Birth Small Talk

Talking about birth

Practice Obstetrics like a Feminist

Photo by Miguel Bruna on Unsplash

What is feminism? My definition

I’m interested in epistemology – the study of knowledge – so my definition of feminism relates to feminism as a body of knowledge, a way of knowing, and therefore acting, in the world. Feminism is the knowledge that women and girls have been systemically disadvantaged in the world and continue to be disadvantaged. Women and girls are provided with less opportunity to participate fully in all social sphere and encounter more barriers to full participation. My definition of feminism is intersectional, in that it incorporates an understanding that other groups of people also face systemic disadvantage (for example people with disability, people of colour, those who are members of the LGBTQ+ community, and many others), and that when different layers of disadvantage map to the one person, significant forms of oppression co-exist. 

With this knowledge comes responsibility. As a feminist, I have a responsibility to examine the social systems I participate in and to consider who the winners and losers are, in order to understand these systems and how they operate. With this knowledge I can (at least in theory) make decisions about how I conduct myself to avoid participating in and reproducing disadvantage for myself and others, including working to change the social world to be more equitable. 

Is obstetrics feminist?

Ah, in a word – No. Obstetrics is inherently anti-feminist.

I also define obstetrics a way of knowing the world. We can ask to what degree the processes used to generate obstetric understandings and the knowledges generated from these align with feminist ways of knowing. Looking back at the history of the development of obstetric knowledge makes it clear that women were viewed as a mysterious object, to be examined, dissected, and explored in the pursuit of knowledge for men and by men. Jo Murphy-Lawless’ book Reading Birth and Death (1998) provides an excellent and detailed examination of the development of obstetric knowledge in Ireland if you want to take a deep dive into this idea. 

Obstetric knowledge began to be built systematically in the 18th century as “male midwifery” emerged and was publicly sanctioned, while traditional midwifery knowledge and practice (with female practitioners) were increasingly disparaged. Post-mortem examination had become a common practice, used to generate better understandings of how death occurred and what the effect of disease processes was on the internal parts of the body that could not be seen on external examination (Shaw, 2012). In obstetric practice, dismembered women’s bodies and their dead babies were used for students to learn practical skills such as forceps birth or turning the baby to breech and pulling it through the structures of the pelvis. It is not difficult to imagine that the knowledge that was developed in this way did not incorporate understandings of birth as a physiological event, nor of women as active participants in their birth, nor of women as knowledgeable decision-makers who might want to have a say on what happens to their bodies.

The stethoscope was invented and in the 19th century fetal heart rate monitoring began to be used routinely during labour (Gültekin-Zootzmann, 1975). Increasing knowledge of chemistry, microbiology, and radiation during the 19th century set the ground for what we now call modern medicine. It is important to bear in mind that all knowledge exists because there is a knower and each knower occupies a certain social context (Smith, 2005). During the period of rapid expansion of medical knowledge, men where almost exclusively the generators of new knowledge, the teachers of knowledge, and the practitioners of obstetrics. Their knowledge work was undertaken against a background of cultural values that saw women as inferior to men, their primary purpose the keeping of the home, producing and raising children, and meeting the needs of their husbands. 

The “facts” that have moved forward into our practice of obstetrics in the present time bring with them the vestiges of these cultural values. These patriarchal values can never be entirely divorced from obstetric knowledge and therefore from obstetric practice. Obstetrics is therefore not feminist.

Can feminisation of the obstetric workforce make obstetrics more feminist?

Over time the number of women gaining entry to the profession of obstetrics has increased, so that (in Australia at least) women now outnumber men. It would be incorrect to assume that being in possession of a female body would automatically undo the history of obstetric knowledge production and mean that women practicing obstetrics would do so in a way that would over turn the antifeminist history and knowledge of obstetrics. To gain entry to the profession, all obstetricians must be successfully oriented to the knowledge of the profession and demonstrate their ability to apply it in clinical settings. This is as true for women and nonbinary people as it is for men. This ensures that all obstetric practitioners, to at least some extent, continue to reproduce antifeminist ways of working. Even me.

Feminisation of the obstetric workforce might help to begin the process of feminising obstetric knowledge, but this isn’t an automatic guarantee that this work will be done.

What would feminist obstetric practice look like?

The answer to this is that I honestly do not know. To get to a point where obstetrics is genuinely feminist would require a radical undoing and remaking of the entire knowledge base on which the obstetric profession is founded. Yes, feminist research approaches should be applied to all future research in obstetrics. However, this alone is not enough to transform obstetric knowledge as it is built on the definitely-not-feminist ways of knowing women that already circulate. Our understandings of anatomy, physiology, and pathology would need to be discarded and built again using approaches that respected women and their bodies. I’m not entirely sure that what we currently know as obstetrics would continue to exist if this work could actually be done.

This does not mitigate our responsibility as feminists who work in obstetrics to do whatever we can to ensure that our practices do not simply reproduce oppression. Given that knowledge sits at the heart of obstetric practice, becoming informed about the histories of how that knowledge came about is the first step along the way to transforming obstetric practice. This is not something that is taught during our training – which is not surprising as it would make it very hard to pass exams once you knew where that knowledge came from!

I’m interested in starting a discussion with other obstetric practitioners about how we go about building a feminist obstetrics. What would it look like for you?

A shout out to Milli Hill

The heading for this blog post was inspired by and reflects the title of Milli Hill’s book, Give Birth Like a Feminist. It’s a great book and a good starting point if you are new to the idea that we need a feminist revolution in maternity care. Go buy a copy!

References

Gültekin-Zootzmann, B. (1975). The history of monitoring the human fetus. Journal of Perinatal Medicine, 3(3), 135-144. 

Murphy-Lawless, J. (1998). Reading birth and death. Cork University Press. 

Shaw, J. (2012). The Birth of the Clinic and the Advent of Reproduction: Pregnancy, Pathology and the Medical Gaze in Modernity. Body & Society, 18(2), 110-138. https://doi.org/10.1177/1357034X10394666

Smith, D. E. (2005). Institutional ethnography. A sociology for people. AltaMira Press. 

Categories: Feminism, History, Philosophy

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5 replies

  1. Dear Kirsten  As usual, a superb and informative paper.  I wonder, however if the following:

    “or students to learn practical skills such as forceps birth or turning the baby to breech and pulling it through the structures of the pelvis” should actually read “turning the baby from breech”?

    If I am wrong and they were deliberately turning the baby to breech in order to learn how to manage a breech presentation perhaps a little more explanation is needed?

    To answer your question about how to go about building a feminist obstetrics, I would suggest that an early change would be a fundamental requirement for obstetricians to study normal birth and be required to attend births at home or in Free Standing Midwifery Units, and their qualification would require them to attend (as observers) a minimum of three normal births outside obstetric units.  I recall Marsden Wagner telling me of the first occasion he observed a normal birth at home, it blew his mind and changed his attitude and career path.

    I think one of the biggest barriers is obstetricians, and many others, failing to understand what normal birth is, and what is required to enable it to occur.  Best wishes, Yours, Beverley

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    • Thanks for your insights Beverley. In the book I read recently about Semmelweis, students learned internal podalic version and breech extraction this way. It was prior to the caesarean section era so this approach was used as an alternative for forceps for difficult births.

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  2. Lovey article Kirsten. An interesting concept for contemplation. The first struggle is the male domination of the college and I can’t even begin to think how this will be achieved
    My understanding of pedalic version was its use on the second twin to turn it if breech

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  3. My second attempt to comment! Hopefully I can remember some of my first try!

    Thank you for this wonderful article. As a patient, a woman and a mother what does feminist care look like to me?

    1) Availability of 100% continuity of midwifery care, regardless of age, health status, location of birth:

    If a woman needs more care, then she needs MORE care, there’s no swapping parts out, she still needs a known midwife for antenatal, birth and post natal care. The “high risk” woman with a complex case needs this continuity MORE, not less than the “low risk” woman.

    2) Genuine choice and partnership in decision making:

    Patients (in almost all areas of health) don’t actually have choices. We don’t have an array of options which we are genuinely educated about, and are able to join in a joint decision making process. Patients are offered “advice” “opinions” or “regulations” and may “consent” or not. If you don’t consent, you do so knowing that you’ll be labeled “difficult”. The closest we get to choice is, if we can afford private care, to choose a doctor who we believe might be aligned with our values.

    In maternity care there is more of an illusion of choice. You could “choose” the labour ward, birth center or home birth, if your service offers these. But the truth is, you can “consent” if they’re offered to you personally. And you know that the system could, at any time, change its mind.

    If you’re in the public system you can’t choose your midwife or OB. For healthy people there are very few other medical experiences which are so prolonged, intensive and profoundly personal as giving birth: and you have no say in who is there.

    3) No Junior OB should do advanced perineal repair unsupervised. By this I mean if your in your first month (or year) of unsupervised practice (especially if no midwife at the hospital has ever seen you lay a stitch before) there should be a limit on what perineal work is done without supervision. The long term consequences are huge. (Yes that’s a very personal anecdote).

    ____

    I feel like there should be more points. But getting this right covers a lot.

    I’ve had 3 babies. I’ve had 3 amazing midwives. One bent the public system to give me 1:1 care for antenatal & birth. Two were private.

    I’ve desperately wished I had a senior Ob available to repair my perineum. And I’ve had two private OBs, and two private gynecologists.

    All exceptional. My thoughts are no home vs hospital. Midwives vs OBs. My thoughts are that I should not have had to pay so much to get this level of midwifery care. Or to choose an OB that would treat me, and my midwife, with such respect. I should not have had to pay so much in order to access genuine choices, and shared decision making where tricky conversations could be had with honesty and trust.

    If we each had a few hours to spare I could write you a “limited highlights” story of my third child’s medicalized conception, high risk pregnancy, and text book 1.5hr home water birth. Neither of us have the time I’m sure.

    Actually that is my 4th point TIME. Women and babies are not part of a sausage factory. It’s a profound act of feminism to grant them and their careers the TIME they truly need. Appropriate length appointments, which vary based on complexity (social or medical). Appropriate caseloads so that carers have time to be with women AND to think. To prepare. To make the right choices not the fast/easy choices. This breeds safety, medical safety, and emotional safety.

    Back to my ultra complex conception & pregnancy, super “easy” birth and complex post natal care. If it would take me hours to convey my complex history, how does that work at my 1hr labour? When I haven’t slept for more than an hr still a time in 3 weeks, have I got the energy to tell a random visiting midwife about how we got to this moment? Have they got the time to hear it? If not what value can they provide to our complex mother/baby debacle? How will they, and I, feel when they offer basic advice I worked through two babies ago? And so I snap at them because I’m shattered and need someone who knows everything I’ve already tried and might have one more stroke of genius idea? Or perhaps just a referral to a neonatologist from someone who doesn’t need me to tell them the whole damn story again…

    Oh, and point 5… women need carers with the time, the skill, and the confidence to know when to sit on their hands. When to sit in the corner and reassure with their presence, while DOING nothing. No bustle. No need to DO. But offer the confidence of your presence. Especially the first time. My first labour my midwife sat in the corner with my old family friend, who was at the birth with us. Our friend is a very special woman and had attended many other births, she was well known and welcome at the hospital. They had cups of tea and mostly ignore my husband and I. I can’t remember what they talked about. I remember knowing I was safe. I remember knowing their unconcern for me, meant my husband and I were doing just fine. I also knew they weren’t really ignoring us at all, and I’d have help literally the second there was any sign I needed it. This is a fear free environment. the few times my midwife came and went interrupted the flow of my labour in a way that her quiet chatter in the corner did not. I believe it was Michel Odent that wrote about reading the paper in the corner of the birthing room. Maybe that’s actually a story about my OB from the third birth, he’s well known for his calm ways. Which ever it was, it’s the same vibe: “I’m here so you can feel safe. I’m reading the paper because you’re so safe you don’t need anything from me right now.”

    My apologies for my typos, it’s really hard to proofread in this box on my phone.

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