Counter-Narratives of Childbirth: Homebirth and Midwifery, Lecture notes of Business Demography and Environmental Studies

Download Counter-Narratives of Childbirth: Homebirth and Midwifery and more Lecture notes Business Demography and Environmental Studies in PDF only on Docsity! UC Riverside UC Riverside Previously Published Works Title Countering technocracy: "natural" birth in The Business of Being Born and Call the Midwife Permalink https://escholarship.org/uc/item/9fs2b0bh Journal FEMINIST MEDIA STUDIES, 17(3) ISSN 1468-0777 Author Takeshita, Chikako Publication Date 2017 DOI 10.1080/14680777.2017.1283341 Peer reviewed eScholarship.org Powered by the California Digital Library University of California Countering Technocracy: "Natural" Birth in The Business of Being Born and Call the Midwife Chikako Takeshita Associate Professor Gender & Sexuality Studies University of California, Riverside Final Revision Submitted to Feminist Media Studies September 13, 16 4 foundation of the objectification of maternity ward patients as something to be managed and controlled. Davis-Floyd (1992), who theorizes that childbirth functions as a rite of passage that sends strong cultural messages to a woman who is in a liminal state of transitioning into motherhood, argues that hospital births that heavily and frequently utilize medical interventions propagate technocracy by impressing upon a new mother that she must relinquish herself to experts and technologies at all times because they are superior to her own endowed capacities. Meanwhile today on TV and film, the ritual that imprints the core American value of technological superiority is “enacted not just in actual hospital births but also in the fictions we create about hospital births” (West 2011 p.121). Media representations are not inconsequential since it is one way in which women learn about pregnancy and childbirth (Hall 2013). Feminist media studies scholars who have studied recent representations of childbearing concur that problematic aspects of medicalized birth are uncritically presented on the screens as the cultural norm (Kline 2007; Lothian & Grauer 2003; Morris & McInerney 2010; Sears & Godderis 2010; West 2011). They uniformly express concerns about how the media reinforces and naturalizes the medical domination of maternity care and women’s subordination to it. Some have searched for oppositional images in their studies, but found there to be little or no resistance against the normative. My motivation for this article is to fill the gap in the analyses of alternative representations and discourses of childbirth and to parse out the ways in which they might disrupt the technocratic model of birth on the screen. I utilize the documentary film The Business of Being Born and the BBC TV series Call the Midwife for this task. Both productions, which have had some exposure in the U.S., push 5 against medicalization with representations of "natural" childbirth in the home.1 Business systematically critiques medicalized birth and presents midwifery-assisted home birth as the solution to the ills of modern day childbearing, while Call contradicts the dogma of necessary medical attention during childbirth and normalizes midwifery by illustrating how women regularly gave birth at home in the past. Although their socio-historical contexts are vastly different, Business and Call augment each other as the former reveals the contemporary struggles and offers a solution to de-medicalize birth and the latter serves as an example of how homebirths may be supported by medico-midwifery collaboration in an urban community. By "naturalizing" childbirth as an essential quality of women, however, Business and Call both fall short of questioning the institution of motherhood as a potential source of gender oppression. Nonetheless, analyzed in conjunction, these visual stories foster a shift in perspective and provide groundwork for an alternative discourse of childbearing that embraces embodiment and opportunities for empowerment. Dominant media representations of childbirth Feminist scholars who have studied TV shows that follow pregnant women in real life such as Birth Story and Maternity Ward on TLC and Discovery Channel’s Birth Day report that what are shown on television as “reality” are highly skewed in ways that give 1 Where to draw the line between "natural" and "technological" is complicated since midwives, too, utilize low-tech devices to check for fever, fetal heartbeat, and mother's blood pressure. They also use simple tools such as heat pads and birthing stools to ease the pain and facilitate labor as well as carry oxygen tanks, anti-hemorrhage medication, and needles and thread to suture tears. In a hospital setting, "natural" birth may refer to a non-surgical birth or may be defined as vaginal birth without pain medication. For the purpose of this article, "natural" birth is a vaginal birth achieved through physiological processes without the use of constant electronic monitoring, IV, pain medication and anesthetics, drugs to manipulate contraction, episiotomy, forceps, or vacuum extraction. 6 the impression that every pregnancy can turn into an emergency situation. At the extreme end, Maternity Ward, which takes place in high-risk medical centers around the U.S., promotes what Lothian and Grauer (2003) call “real terror” (vii) by frequently playing up live or die scenarios. Morris and McInerney (2010) note that Birth Day also pathologizes pregnancy by focusing on what can go wrong during pregnancy and childbirth and by over-representing complications such as abnormal fetal positions, hypertension, postpartum bleeding, cervical cancer, bicornuate uterus, preterm labor, and diabetes, making pregnancy and childbirth seem much more perilous than what is supported by evidence. Reality TV shows, thus, invite viewers to believe that heavy medical surveillance over pregnant women is legitimate at all times. Simultaneously, they instill fear of childbirth and prime women to readily accept medical interventions that may not be entirely necessary. These shows also function as advertisements for technological “solutions,” such as pain medication, anesthesia, artificial labor facilitation, and cesarean section. In Birth Day, women in vaginal birth received Pitocin and epidural at a rate higher than the national average (ibid). Many scenes in A Baby Story included sights and sounds of various equipments as well as physicians, nurses, husbands, and pregnant women examining printouts from electronic fetal monitors. Women were rarely seen debating or expressing their preference for pain medication or birthing positions, while the medical staff was often shown making decisions for them without offering any options. Informed consent was rarely shown, indicating that the women’s preferences did not matter. Sears & Godderis (2010) contend that viewers learn to fear childbirth, accept medical 9 analyzed how the imageries, testimonies, and storylines in the documentary construct a certain kind of discourse about an idealized childbirth that, although not without its own flaws, works effectually against medicalization by visually and verbally reiterating the feminist critique of technocratic maternal care. Although Business deserves a thorough feminist analysis of its own, instead of scrutinizing the problematics of its images and rhetoric, I chose to combine it with a second counter-narrative provided by Call in order to explore greater opportunities to debunk the contemporary myth of medicalized childbirth.3 I watched a total of thirty-three episodes (60 to 75 minutes each) from seasons one through four on Netflix, taking notes on every case of childbirth for its circumstance, outcome, visual portrayal, and other notable characteristics. I made observations about Call's discourse of childbirth through its dominant story-telling patterns paying attention to how it reinforces midwife-assisted childbirth as normal and healthy. In order to concretize how the two counter-narratives function against the dominant representations of highly medicalized birth at hospitals, I directed my analyses of Business and Call towards identifying how each medium counteracts the five negative messages delivered by the popular media outlined above.4 Counter-Narrative in The Business of Being Born The Business of Being Born advocates for homebirth and midwifery while criticizing technocratic childbirth. Produced by actress and TV show host Ricki Lake and directed 3 Season five on PBS has started in April 2016. 4 My discussions of alternative childbirth will focus on homebirth, although birth centers and in- hospital midwifery may be another approach to facilitating less technocentric birth. These options that stand somewhere in between obstetric birth and homebirth are worthy of full exploration of their own. 10 by her friend Abby Epstein, it is the best-known documentary of its kind.6 Business was conceived through Lake’s personal history of a disappointing first childbirth in the hospital and an entirely different and satisfying homebirth experience with her second child. The primary message delivered by the film is that midwife-assisted homebirth offers a positively transformative and empowering experience, which is denied to women who give birth under the financially and technologically driven American healthcare system. Reflecting on her own hospital birth, Lake asserts that women need to be better educated about maternal care and childbirth options so that they do not wind up blindly following their caretakers and be scared into having medical procedures they may not need or would have liked to reject. From this standpoint, she strives to inform the audience about how obstetrics operate as a business driven by the bottom line and about the benefits of giving birth at home. The film convincingly portrays the hospital as an exceedingly sterile, impersonal, and mechanistic environment while juxtaposing it against the warm and personalized care provided by midwives at home. It also showcases leading figures in the natural birth movement including Barbara Katz Rothman, Marsden Wagner M.D., Ina May Gaskin, and Michel Odent M.D., who serve as experts of the negative effects of medicalization and the advantages of non-medicalized childbirth. Between oral testimonies and visual illustrations, Business reiterates the classic feminist critique of technocratic maternal care in the U.S. made by Rothman (1982), Davis-Floyd (1992), and others. The documentary has been welcomed by childbirth advocates, midwives who assist homebirths, aspiring 6 Other films in this genre include: Orgasmic Birth: The Best Kept Secret (Debra Pascali-Bonaro 2008), The Face of Birth (Gavin Banks & Kate Gorman 2012), Birth Story: Ina May Gaskin and the Farm Midwives (Sara Lamm & Mary Wigmore 2012), Midwife: A Look into the World of Homebirth Midwifery (Allison Kuznia 2013). 11 mothers-to-be with sufficient resources to hire them, and feminist professors who screen the film in their classes. Medical/Business Model of Birth Exposed By revealing the negative aspects of in-hospital childbearing, Business turns the table on the notion that hospitals are the safest (and the only safe) place for childbirth. Business shows how a typical maternity ward manages patients to protect the hospital's profit margin. Doctors supervise multiple laboring women by relying heavily on monitoring machines, drugs such as Pitocin to induce or speed up labor, and epidural to manage pain. Induction and augmentation of labor, however, are not only unnecessary for most women, but often trigger a cascade of interventions. The film explains that Pitocin inflicts pain on women by causing longer and more intense contractions; as a result many women end up accepting an epidural, which tends to weaken the contractions, and thereby necessitate a larger dose of Pitocin. More often than not, drug-induced contractions cause fetal distress leading to an emergency cesarean section, which could have been avoided had the labor not been so rushed or meddled to begin with. Business cautions women that doctors and medical treatments cannot always be trusted to be safe and argues that it is less dangerous to give birth at home. The film also lures the viewers to feel repelled by Obstetric Taylorism or the factory-style maternity ward operation that focuses on the production of babies and objectifies women in the process. The film shows a large whiteboard that keeps track of more than a dozen women in labor who are being managed concurrently. While referring to their patients by their room numbers, nurses and doctors discuss ongoing treatments 14 "homey" environment in the presence of the father and older siblings. Residential childbirth scenes convey that not only the home has everything the woman needs during labor and delivery, but it is a "better" place, and a special space, in which the arrival of the new member is seamlessly integrated into the family's life. Business stresses that having a positive birthing experience empowers women because it proves their strengths to themselves. Ricki Lake includes footages of her own attempt to give birth at home, which begins with her leaning on the kitchen counter whimpering in pain. Some time later she is shown giving birth in the bathtub, followed by many ecstatic shouts and embracing and kissing of her newborn. Lake recalls this moment as intensely empowering, comparing it to how she felt "cheated" after her first child was delivered at the hospital. One of the midwives states that women will remember how they were made to feel at birth and that a non-medicalized childbirth can be positively transformative because a woman would be able to say to herself: "If I could do that, I could [sic] do anything." The film thus conveys that childbirth can indeed be a rite of passage that affects the woman's outlook on life. The Pitfalls of Naturalizing Motherhood The oppositional formula between "empowering natural homebirth" and "oppressive medicalized hospital birth" that composes the backbone of Business's powerful counter- narrative is also a source of its shortcomings. As a result of playing up the claim that women have an innate or "natural" ability to give birth, when a homebirth does not go as planned, the woman can be left with a sense of failure and guilt for letting her baby down. This becomes evident when Abby Epstein, the film's director who had planned a 15 homebirth, winds up with a cesarean section. When she discusses her childbirth experience with Ricki Lake several months later, Epstein seems simultaneously resolved and disappointed. She feels that because she missed out on the oxytocin rush, she and her son had a difficult time bonding and breastfeeding. While Epstein's testimony seems to support the claim that technological intervention disempowers women, her transfer to the hospital in the middle of labor also disrupts the confidence the audience was building toward homebirth. This episode, which comes at the very end of the film, ironically exposes the limitations of arguing for an alternative model of maternal care based on naturalizing childbirth, which leaves little room between the "natural" and the "medical." Viewers should understand that Epstein's doctor, who in the film offered to be the backup physician for her homebirth, is an exception to American physicians, most of who are skeptical of homebirth and unwilling to lend their support. Women and their midwives who decided to go to the hospital after laboring some time at home have reportedly been treated poorly by doctors and nurses, who view them as selfish women that endanger the baby for a frivolous "experience." Apart from interviews with a few sympathetic physicians, Business's counter-narrative consistently falls back on the polarization between the pure, perfect, and empowering non-interfered homebirth and the tainted, imperfect, and disempowering meddled-with hospital birth. While this contrast functions as an effective critique of technocracy, the oppositional positioning of the "natural" against the "medical" unfortunately restrains our imagination from moving towards a cooperative relationship between obstetrics and midwifery. Later I will demonstrate with Call that non-exclusive relationship in which the midwives and doctors partner up in maternal care is conceivable. 16 By grounding their argument in woman's "natural," or biological and hence universal, capability to give birth, the filmmakers also overlook race and class disparities that render the type of personalized care they show on Business out of reach for most women. To its credit, the film briefly shows two birth centers that primarily serve African American women, one of which is forced to shut down due to financial difficulties created by rising insurance premiums. This incident, however, is featured as an example of insurance industry's indifference to women's wellbeing instead of as a problem stemming from the marginalization of communities of color. Homebirthing in the U.S. today requires that the woman first educates herself about childbirth, carefully chooses and enlists the caretakers, prepares and controls the birthing space, and secures physical and emotional comfort during labor, all of which are part of building the social infrastructure needed to achieve the desired style of birth (Mansfield 2008, Halfon 2010). While the film does show this process, it neglects to remark on the fact that every homebirther in Business is equipped with the socio-economic capital necessary to put together a network of information, supporters, and environments that help her achieve the "natural" birth she desires. The film thus fails to acknowledge that most women do not have the financial resources or social support to pursue non-medicalized childbirths and that gaining "empowerment" through an ideal childbirth is a privileged commodity.8 Moreover, the stories in the film end up affirming a classic pro-white-natalist position that omits minority women, who have historically been deemed as unsuitable mothers and targeted by anti-natal policies, from its empowerment narrative (Takeshita 2012). 8 See Jennifer West (2011) for a critique on the class and regional exclusivity of The Business of Being Born. 19 Whether it is sidelined in the popular representations of childbirth or enthusiastically supported in pro-homebirth films like Business, midwifery has been presented as an anomaly in most of today's media. In Call, however, there is no question that midwives are the norm as they are the primary attendants of most if not all births. In every episode, there is at least one labor and delivery scene attended by a midwife, which typically goes as follows: When Nonnatus House is notified that a woman is in active labor, the midwife on call grabs her black leather suitcase, flings herself on a bicycle, and makes her way to the pregnant mother’s residence. A woman is propped up in her bed screaming in pain with her mother or husband at her side. Upon arrival the midwife quickly orders a family member to prepare hot water and warm towels, and rushes over to the patient to listen to the baby’s heartbeat with her pinard. She declares that the baby is fine, unless she finds something unusual such as a transverse or breech fetal position. The expressions on the pregnant woman and her family relax as they feel reassured by the presence of the midwife. When it is time for the woman to deliver the baby, the midwife talks her through the process. “Now, hold the pushing and pant. Pant… Pant… That’s it… Almost there…The baby’s head is born! Now, with the next pain, give me one big big push!… Common now, PUSH! That’s it!” Meanwhile the camera cuts back and forth between the face of the mother, who is trying hard to follow the midwife’s guidance despite being in agonizing pain, and the midwife’s gloved hand placed between the mother’s legs waiting to catch the baby. As the woman moans and groans, the screen shows a baby’s wet little head emerge behind the mother’s thigh. Eventually an entire baby — bloody, squirming, and very much looking like a newborn — slips out, as the midwife cheerfully announces, “Good job! You have a boy (girl)!” The baby is quickly wrapped in a warm towel and 20 handed over to the mother, who looks down at it with an expression that has now transformed from agony to a glowing mixture of fatigue, relief, and satisfaction. The midwife cuts and clamps the umbilical cord and smiles down at the pair, happy to see that the newborn is crying vigorously. She delivers the placenta and checks it in a kidney tray to make sure it is in tact. A family member bustles into the bedroom to clean up the mess. Once the baby is latched on to the breast, the midwife leaves, promising to be back the next day to check up on them. This pattern is repeated countless times, normalizing midwifery-assisted birth and weaving it into the fabric of everyday life of the community. The show integrates occasional inevitable maternal and infant death in its stories. At the same time, it demonstrates how midwives skillfully help women give birth to twins, a breech baby, one with a prolapsed umbilical cord, and another with shoulder dystocia, all of which are likely to be surgically delivered in the hospitals if they were to be born today. The nuns and nurse midwives of Nonnatus House also provide comprehensive maternity care based on scientific principles. Antenatal care is offered in weekly prenatal clinics, during which the midwives conduct pelvic examinations, palpitate and measure the abdomen, and check for signs of prenatal complications such as ankle swelling. They also perform urine tests by boiling the liquid in a test tube over a Bunsen burner and checking it for any clouding. Midwives also visit the pregnant women's homes during pregnancy to evaluate the suitability of their residences for a home delivery as well as provide postnatal care by making regular house calls to check on the health of the mother and the baby. Whereas Business emphasizes the negative side of the medical model of birth to counter the dominant technocratic narrative, Call does so by showing that midwifery-assisted homebirths are normal and medically sound. 21 Affirmation of Embodied Childbirth That self-reliant childbirth positively affects a woman's wellbeing is communicated much more subtly in Call than in Business. While Call apparently endorses "natural" birth, it is not something that the women in the drama aspire to have or see as an act of defiance against the establishment like homebirthing mothers in Business do. Birth without medical intervention is simply a lived reality when no other options are available. The idyllic impression of homebirth we get from Business is not represented either in Call, in which impoverished women have babies in dilapidated apartments with nothing but newspapers to protect their mattress from body fluids and middle-class women, though in more comfortable homes, are confined to bed during labor and give birth on their backs or sides. Rather than considering childbirth without painkillers as something desirable, Jenny's clients dread it and grudgingly tolerate it. Homebirth, while romanticized to a degree, is not presented in Call as an empowering agential choice made by women. Likewise, Jenny and her colleagues probably would not characterize their work as "giving power to women," like Cara in Business did, since giving birth "naturally" does not challenge the status quo in any way. Nonetheless, Call portrays childbirth as a beautiful thing for the mother to be fully present for. Even though women in Call are not granted an autonomous choice as to how one gives birth, they are undoubtedly the central actors of their own childbearing. Far from being a passive object at the mercy of the caretaker, in almost every birth we witness, the woman in labor is fully involved as she concentrates all of her mental and physical energy on the birthing process. In one episode, the midwives encounter a woman who 24 exist in fitting with the historical context, Dr. Turner is an avid supporter of the midwives and a respected and reliable partner to them. Female caretakers work autonomously and look after pregnant women, while the male doctor only steps in when his assistance is needed. Unlike Business that sets up an oppositional dichotomy between medicine and homebirth, the historical drama shows that it is possible for a community to receive care from both midwives and doctors who worked together. Although working relationships between midwives and physicians that parallel the one in Call are institutionalized in some European countries, "collaborative care" has had limited traction in the U.S. (Downe, Finlayson, & Fleming 2010). The reasons American obstetricians are reluctant to be a backup physician for homebirth are too complex to discuss here. Suffice it to say that medical liability and insurance premiums are set up against such collaboration between homebirthing midwives and doctors. Laws regulating midwifery also differ from state to state with varying degrees of prejudice against out-of-hospital births.12 In my opinion, homebirthing midwives in the U.S. by default have far less support than they deserve from the medical establishment, insurance industry, and public health policy. If marginalization of out-of-hospital continues homebirths will unfortunately remain an option for a few fortunate people in the U.S. (Klassen 2001; Nolan 2011). However, by seeing how care is provided in Call and applying it to today's context, we can begin to picture how a socio-technical network supporting homebirth may be built for less privileged Americans if we can garner trained 12 It is important to note here that there are two types of midwives in the U.S. Certified Nurse Midwives (CNM) are trained as nurses first and specialize in midwifery. They tend to work in medical settings with different degrees of physician oversight. Licensed Professional Midwives (LPM) enter directly into midwifery training without a nursing degree. The majority of homebirthing midwives are LPMs. 25 midwives, sympathetic medical personnel, favorable hospital policies, reasonable insurance premiums and good coverage, cultural acceptance for non-medicalized birth, and legal protection for midwifery. In summary, Call does not directly criticize medicalization or explicitly demonstrate the differences between medicalized and midwifery models of birth. Nevertheless it offers a brilliant counter-narrative against the dominant media representations of technocratic childbirth by showing that: 1) there is no need to be afraid of childbirth under the care of capable midwives; 2) home is a normal place to give birth; 3) technological interventions are not essential to a safe childbirth; 4) women are embodied agents of childbirth; and 5) midwifery is scientifically sound and is not incompatible with medicine. Like Business, the historical drama series uncritically reinforces gender roles and the idea that motherhood and nursing are inherent qualities of women. However, Call manages to escape the medical/natural opposition that Business trapped itself in and presents an alternative counter-narrative that consists of a medically supported, yet autonomous, robust midwifery care that is integrated into the social networks of a community. Conclusion Feminist media studies have revealed that the dominant representations of childbirth in Reality TV shows, situation comedies, and entertainment films uphold the medicalized model of childbirth, which has been criticized by feminist scholars as a patriarchal practice that objectifies women. In this article I examined how the documentary film The Business of Being Born and the historical drama series Call the Midwife offer alternative 26 narratives to counter the stereotypical depiction of childbirth as always potentially dangerous and pregnant women as helpless and submissive patients. Business delivers a sharp critique of technologically and financially driven obstetrics while endorsing midwife-assisted homebirth as the solution to the mistreatment of women in the hospitals. Call on the other hand portrays midwifery as the norm and childbirth as an everyday event rather than a medical problem. Both represent natural birth as self-affirming experience for women. This article demonstrated that the two counter-narratives complement each other. For one thing, viewers of Call may assume that natural births are an artifact of the past. Business corrects this perspective by presenting homebirths as a desirable alternative to technocratic maternal care today. Meanwhile Business suffers from the oppositional relationship it builds between the "medical" and the "natural," which eliminates the potential for hybrid models of care. Call fills this vacuum by exemplifying a model of maternal and infant care that is enhanced by a partnership between midwives and doctors. The two counter-narratives, though not without limitations, help us re-imagine how labor and delivery may be accomplished for individual women at home and how non- technocratic childbirth might be institutionalized as a viable option for women with varying degrees of resources. Simultaneously, however, both of these media represent the type of counter-technocracy narrative that supports heteronormative middle-class white femininity based on essentialized motherhood. It is likely that Business and Call are able to attract significant number followers because their adherence to gender and racial norms make them culturally amenable. Going forward, the feminist challenge might be to 29 McGibbon, E., Mulaudzi, F. M., Didham, P., Barton, S., & Sochan, A. (2014) 'Toward decolonizing nursing: the colonization of nursing and strategies for increasing the counter-narrative', Nursing inquiry, 21(3), 179-191. Merchant, Carolyn. (1980) The Death of Nature: Women: Ecology, and the Scientific Revolution, Harper and Row, San Francisco. Morris, Theresa & McInerney, Katherine (2010) 'Media representations of pregnancy and childbirth: an analysis of reality television programs in the United States', Birth: Issues in Prenatal Care, vol.37, no. 2, pp. 134-140. 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Author's Bio: Chikako Takeshita is associate professor of gender and sexuality studies at University of California, Riverside. She is the author of The Global Biopolitics of the IUD: How Science Constructs Contraceptive Users and Women's Bodies (2012, MIT Press). Her research and teaching interests include feminist science and technology studies, 31 reproductive medicine and politics, and discourses of sustainable futures. Her current project looks at cesarean section and mother-fetus symbiosis.