I recently responded to a Twitter conversation with the comment – “and then we are back to having to overthrow the patriarchy…” The conversation had started with midwife Gill Moncrieff asking “how do you solve a problem like midwifery?”, pointing out the demoralisation of many midwives who are unable to practice midwifery in a way that is consistent with midwifery philosophy. I replied that research suggests that the answer is midwifery continuity of care models. Gill responded by pointing out that it has been very difficult to introduce midwifery continuity of care models – which prompted my response about the patriarchy.
It was a bit of a throw away answer, but the feedback I got from people suggests that the term patriarchy doesn’t hold the same rich meaning that it does for me as it does for them. So in today’s post I want to explain what I mean by the term patriarchy and provide an example of how patriarchal ways of knowing women’s bodies impacts on maternity practice.
One of the common responses to mentioning the patriarchy I have encountered is along the lines of – “why blame men for this?”. The first thing to make clear is that the term patriarchy isn’t a substitute for “all men”. The patriarchy is a social system, not a group of people. Given my research interest in epistemology (systems of knowledge), the primary way I view the patriarchy is as a system of knowledge. This means that there are particular ways of knowing about the world, ways of giving names to people, objects, and experiences. These ways of knowing have a particular “flavour” to them which carry values and assumptions. Sometimes people choose these deliberately for effect, but most of us apply this knowledge in an uncritical manner most of the time.
The flavours of patriarchy arise from a knowledge system that sees white, straight, educated, Christian, able bodied men as the ideal – the norm – in society. This particular group of people are considered to be capable, in charge, and deserving of a series of entitlements that are valued within this particular system of knowing. It’s not just about knowing something though. The way we know the world largely determines how we act in the world. We use knowledge to determine what is important, what isn’t, what is a problem, and what the available solutions and preferred outcomes are.
Yes, men can hold patriarchal views. Women can too. In fact, all of who have lived in patriarchal societies operate within this knowledge system and can, sometimes unknowingly, contribute to recreating and reinforcing patriarchal values. I know I still do from time to time. One of the goals of feminism is to support us as individuals to explore how we see the world and to question our beliefs. This work is typically called decolonisation of the mind.
I see evidence of patriarchal knowledge systems often in my research in maternity care. I wrote recently about the hidden trauma in our perinatal data collection systems, drawing out the point that genital tract trauma to the uterus at caesarean section is common yet invisible, while trauma to the vagina and perineum are foregrounded. What does the patriarchy have to do with that?
One of the things that the privileged group of people under the patriarchy are considered entitled to is the enjoyment of female bodies. Arney (1982) has explored the history of obstetrics by analysing obstetric texts. One of the issues he explored was the relatively recent (in the history of childbirth) addition of episiotomy (a surgical incision in the vagina, perineum and pelvic floor muscles) to the skill set of obstetricians, which became routinised in the early 20th century.
One of the lines of argument that supported the routine use of episiotomy was that performing and repairing an episiotomy would, as prominent obstetrician De Lee claimed “restore virginal conditions” (cited in Arney, 1982, p 71). Arney pointed out that men’s sexual priorities where the focus. A properly completed repair was considered to be one that restored the vaginal anatomy to a state viewed as sexually desirable by the obstetrician performing the repair. This preferred state of women’s anatomy continues to have echoes in current practice in the form of what is known as the “husband stitch”.
Women were not (and haven’t really ever been) consulted about whether episiotomy was something they wanted. When Shere Hite published the Hite report in 1976, it came as quite some surprise to many that having something wiggled about in a woman’s vagina was not the central focus of women’s sexual pleasure. While women’s voices have started to be considered in research about birth related pelvic floor trauma, the findings demonstrate that patriarchal views of women’s bodies, expressed by male sexual partners or health professionals, are a source of distress for women with pelvic floor trauma (Priddis et al., 2013).
Severe pelvic floor trauma is an issue in maternity care, but it occurs for only a small number of women. The data from the Queensland Perinatal Data Collection service I shared last week put it at 2.7%. The same report also found that the caesarean section rate continues to rise, with 36.3% of women experiencing this particular form of genital tract trauma. In both Australia and the UK, maternity professionals have been asked to routinely apply a “bundle” of interventions (some lacking evidence – Thornton & Dahlen, 2020) to prevent severe perineal trauma, yet there is no equivalent package to turn back the tide on caesarean section rates.
The patriarchal knowledge system is not new. Because it has been around a long time, the way we structure our social systems – like our legislation, education, and our workplaces – have built this patriarchal world view into the social fabric. The same is true for the healthcare system. Undoing the patriarchy requires both a personal commitment to examine our own ways of knowing, doing, and being in the world; and a commitment to changing our social systems with the aim of achieving equity.
Arney, W. R. (1982). Power and the profession of obstetrics. University of Chicago Press.
Priddis, H., Dahlen, H., & Schmied, V. (2013, Apr). Women’s experiences following severe perineal trauma: a meta-ethnographic synthesis. Journal of Advanced Nursing, 69(4), 748-759. https://doi.org/10.1111/jan.12005
Thornton, J.G., & Dahlen, H.G. (2020) The UK Obstetric Anal Sphincter Injury (OASI) care bundle: A critical review. Midwifery, 90, 102801. https://doi.org/10.1016/j.midw.2020.102801
Categories: Feminism, History, Philosophy, Reflections
Tags: Episiotomy, Patriarchy, Perinatal data, Perineal trauma
Birth Small Talk 
Maternity Care is the unfinished business of feminism.
The harmful effects of patriarchy are sustaining the oppression of women in the world. This is impacting on maternity services with unacceptable rates of maternal mortality and morbidity and the limiting of women’s choice of care provider and place of birth options. Gloria Steinem once said feminism at its core is about choice. If pregnant women cannot choose freely how to birth, speak to their choices, be respected as competent and have their autonomy respected, then we’re moving backwards
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