the publication of the Changing childbirth (DH, 1993) report did not see the reversal of medicalised birth, it did identify the need for women to be offered choice in relation to maternity services and reaffirmed that midwives should be at the fore of normal pregnancy and birth. However, this report has been instrumental in reinforcing the power base of obstetricians by continuing to place them as the lead for ‘complicated’ childbirth, itself a concept which has long been poorly defined (Cahill, 2001).

Half a century of doctrine and medicalisation coincided with a time of improvement in maternal and neonatal mortality rates in the UK, once again strengthening dominance of medicine over birth. The unsubstantiated links subsequently drawn between association and causation assumed that biomedical knowledge and technocratic births were the reason for improvement in this area, these have since been discredited (Tew, 1995). Cahill (2001) identified other factors working to underpin and sustain the status quo. The theory that dominant professions may be selective in the evidence they pay credence to, as mainly that which supports their position of power within any institution and society, is likely to have a significant role in this. With the publication of Midwifery 2020 (Midwifery 2020, 2010), there is once more a vision that seeks to place midwives as the lead professional for women with straightforward pregnancies, but also as coordinators of care for those women who have more complex pregnancies. The report acknowledges that the coming decade will present challenges as well as opportunities for midwives to develop their role as leaders in the delivering and shaping of maternity services in a changing environment (Midwifery 2020, 2010: 1).

Authoritative knowledge in childbirth
It was initially the French philosopher, Foucault (1972) who supported the theory that the ontological ‘truth’ is that which is socially constructed, recognising that dominant discourses were accepted as ‘true’. Hagell (1989) argued that every occupational profession will seek to create their own individual epistemology. This epistemology will lead to the creation of social norms which are embedded within dominant discourse, subsequently working together to encourage conformity (Fahy, 2008). Jordan proposed this theory of ‘authoritative knowledge’, whereby one form of knowledge gains ascendence and legitimacy over another, as early as 1988, and Oakley (1992) applied this to the scientific paradigm of medicine and obstetrics, proposing that both had long worked to suppress competing forms of knowledge within the hierarchy of healthcare practice. Non-authoritative knowledge systems, such as that of the midwifery profession, are frequently devalued through this dominance of hierarchical knowledge (Jordan, 1997). The medical view of childbirth presents a process that is inherently full of danger, for which only hospital can offer the safety required for all childbearing women. This ‘pathologising’ of childbirth marginalises the philosophy of midwifery as one which seeks to maintain pregnancy and birth as a normal, non-pathological process (Thachuck, 2007).

Benner (1984) and Jarvis (1986) identified different ways of knowing; propositional knowledge (knowing that) and practical knowledge (knowing how) used within the profession of midwifery. It was Belenky et al (1986) who explored women’s ways of knowing and quantified these as forms of knowledge that could be seen as subjective, procedural and constructive. In reality, multiple discourses and knowledge systems surrounding childbirth will exist, creating multiple ways of knowing (Jordan, 1997). Propositional knowledge resides comfortably within the dominant, reductionist, bio-medical model of childbirth in support of medical knowledge; that which is male and scientific and thus viewed as superior in nature to female intuitiveness (Cahill, 2001). The midwifery profession, which values scientific knowing, but also incorporates subjective knowing as ‘legitimate’ knowledge, may experience conflict in supporting women’s choices within the institutions they work and Hunter (2008) argued that the often polarised professions of obstetrics and midwifery present competing forms of knowledge, both of which are rivalling one another for authority.

Church and Raynor (2000: 25) refer to this tacit concept of ‘knowing how’ as that which cannot be quantified, therefore, it is often undermined and undervalued by those supporting the dominant discourse. Parratt and Fahy (2008) advanced this concept with their discussion of the ‘rational base’ of western medicine, seen in the structure and function of maternity services. Non-rational ways of knowing that may be employed readily by women and midwives can be difficult to express and quantified in standard, ‘rational’ ways.

Medicine does not provide credence to this, due to such knowledge residing outside the established concept of evidence-based practice. This concept is largely driven by the positivist paradigm of research; that which can be objectively quantified and tested, which cyclically authenticates the dominance of obstetric discourse. Stewart (2001) referred to this hierarchy of evidence, whereby studies that employ methodologies and methods, such as randomised controlled trials and meta-analyses, are seen as ‘gold standard’ and viewed by many as the pinnacle of medical science. It is clear that quantitative studies, which provide statistical evidence of outcomes, are still favoured for publication in historically ‘prestigious’ journals with an ‘obstetric’ focus. This consensual co-construction of authoritative knowledge (Jordan, 1997) is further preserved through publications produced by the Cochrane database and NICE guidelines which adopt this ‘ranking’ of evidence with these publications then commonly being incorporated into clinical guidelines adopted in everyday practice.

Normal birth?
Jordan (1993) suggested that women’s decision-making power regarding birth is intertwined with the concept of birth territory and ownership. Anderson (2003) defined normal birth as one without intervention in an environment that enables choice and empowerment for the woman. Midwives have previously been referred to as the guardians of birth ‘normality’ (RCM, 2004). It is clear that an ideology can guide that which is viewed as ‘normal’ and childbirth is no exception – historically it has been targeted and used effectively as a means for social regulation (Price and Johnson, 2006). A collaborative working party (RCOG, 2008: 32) highlighted that the promotion of normal birth is the philosophy of maternity care, but qualifies this with the statement ‘…with intervention only if necessary for the benefit of mother and child’. How can women deem which interventions are necessary and which ones are not? Definitions of normal birth vary from author to author with no universal agreement (ICM, 2008; RCM, 2004) with such complexity it is difficult to perceive how women can exercise true choice in such circumstances.

Henley-Einion (2003) discussed how women are only offered the illusion of choice. Often the very information received by women is such that is controlled and restricted by the institution itself as the language used by the dominant domains in such descriptions may only be understood by the initiated (Foucault, 1976). Savage (2006) acknowledged this issue of ‘knowledge control’, whereby healthcare professionals may actually withhold information from women, directing them towards socially accepted choices, thus reflecting Foucault’s (1980) theory, which acknowledged that people will behave as they are expected to behave following the norms constructed through pervading belief systems (Snowden et al, 2011). Authors such as Henley-Einion (2003: 178) suggest that in this context the only real options related to childbearing are of ‘normal medical labour’ or ‘complicated medical labour’.

The power that dominant obstetrical discourse conveys can often be seen by some as that which is perpetuated by many within the midwifery profession (Hunt and Symonds, 1995). As a profession, which consists of a largely female workforce, they can be viewed by some as ‘handmaidens’ to those holders of power – obstetricians – who themselves provide an invisible authority and are frequently male (Savage, 2006). Midwives can be submissive to the dominant medical discourse and may themselves unintentionally contribute to the marginalisation of women. In an increasingly litigious society, the desire to avoid responsibility and not to be held accountable, may lead to them handing over decision-making power to that ‘powerful other’ (Foucault, 1980). Within a patriarchal society ‘gendered power’ is prevalent in identifying knowledge as that which supports the authority of the masculine profession of medicine (Lee and Kirkman, 2008). Midwives will frequently identify themselves as advocates for women but may be hampered by the institutionalisation of their profession, which remains largely hierarchical in nature. In western societies this sees obstetricians placed at the pinnacle of that hierarchy, with  women at the bottom and midwives situated somewhere in between (Stapleton et al, 2002).

Kitzinger (2005) discusses the importance of midwives being able to understand and critically analyse all forms of research evidence, in order to challenge dogma and rigid institutional practises in the light of such evidence. She suggested that midwives needed to place themselves ‘at the edge’, an uncomfortable place to be involving confrontation and conflict with the existing hierarchy. Straddling this divide, with the ethos of midwifery as the guardians of normality but while working within an obstetric framework, is inherently problematic.

Odent (2008) goes further and proposes that the dogma of evidence-based medicine has the potential to lead to the erosion of ‘normal childbirth’, and the promotion of birth by CS, as the norm for all women. Three years later, with the recent publication of NICE guidelines (2011) for CS in childbirth, some may feel this view sanctioned. Women are now able to request a CS in the absence of medical need under the guise of ‘choice’, constructing CS birth as an alternative to vaginal birth (Douché and Carryer, 2011). This could reconstruct the way in which women experience birth and may be seen as a new form of obstetric and ‘consumerist discourse’ (Douché and Carryer, 2011: 143). Hewer et al (2009) suggested that we need to view the current debate on elective CS within its social context, whereby birth is viewed as inherent within the discourse of risk, with technology seen as progressive, and recognising the medical profession as dominant. Dominant groups will find their interests served by outlining CS as the woman’s choice and marginalising any voices of dissent (Hewer et al, 2009). The portrayal of CS delivery, as an alternative to vaginal birth again exposes a pathologising paradox in which ‘normal bodily performance emerges as the abnormal and the abnormal as normal’ (Douché and Carryer, 2011: 144).

Rates of CS have been increasing over the years with levels in the UK, at some maternity units, now at 25% or above ,with the normal delivery rate remaining consistent at around 62% (The Information Centre, 2012). This may partly be attributable to the endorsement of the benefits of CS within discourse clearly portrayed in citing the avoidance of pain and reduction of anxiety and fear (Handelzalts et al, 2012). The unequally balanced discourse surrounding CS covertly minimises its proven risks, including higher maternal morbidity and mortality rates, as well as the potential for negative compromise in future pregnancies (Hewer et al, 2009).

Influencing choice
Porter, in 1998, acknowledged that as scientific discourse remains largely inaccessible to those whom it is written about, women will continue to have little opportunity to affect it in striving to create their own childbirth identities.

It is recognised that this authoritative knowledge of medicine will invariably supersede women’s intuitive personal knowledge which, in turn, may lead them to distrust their own body’s ability to birth without intervention (Savage, 2006). Lee and Kirkham (2008: 459) suggest that it is medicine which has appropriated birth for which childbearing women themselves are the experts and should be acknowledged as such.

Kitzinger (2006) discusses how the admissions procedure on entry to hospital marks the handing over of power and control for many women, which is often then compounded by the ‘active management’ of labour. With the policy of only one birthing partner being allowed in many maternity units, women are separated from friends and family, expected to conform to the image of a ‘good patient’ agreeing to that care, treatment or intervention, which is recommended by those in authority. Kitzinger (2006) acknowledges that in most countries birth is seen as ‘men’s business’ with the dominant discourse of obstetrics expressing suggestions of female incompetence and male superiority. Terms such as ‘failure to progress’ and ‘incompetent cervix’ in relation to a woman in labour are often still used in many maternity units today. This demonstrates the woman’s ‘failure’ to adhere to clinical guidelines, which then has to be rectified by the expert obstetrician at the pinnacle of that medical hierarchy (Kitzinger, 2006).

Childbirth is individual to each woman and, as such, is multifaceted in its meaning and identity. Governments have now long recognised that choice during childbirth should be acknowledged as an integral right for every woman with influential publications such as Maternity matters (DH, 2007), National service frameworks (DH, 2004) and NICE guidelines (2007) all paying reference to this. While the publication of the NICE (2011) guidelines for CS will be seen by many women, midwives and obstetricians as a positive step forward in affording true choice during childbirth, it should be recognised that this is still a choice that has been legitimised within current dominant discourse in society. The guideline (NICE, 2011), which offers the possibility of choosing CS in the absence of medical need, may be empowering for some women, but it further supports the premise that birth requires technological support in order to occur. The guidelines place the ‘positive’ aspects of CS birth at the outset with the risks placed secondary to these (NICE, 2011).

It is interesting that CS birth appears to warrant its own individual guidelines while discussion surrounding women’s options for midwifery-led care and home birth remain within the generic NICE guidelines related to intrapartum care (NICE, 2007), thus ascribing less importance. It is not ignored that it is the women who give birth and their individual choice should be respected, but Henley-Einion (2003) suggests that women should still be challenged as to the reasons why they are choosing to medicalise their birth.

In many western patriarchal societies, the rights of the fetus are clearly set against the woman’s right to autonomy, self-determination and choice. Lee and Kirkman (2008: 460) identify how discourse has previously been used to overtly portray women who requested an ‘unnecessary’ CS as those women who were ‘foolish, irresponsible, and with unreasonable expectations’. At the heart of this, is the concept of the ‘good mother’, which requires women to be selfless in their choices, ultimately putting aside personal desires in order to succumb to medical reasoning, thus ensuring the health of their newborn. Almost 20 years ago Schwarz (1990) identified this as ‘engineering childbirth’, suggesting that the choices made by women will only ever be individual to them within the context of the dominant obstetric discourse prevalent at that time. This perception has since been supported in studies by Shaw (2007) and Snowden et al (2011) exploring women’s experiences of researching choices related to childbirth. Both identified that these choices often failed to translate into the levels of confidence required to discourage the dominant medical view. Women may want to exercise choice surrounding their birth, but this is set against what Foucault (1991) previously described as ‘led by rewards for compliance’. More recent research by Fahy (2008) drew attention to to the dilemma facing women who fear ‘punishment for non-compliance’, which included fear of pain, disability or death. The echoes of fear persist across the time barriers, and the comments by Machin and Scamell in 1997 remain as poignant today as they were 15 years ago: a brave woman may be prepared to accept such ‘punishments’ for herself but the added complexity of being ‘with child’ will often lead to the most informed losing faith in her convictions as childbirth advances ever closer.

Conclusion
The aim of this paper was to explore the concepts of dominant discourse and authoritative knowledge in relation to the concept of ‘normal birth’. It is a salient point that, while some progress has been made, there remains a continuing polarisation of views regarding the concept of ‘normal birth’ between professional groups that practice within the maternity services and who directly care for women. It is recognised that Foucault wrote of the single concept of power and knowledge, such a concept is intertwined with dominant discourse which will seek to promote power through attaining authoritative knowledge (Lee and Kirkman, 2008). At present, it appears that women are offered, or only able to exercise, choice in relation to childbirth within the context of the dominant medical discourse of obstetrics. Continuing and active engagement is required by midwives, firstly in the critique of dominant discourse surrounding obstetrics, coupled with an appreciation of how authoritative power functions to control birthing practices, in order to affect change. The issue of CS in the absence of clinical need offers a challenge to the midwifery profession. The need to strengthen our own professional epistemological stance is required at a pivotal moment in the creation of our own legacy and history surrounding childbirth. The profession needs to reclaim the fragile construct of normal birth as a physiological and social process in order to truly empower women in affording genuine choice in relation to childbirth in the future.


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