Authoritative vs. Authoritarian

This is another post inspired by Dr. Rixa Freeze’s “Born Free” doctoral dissertation; this time from the section starting on p 169 of the pdf, on “Intuition as Authoritative Knowledge.”

Often when the discussion is on unassisted childbirth (UC), the question becomes, “How do you know what to do when?” This type of question can come from women contemplating a UC, in which case they are asking a legitimate question; or it can come from skeptics or people completely opposed to UC, in which case they are asking the question rhetorically, implying that women can’t or won’t know what is happening to them in labor and birth, either at all, or until it is too late to prevent the “it” from happening [shoulder dystocia, cord prolapse, placenta previa, fetal distress, etc.], or the “it” from having serious or even deadly consequences.

The typical response from UCers is that women will “just know” via intuition what is going on — that when women are completely in charge of their own bodies and labors and births (as can only happen in a UC, since even a very hands-off midwife will intrude at least somewhat simply by her presence) — that they will “tune in” to their bodies in such a way as to know or be aware of what is going on that no external machine or person can even approach to knowing. I’ve read several stories along these lines — one that sticks out was not a UC, but rather a woman who “just knew” that something was going wrong, although the EFM didn’t show any problems, and the nurse didn’t think anything was wrong. She actually had a hidden partial placental abruption, which was ignored because the nurse believed the machines instead of the woman. Often, the reverse case is told in UC circles — women who are showing clinical signs of something being not quite right, but intuition saying that everything is fine and no steps need to be taken.

This section of the dissertation made me think of the difference between “authoritative” and “authoritarian.”

First, the quick definitions (taken from OneLook dictionary):

Authoritative — ▸ adjective:  sanctioned by established authority; having authority or ascendancy or influence; of recognized authority or excellence
Authoritarian –▸ noun:  a person behaves in an tyrannical manner▸ adjective:  likened to a dictator in severity; characteristic of an absolute ruler or absolute rule; having absolute sovereignty; expecting unquestioning obedience.

A person can be both authoritative and authoritarian, but these are not the same in meaning. As an example, Rixa may be an authority on the subject of UC, having not only had one herself, but having studied the topic extensively and written this extremely long thesis on it; yet she would only become authoritarian if she insisted that everyone have unassisted births as she did.

Quoting from the dissertation:

Anthropologist Brigitte Jordan, best known for 1978 book Birth in Four Cultures, explained that authoritative knowledge is “the knowledge that within a community is considered legitimate, consequential, official, worthy of discussion, and appropriate.” It is not simply the knowledge of those in authority positions, as the term might suggest, but rather a “state that is collaboratively achieved within a community of practice.” Whether or not the knowledge system is “right” or “truthful” is irrelevant; “the power of authoritative knowledge is not that it is correct but that it counts.”

So, in OB circles, only such information as may be presented in journals and textbooks is considered authoritative; whereas in UC circles, this information is considered less important (or even unimportant altogether) compared to intuition, or a woman’s innate knowledge. This is larger than just birth — “authority” exists in every circle — religion, education, politics, etc. Dr. Amy may be authoritative — she’s got a whole bunch of school and book-learning, and practiced as an obstetrician for years; but she’s also authoritarian in her insistence of no home births. But what she needs to learn is that her “authoritative knowledge” means nothing to women who disagree with her, because she comes across as authoritarian, and nobody likes to be told what they can and cannot do — especially by someone they disagree with, and who insists on “my way or the highway.”

Further on in the dissertation comes this quote:

Dr. D. Ashley Hill wrote: “Women who choose to have an unassisted birth are at best uneducated about the potential complications of giving birth. At worst, they allow negative feelings towards hospitals, physicians, or midwives to place their babies in danger.”

This makes me wonder — why should/do these women have negative feelings in the first place? What can these people and institutions do to reduce or eliminate said negative feelings so that women will want to give birth there or with the people? Rather than legislating away a woman’s choice to give birth in the manner and place of her choosing, they can make the choice become a positive one — she can still choose a home birth alone or with a midwife, but why when the hospital is so much better? The problem for those who promote hospital birth is that we home-birthers don’t think that a hospital is better, after considering all the pros and cons. If these people want us to think the pros outweigh the cons, they need to see what we consider to be things against hospital birth and change those things — much as they did in the late 70s and early 80s when they made birth rooms more home-like and began allowing fathers in to see the birth of the baby, in response to pressure from mothers — rather than just insist in an authoritarian manner (which typically only serves to increase our stubbornness and resolve to continue in our path and ignore and flout them) that birth at home is dangerous and shouldn’t be attempted and should be outlawed.

ICAN VBAC ban/allow list!!

Earlier I blogged about the VBAC article in Time magazine, and now the awesome, wonderful, and amazing volunteers of ICAN have put together a comprehensive list of all the hospitals in America, and whether they allow VBACs or not. The number of hours that it took for all the volunteers to call the hospitals and enter the information was incredible — somebody estimated that it would have taken $100,000, had they been paid, so this truly was a tremendous effort.

Unfortunately almost half of the hospitals have either a formal VBAC ban or a de facto VBAC ban — that is, there is no official policy against allowing VBACs at that hospital, but no doctor will actually attend one.

But just because a hospital is listed as “allowing” VBACs doesn’t mean you’ll actually get one, or that it will be easy. Many of the volunteers who called hospitals noted that many hospitals or doctors had such strict guidelines for the VBACs they allowed that it would be difficult for anyone to actually have a successful VBAC. Some restrictions include that the woman has to have had a successful VBAC already in order to attempt another one, or at least that she has to have a “proven pelvis” — a vaginal birth. That means that if her first baby was breech and she’s currently pregnant with her second, then she will not be allowed even a chance at a vaginal birth. Other hospitals won’t allow women who have had more than one C-section to attempt a VBAC. Some hospitals or doctors require that women attempting a VBAC to give birth by 5:00 p.m., or be wheeled back for an automatic C-section — regardless of any other factor!

Controversies in Childbirth Conference

A reader reminded me about this upcoming conference, which will be held in Dallas/Fort Worth from March 27-29. If you register before March 1, you will get a discount on the cost of the conference. From the conference website’s home page:

The Only Conference Bringing Together:

Obstetricians, Pediatricians, Family Physicians, Certified Nurse Midwives,  Certified Professional Midwives, Certified Midwives, Nurses, Doulas, Educators, Lactation Professionals, Hospital Administrators, Health Insurers, Regulators, Advocates, Legislators and Insurers to address the major contemporary controversies in childbirth.

The Only Conference that Discusses the Real Issues:
Obstetricians stop delivering babies
Hospitals close their L&D units
Midwifery schools are unable to fill their slots
Malpractice premiums continue to rise
Patients are losing jobs and health insurance
Number of Medicaid patients will explode
MEANWHILE
Patients are seeking more options
The press runs stories on the surge in homebirth
Patients are hiring doulas to be advocates

This conference will examine whether it is feasable to continue to deliver babies and under what circumstances.

We will examine, debate and discuss: Evidence, Economics, Perception and Politics.

The Birth Conference Where Real Solutions are Discussed!

A debate and discussion of the issues is half the job.  We will also look at various solutions that have been successful, or, could be successful with modifications, or may be possible to implement in the near future.  Solutions must work for patient, provider and payor to be viable.
This Birth Conference is Neutral Territory!

This birth conference is not produced by any organization beholden to its membership or other group. Many seminars will be debate format or panels with opposing viewpoints.  No predetermined outcomes or hidden agendas.

The Conference Where the Speakers are as Diverse as the Audience

Our speakers include: obstetricians, nurse-midwives,  family physicians, neonatologists, hospital administrators and executives, nurses, doulas, birth advocates, insurance executives, risk managers, home birth midwives, lawyers, and other disciplines to assure that various viewpoints are fairly represented.

No preaching to the choir!

An ideal setting for intelligent progress!

The Trouble With Repeat Cesareans

Woo-hoo!!! Finally! An article — in Time magazine, no less — that highlights the burgeoning number of women who are being forced to undergo “elective” repeat C-sections, since they are not allowed to attempt a vaginal birth.

While I had some quibbles with the wording of the article (doctors don’t perform VBACs — the mothers do!! Doctors perform C-sections! They attend vaginal births), it was an excellent and timely article.

In England and America, more women choosing home-birth

In America, where we pay for our own health insurance and health care, there is this story from Utah, which looks at economics as one reason for the increase in women choosing to give birth at home. (For those of you in Utah, you may be particularly interested in the chart showing the average hospital-birth cost by hospital.)

And in England, where everyone pays for everybody’s health insurance and health care (it’s by “the government” which is, of course, funded by taxes), comes this story, which shows a large percentage increase over former years, but still less than 2% of all births.

Midwives, fear, and unassisted childbirth

I’m reading through Dr. Rixa Freeze‘s doctoral thesis on “Free Birth” or “unassisted childbirth” (UC), which is extremely interesting, and well worth reading, regardless of whether you are an extreme supporter of UC, or think it’s the worst thing to happen in the world since the A-bomb. You will certainly learn something, regardless of where on the spectrum you find yourself.

On the 81st page of the pdf (p. 66 of the numbered pages) is this statement: “Morgan argued that midwives’ training in how to handle complications would inevitably instill fear in the birth process.”

I understand this; but whether this fear is unfounded or not is another question entirely. The problem is, on one hand there are a whole host of L&D nurses, midwives, OBs and other doctors who have a view of childbirth as a medical problem, attendant with innumerable potential complications (including death or severe disability for mother and/or child), and it is their job to prevent these negative outcomes from happening, or reduce their severity, and to accomplish this through the use of technology. While I and a great many others would argue that their use of technology is not “judicious”, and they should practice evidence-based medicine, and conserve their interventions when they will be beneficial as opposed to introducing unnecessary risk (such as elective inductions), the truth is that sometimes even in the best, “freest” or “purest” circumstances, bad things can and do happen.

Different people have different ideas when it comes to risk and responsibility in childbirth; and that is one thing that I greatly admire about the UC movement, and that is that the parents assume full responsibility for their child in labor and birth, and don’t put any of that responsibility on anyone else, be it doctors, nurses, or midwives. But this weight of total responsibility is too much for many people to bear, so they put (some would probably use the word “shirk”) part of their parental responsibility onto the shoulders of one or many care providers. In this way, when something goes wrong, the parents can always blame the doctors; in a UC, that’s impossible — all blame must rest with the parents, since no one else had anything to do with the birth. Some would argue that the parents still should shoulder all responsibility, since they choose the care provider who may end up being overly interventive. I agree that in this situation, the parents do share some part of the burden of risk and responsibility in what happens in birth due to their choice of care provider; but that the care-provider, in that s/he holds a position of trust, takes on more.

While most births — even among the very high-risk, such as births which occur in countries like Sierra Leone with little or no access to anything like decent medical care, much less clean water, plenty of food, good nutrition, availability of medications and C-sections when needed, etc. — do not end in the death or serious disability of mother and/or child, there is always a possibility that something might go wrong. Because that’s the way the world works; and anyone who says, “Just think happy thoughts, and happiness is guaranteed to follow,” is either trying to deceive you or is seriously deluded himself. I do think we should “think positively,” but that doesn’t mean that it is only “positive thoughts” or “positive energy” that is keeping us from disaster. That’s superstition. There’s no point in being overly negative, of course; but I think there needs to be some sort of middle ground between the “head in the clouds” idea that everything will be just peachy if we just keep negativity away from us, and the “birth is only normal in retrospect” idea of many obstetricians who spend hours attending women in labor and birth all the while sweating and fearing that something somehow somewhere is going to jump out of the middle of nowhere and cause disaster.

Back to the quote: “Morgan argued that midwives’ training in how to handle complications would inevitably instill fear in the birth process.”

I agree with this statement, but tend to think it is a “healthy fear” or rather “respect” of the birth process which usually works well, but is not guaranteed to do so.

Some months ago, I read of a woman who died from an amniotic fluid embolism when her placenta suddenly detached at 34 weeks gestation; both she and her baby went from (seemingly) perfectly healthy to dead within hours. Those who are of the hospital bent cannot blame “crazy UCers” or “crazy home-birthers,” because she was under the care of an obstetrician; and those of us who are of the home-birth bent cannot blame any medical intervention at all, because she wasn’t induced or anything. It just happened, with little or no warning.

Friends of mine lost their baby a little over 3 years ago, due to cord strangulation, right around the due date. Up until that point, everything had seemed to be perfectly fine and normal, although I think the mom felt less movement leading up to the death but thought it was normal. It wasn’t. She was under the care of an obstetrician, planning a hospital birth — you can’t blame it on home birth. She noticed the last movements either right before, or in the early stages of, her labor, before going to the hospital — you can’t blame it on hospital birth.

One problem I have with the UC movement is the talk I hear in various quarters that pretty much reaches the level of superstition — that if you plan a UC, and don’t have a midwife, and have an unassisted birth, and don’t worry, then everything will work out just fine; but that if you ask to plan a midwife-attended birth or you can’t quite squelch your fears, then you’re asking for trouble, and something negative will happen.

Sometimes complications happen in unassisted births — refusing to have a midwife there is not a talisman against that evil; although I do understand and accept that sometimes midwives (even very relaxed and hands-off midwives) can interfere in the normal birth process, and may even introduce some types of risk or “intervention” that wouldn’t have been there before. Some people think that even the midwife’s presence in the room is an intervention; others do not want to have the midwife intrude into their birth space to check the fetal heartrate. But if a complication arises, and there isn’t a midwife there — then what? In the Discovery Health Channel show “Freebirthing”, the American woman they showed having a UC ended up with a retained placenta, so she went to the hospital (where it ended up coming out on its own, without any intervention). Had she had a midwife, she might have avoided the hospital entirely — either because the midwife would have helped, or just let her know that what she was experiencing was “a variation of normal” or whatever.

So, yes, midwives have to know a lot of the potential negatives of birth, including what to do — how to intervene, when to transfer to a hospital and/or doctor. And I’m sure it does make them not trust in the usually perfectly normal process of birth quite as much as someone who has never seen nor heard of a bad outcome. And they may intervene a little too quickly at some points. But the alternative may well be a dead baby, and who wants that? If there is no trained person, and complications arise and the mother does not have intuitive knowledge that something is wrong (which is, after all, a possibility!), then someone could be very badly hurt or even die. That’s life. That’s death. Most births will turn out just fine — unassisted, midwife-attended, obstetrician-attended, low-risk, high-risk, VBAC, elective repeat C-section.

If I were to plan a UC, I think that my not knowing all of the complications that can arise (which midwives do know) would bother me more than having a midwife there who might possibly step into my birth space, because I like to know and understand all facets of a process or event before stepping into it. So, were I to plan a UC, I would take a lot of time to research the common complications… and then rather than it being, “midwives’ training in how to handle complications would inevitably instill fear in the birth process,” it would become that my training (or lack thereof) in how to handle complications would inevitably instill fear in my birth process. For my part, I’d rather turn the training and fear and study of complications over to someone else, so that I can get out of my head and into la-la-labor land.

Alternative Reality

Continuing the series of blog posts on Dr. Rixa Freeze‘s doctoral dissertation on unassisted childbirth…

On page 167 of the pdf (p. 153 of the document), she notes that with the advent of the internet, it has become easy — or even possible — for people in otherwise isolated locations to come together around a common purpose. In this case, the cause or practice of unassisted birth; but it could be anything — birth-related or not — it could be “people with pink poodles” or afficionados of Pride and Prejudice, or a specific food, musician, artist, etc., as far as that goes:

With unassisted birth, there is a paradoxical withdrawal from conventional social interactions that surround pregnancy and birth and an immersion in alternative virtual communities in which unassisted birth is seen as a normal, reasonable choice. Women often withhold their birth plans from family and friends, fearing disapproval and negativity. Some also worry about governmental interference because of their alternative choices, so they too choose not to reveal their plans. In order to make up for the social isolation that UC often brings, they selectively enter into intentional communities that support unassisted birth.

I recently expressed this same type of feeling on one of my email lists. Out of hospital births, intentional or not, make up about 1% or so of all births in the nation. Intentional home births are even less. We who support the idea of home birth are a small group — obviously! But it doesn’t feel that way when I’m online and reading and writing to the women who are on these lists who share my opinion and thoughts on the matter.

There is a story I heard of years ago, of a preacher back in the olden days who had a member of his church who had stopped coming to church. The preacher stopped by to see the man one cold winter day, and sat by the fire to warm himself. The man braced himself for a lecture, and was getting ready with all the excuses he could think of; but the preacher didn’t say anything. He merely took one of the coals out of the fire and set it apart from all of the other coals. Of course, within a short period of time, the coal died out. The preacher picked up that piece of coal and put it back in the fire, where it instantly caught fire again and burned brightly. Then he got up and left. The man was back in church the next Sunday, having caught the message of the silent lecture: when you are isolated from the group, you can only burn so long before you burn out and get cold; but by going back to the group, you rejuvenate yourself and help others to stay warm, as well.

That’s the same kind of thing that happens with online communities, for good or bad, regardless of the subject matter. It happens just as much on pro-C-section groups getting the women to all conform to the group norm and willingly choose a C-section, as it does on UC groups who promote giving birth unassisted.

If I had only my “in real life” friends, I’d probably burn out on birth pretty quickly, because most of them don’t really care too much about it, are certainly not as passionate about it as I am, and some of them think I’m a little weird for having home births instead of having epidurals, etc. Some people support home birth as a choice — have even given birth at home themselves — but it’s not their “thing” — their “thing” is… fill in the blank — home schooling, quilting, literature, economizing, music, art, etc. Birth is a side issue for them, just like art is a side issue for me. Sure, I like to look at pretty pictures, but I’m not enthralled by it the way some people are. I am, however, enthralled by birth. Fellow “birth junkies” get that; other people don’t — although they may be equally “into” some other issue or cause that I’d become bored with after a day. Diff’rent strokes for diff’rent folks.

If it was just me and no internet… I can’t even imagine it! In some ways, it might be better, because not having an online community (this blog, other blogs I read, my email lists) would force me to move beyond my comfort zone in my real community and reach out and find some connections somewhere. But if I couldn’t, I’d probably burn out. That’s one thing that conventions do, I’m sure — bring together far-flung Trekkies (or birth junkies, or whatever other die-hard fans you can think of) into one big fire, and stoke the individual coals into a huge flame — far bigger than the sum of the individual parts could be.

I’ll admit it: sometimes I get so immersed in my pro-natural or pro-home-birth online culture, that when I step out into the real world and have discussions about birth, I’m taken aback by some of the things I hear. These things are, almost certainly, the norm — or at least are valid choices by most people’s thinking; but they seem weird to me: “you’re choosing a C-section when the doctor is willing to attend a VBAC??”; “you’re getting induced for no medical reason?”; “you’ve already planned on having an epidural, and you’re not even pregnant yet?” — that sort of thing. But in my little corner of the ‘net, these things are weird. And I think they ought to be! I like living in my alternative reality, and have no plans to change that any time soon.