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Pregnancy and paradigms : possibilities for empowerment

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Pregnancy and paradigms : possibilities for empowerment
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McNellis, Janet R
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Childbirth ( jstor )
Hospitals ( jstor )
Infants ( jstor )
Midwifery ( jstor )
Midwives ( jstor )
Mothers ( jstor )
Paradigms ( jstor )
Physicians ( jstor )
Pregnancy ( jstor )
Women ( jstor )
Dissertations, Academic -- Educational Psychology -- UF ( lcsh )
Educational Psychology thesis, Ph. D ( lcsh )
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Thesis (Ph. D.)--University of Florida, 1999.
Bibliography:
Includes bibliographical references (leaves 183-188).
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Printout.
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Vita.
Statement of Responsibility:
by Janet R. McNellis.

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PREGNANCY AND PARADIGMS: POSSIBILITIES FOR EMPOWERMENT










By

JANET R. MCNELLIS


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1999













ACKNOWLEDGMENTS
This dissertation would not have been possible without the help of many individuals, and I would like to thank these people for all of their assistance. First, I would like to thank the women who graciously agreed to participate in my study. I could not, of course, have done this study without them. I truly enjoyed talking to them, watching their pregnancies develop, and meeting their beautiful babies. I am honored that they and their partners let me share in their experiences.
I also would like to thank the health care professionals who not only cooperated fully with my study, but who actively took steps to ensure the success of my research, and who maintained interest in my progress. I hope that they find this report accurate and useful.
Each of my committee members gave me valuable guidance
throughout the proposal and research stages. I would like to thank Bridget Franks, William Marsiglio, Robert Sherman, Rodman Webb, and Robert Ziller for their help and their patience with my numerous proposals. They gave generously of their time and advice, even during their "vacations." They also uncomplainingly read and responded to my dissertation drafts at short notice. Rodman Webb was my "guru" throughout the entire process; encouraging me, guiding me, and pushing me along the way.
I would not have been able to complete this dissertation without the
help of my husband, Bob, who was an inexhaustible source of encouragement and a valuable font of practical advice.








Finally I would like to thank my children, Niall, Molloy, and Aidan,

without whom I never would have developed this idea for a dissertation and who also gave me an incentive for finishing.













TABLE OF CONTENTS

page

ACKNOW LEDGEMENTS ............................................................................................ ii

ABSTRACT ................................................................................................................... vii

CHAPTERS

1 INTRODUCTION ............................................................................................ 1

Statement of the Problem ................................................................................ 3
Theoretical Framework ................................................................................... 3
Purpose of the Study ....................................................................................... 6
Significance and Limitations of the Study .................................................. 6
Organization of the Dissertation .................................................................... 7

2 REVIEW OF LITERATURE ........................................................................... 9

Introduction ...................................................................................................... 9
The Evolution of Childbirth in America ..................................................... 9
Colonial Times .......................................................................................... 9
Late Colonial and Early National Period ........................................... 13
Nineteenth Century .............................................................................. 15
Early and Mid-Twentieth Century ..................................................... 19
Late Twentieth Century ....................................................................... 27
Relative Safety of Midwifery and Obstetrical Care ................................... 35
Obstetrician-Assisted Births ......................................................................... 37
The Obstetrical Paradigm ...................................................................... 37
The Medical-Care Experience ............................................................... 39
Midwifery-Assisted Births ........................................................................... 40
The Midwifery Paradigm ...................................................................... 40
The Midwifery-Care Experience .......................................................... 43
Childbirth as a Feminist Issue ....................................................................... 44
Empowerment .................................................................................................. 46
Definitions of Empowerment ............................................................. 46
The Empowerment Process ................................................................. 47
The Need for More Research ...................................................................... 49








3 M ETH ODO LOGY .................................................................................................. 52

Research M ethod ............................................................................................ 52
Settings .............................................................................................................. 52
Participants ...................................................................................................... 54
Data Collection ................................................................................................. 56
Interview s ............................................................................................... 56
Observations .......................................................................................... 57
Artifact Review ..................................................................................... 58
Photographic Self-narrative .............................................................. 58
D ata Analysis .................................................................................................... 59
Research Bias and Ethics ................................................................................ 60
Reliability and Validity ................................................................................... 62

4 TH E CO U PLES ................................................................................................. 65

Introduction .................................................................................................... 65
Sim ilarities ...................................................................................................... 66
Reactions to Pregnancy ......................................................................... 66
Physical and Em otional Changes ....................................................... 67
View s of W om en ................................................................................... 68
Differences ......................................................................................................... 73
Reasons for Choosing Caregivers ........................................................ 74
Am ount of Inform ation Sought ....................................................... 78
Expectations for Childbirth ................................................................. 79
View s of W om en ................................................................................... 81
Sum m ary ......................................................................................................... 84

5 THE MIDWIFERY VIEW OF PREGNANCY AND CHILDBIRTH ..... 86

Introduction .................................................................................................... 86
The M idw ives .................................................................................................. 86
The Paradigm .................................................................................................. 89
N ature/God Directs Birth .......................................................................... 90
Women's Bodies are Normal/Birth is Normal/Healthy ............. 92
W om en Give Birth ................................................................................ 94
W om en's W ishes ...................................................................................... 102
Fam ily is Im portant ................................................................................... 103
Pain is Part of Being H um an and is O K ................................................ 106
Women Need to Be Emotionally Prepared ......................................... 108
Importance of the Midwife/Women Relationship ........................... 110
Birth Should Be an Empowering Experience ...................................... 114
Effects of the M idw ifery Paradigm .................................................................. 115
Effects During Pregnancy ..........................................................................115
Effects During Childbirth ......................................................................... 119
Effects After Childbirth ......................................................123
Sum m ary ............................................................................................................. 125
v








6 THE OBSTETRICAL VIEW OF PREGNANCY AND CHILDBIRTH ....... 127

Introduction ......................................................................................................... 127
The O bstetrician .................................................................................................. 128
The Paradigm ....................................................................................................... 129
Without Medical Intervention Childbirth is Unpleasant ................ 130
Medical Personnel Can Make Women Comfortable During
Childbirth .............................................................................................. 131
Pregnancy and Childbirth are Potentially Dangerous but
Doctors Can Make Them Relatively Safe ....................................... 133
Medical Personnel are the "Experts" and Have Specialized
Roles ....................................................................................................... 138
Effects of the Obstetrical Paradigm on Pregnancy and Childbirth ............ 144
Effects During Pregnancy .......................................................................... 144
Effects D uring Childbirth ......................................................................... 148
Effects on the N ew borns ........................................................................... 154
Sum m ary .............................................................................................................. 155

7 CO N CLU SIO N S .................................................................................................. 156

Birth as a Rite of Passage ................................................................................... 157
Role of Rituals ..................................................................................................... 158
Role of M yths ....................................................................................................... 159
The Obstetrical Paradigm: Wonders of Technology/Patriarchy .............. 162
A Technocratic W orld View ................................................................... 162
O bstetrical Paradigm 's Service to Society .............................................. 164
The Midwifery Paradigm: Wonders of Nature ........................................... 167
A H olistic W orld View ............................................................................. 168
Transform ative Possibilities .................................................................... 169
Initial Differences Between Groups of Women ........................................... 175
Research Im plications ........................................................................................ 176
Selection of Pregnancy and Childbirth Caregivers ............................. 176
Im proving O bstetrical Care ...................................................................... 176
Suggestions for Further Research ................................................................... 177
N ature of Em pow erm ent ......................................................................... 177
Effects on M ultiparous W om en ............................................................. 178
Effects on Fathers ....................................................................................... 178

G LO SSA RY .................................................................................................................... 180

REFEREN CES ............................................................................................................... 183

BIO G RA PH ICA L SKETCH ......................................................................................... 189













CHAPTER 1
INTRODUCTION
Pregnancy and childbirth are among the most powerful and
memorable experiences in women's lives. For many women, the birth of their first child heralds a new stage of life, a stage of increasing responsibility and maturity. For some women, pregnancy is an enjoyable time and childbirth is an exciting, agreeable experience that becomes a cherished memory. For others, however, pregnancy is an apprehensive time and childbirth a traumatic experience and a painful memory.

Several factors contribute to these two different experiences of
pregnancy and childbirth. The individual woman's circumstances, such as number of previous pregnancies, personality, age, and general health, constitute some of these factors. For example, women who had high-risk pregnancies or who have major complications during labor or delivery are likely to report that their experiences were negative. Nevertheless, individual circumstances do not adequately explain the differences in women's experiences. Women with similar circumstances often have vastly different pregnancy and childbirth experiences.
Several researchers posit that health care professionals may play a large role in determining the effects that pregnancy and childbirth have on women (Berg, Lundgren, Hermansson, & Wahlberg, 1996; Bortin, Alzugaray, Dowd, & Kalman, 1994; Callister, 1995; Kennedy, 1995; Rothman, 1982; Spitzer, 1995; Walker, Hall, & Thomas, 1995). These researchers report that midwifeassisted women are more likely than obstetrician-assisted women to have






2
positive pregnancy and birth experiences. Most midwife-assisted women say that their midwives encouraged them to make important decisions concerning the births, and offered guidance, support, and needed information. These women report that they feel empowered by their pregnancy and childbirth experiences (Berg et al, 1996; Bortin et al, 1994; Callister, 1995; Kennedy, 1995; Rothman, 1982; Spitzer, 1995; Walker et al, 1995).
In contrast, the birth stories of obstetrician-assisted women describe medical and technological interventions about which they had little understanding, and over which they had little or no control (Leavitt, 1986; Martin, 1987; Rothman, 1982; Turkel, 1995). Most reports of obstetricalassisted births, however, are contained in studies that support midwifery, and consist of retrospective stories. Researchers have conducted little research that directly measures the psychological effects of pregnancy and childbirth on women who have obstetricians as caretakers.

Researchers also have not fully explored reasons why midwifery care appears to yield better physical outcomes for mothers and their babies. Several researchers and theorists argue that obstetricians and midwives view and interpret pregnancy and childbirth differently (Bortin, et al, 1994; Jordan, 1980; Kennedy, 1995; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). These theorists imply that midwives and obstetricians operate under the assumptions of different world views or "paradigms." The existence and nature of the paradigms, however, have not been empirically determined. Also, researchers have not sufficiently explored what consequences alternate paradigms may have on pregnant and laboring women.








Statement of the Problem

We do not know what makes pregnancy and childbirth a positive experience. Pregnancy and childbirth have the potential to be exciting, positive, and empowering events. No other experience offers comparable outcomes or benefits. First childbirths particularly are significant because they signal the woman's transition to motherhood. Subsequent childbirths are important because they can affirm or increase a women's sense of empowerment. Now that most women in the United States become pregnant only two or three times in their lives, it is especially important that each of these pregnancies and childbirths is a positive and meaningful experience.
Midwifery supporters claim that midwifery care is more satisfying for women than is obstetrical care. This claim lacks definitive support because we have little data on women's experiences with obstetricians. Furthermore, although many empirical studies have shown that midwifery care often leads to better physical health for both the mother and the newborn than does obstetrical care (Fischler & Harvey, 1995; Hafner-Eaton & Pearce, 1994; Harvey, Jarrell, Brant, Stainton, & Rach, 1996; Spitzer, 1995), the reasons for these differences are not addressed in available studies. Apparently midwifery and obstetrical care affect the psychological and physical health of mothers differently, but researchers need to further explore the reasons for these differences.
Theoretical Framework
Obstetricians and midwives may view pregnancy and childbirth
through different paradigms. Paradigms are broad theories through which practitioners in a field view the problems and occurrences in that field. Applied to scientific fields, for example, "the shared paradigm [is] a








fundamental unit for the student of scientific development" (Kuhn, 1970, p. 11). Paradigms influence how a person will define and interpret events.
If obstetricians and midwives work under the assumptions of different paradigms, they will interpret the same information in different ways. For although paradigms are based upon facts, "scientific fact and theory are not categorically separable, except perhaps within a single tradition of normalscientific practice" (Kuhn, 1970, p. 7). Indeed, the interrelationship between facts and paradigms is bi-directional. In one direction, scientific paradigms are built upon empirical facts. In the other direction, scientific paradigms give meaning to empirical facts. Facts are meaningful only when they are interpreted through paradigms and have no "absolute" value or significance outside of a theoretical framework. Furthermore, the same "fact" can be interpreted through several paradigms simultaneously, and therefore it can hold several different meanings at the same time. Kuhn emphasizes the significance that individual experiences have upon the interpretation of facts: "What a man sees depends both upon what he looks at and also upon what his previous visual-conceptual experience has taught him to see" (1970, p. 113). Therefore, if midwives and obstetricians hold differing views of pregnancy and childbirth, they will act differently toward pregnant and laboring women and will propose different ways of dealing with identical pregnancy and childbirth situations.
Midwives and obstetricians expose their clients to their paradigms through actions, words, and education. Pregnant women are likely to internalize their caretakers' pregnancy and childbirth paradigms, since these are the primary views that they are exposed to.
The existence of two paradigms in one field, such as pregnancy and childbirth, does not necessarily mean that one paradigm is "right' and the






5
other "wrong." Not only is meaning not absolute, according to Kuhn, it also is impermanent. What determines the particular interpretation of a fact at any particular moment is the problem that needs to be solved, as well as the paradigm under which the researcher works. As science "progresses," problems and paradigms change, and the meanings of facts that were constructed under the old problems and the old paradigms change as well. Nevertheless, change does not necessarily work toward any specific end. According to Kuhn, "Nothing that has been or will be said makes [science] a process of evolution toward anything" (1970, p. 170-171).
Few would say, however, that both paradigms of pregnancy and childbirth are equally valid. Many feminists believe that the obstetrical paradigm of childbirth is inherently patriarchal and disempowers women (Bortin, et al, 1994; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). These theorists state that obstetricians view pregnant women as being ignorant about their own bodies and their physical and psychological needs. Women therefore need the attention of medical "experts" to survive pregnancy and childbirth. Historically, medical experts have been male, working, albeit unwittingly, to support the traditional patriarchal society. Even though an increasing number of obstetricians are female, they have been trained and operate in the male-constructed obstetrical paradigm of childbirth, and their practices thereby are guided by this paradigm.
In contrast, these same feminist theorists claim that the midwifery paradigm of childbirth rests on a woman-centered model, one of women assisting other women through a natural process (Bortin, et al, 1994; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). In the midwifery model, the pregnant women makes decisions








concerning her body and her pregnancy. If a pregnant woman lacks the necessary information for making informed choices, midwives see it as their responsibility to provide the necessary knowledge, information, and training to the woman.
Purpose of the Study
The purpose of this study is to determine how pregnancy and childbirth caregivers help make pregnancy and childbirth a positive experience for women. To accomplish this purpose, I examined both the obstetrical and midwifery paradigms. I described what happened during prenatal care, pregnancy, and childbirth in both an obstetrical setting and in a midwifery setting, and developed explanations of the paradigms. I also interpreted the paradigms through a feminist theoretical framework, tracing the paradigms' effects on the women's feelings of empowerment.
Significance and Limitations of the Study
Researchers and theorists have stated that midwifery care is

psychologically more satisfactory for women and may lead to better physical health for both the mother and the newborn. I conducted this study to identify some of the factors that lead to mothers' satisfaction and beneficial physical outcomes. Health care professionals then can use this information to adjust their practices, and perhaps their paradigms, accordingly. Therefore, this study may benefit both pregnant women and their health care professionals.
Feminist theorists have decried the lack of comprehensive qualitative studies of the midwifery paradigm. There is a corresponding need for studies on the obstetrical paradigm of pregnancy and childbirth. This research explores the midwifery and obstetrical paradigms, and contributes to the








paradigms' theoretical clarity. The research also describes the paradigms' effects on the involved clients.

Furthermore, the results of this study will also add to our
understanding of what empowerment is, and if education works as an empowerment tool. The study may yield insights into the necessary ingredients education has to contain in order to become empowering.
The main limitation of this study is that I could not recruit my
participants until after they became pregnant. I may have obtained valuable information about the participants' pre-pregnancy views of their selves and women if I had interviewed the women before they conceived. A second limitation is that I was not present during the labor and births themselves. Direct observation of the women's interactions with their caretakers during these times may have yielded interesting and useful data.

Organization of the Dissertation
In the first chapter I summarize the problem that I address in the study and describe the theoretical framework of my research. I explain the purpose of the research and explain the significance and limitations of the study. In the second chapter, I review the relevant literature that pertains to the study. This chapter contains three sections, one presenting an overview of the history of childbirth in the United States, another that discusses the literature concerning obstetrical and midwifery paradigms, and a third that summarizes research that compares the relative safety of midwifery and obstetrical births. In the third chapter I explain the ethnographic methodology that I used to gather and analyze data. In chapter four I discuss similarities and differences between the two groups of women. In chapter five I present the midwifery view of childbirth, and in chapter six I present the obstetrical paradigm.






8

Finally, in chapter seven, I present my conclusions, discuss implications of this study, and make suggestions for future research.













CHAPTER 2
REVIEW OF LITERATURE
Introduction
In this literature review, I explain how different paradigms of
pregnancy and childbirth evolved and discuss the ramifications of these views. In doing so, I first briefly review the evolution of pregnancy and childbirth practices in America. I review studies that evaluate the relative safety of midwifery and obstetrical care and discuss the specifics of the current medical and midwifery paradigm. I examine why theorists believe that pregnancy and childbirth are feminist issues. Last, I review two definitions of empowerment most often found in the psychological, educational, medical, and sociological literatures.
The Evolution of Childbirth in America
The biological processes of labor and childbirth have remained the same throughout recorded history. Nevertheless, the social definition of childbirth in America has undergone several changes. Changes have occurred in the following areas: (a) control over labor and births; (b) interventions during labor and birth; and (c) significance of birth for women. In this section, I trace the history of childbirth in America, and explain how changes in the broader society relate to changes in views of childbirth. Colonial Times
Early in United States history, most people viewed birth as a natural

event. Women had their babies at home, with perhaps a midwife or a family doctor in attendance. Women assumed that they could bear labor pain, and






10

knew that if they needed, they could turn to folk remedies for alleviating this pain. Midwives in particular were expert in the use of herbs, exercises, and comfort measures that alleviated the discomforts of pregnancy and helped ensure normal labors and deliveries. Midwives held positions of influence and respect, uncommon for women in early colonial times. Laboring women utilized physicians only in exceptional cases when women or their babies were in danger (Miller, 1979; Mitford, 1992; Starr, 1982).
Birth as a natural occurrence. In the 17th century, and the first half of the 18th century, American colonists viewed childbirth as a normal occurrence, one that needed little medical intervention (Litoff, 1978; Speert, 1980). This view is reflected in the medical literature of the time, which refers to birth as a "natural state" (Oakley, 1984). Perhaps part of the reason why people viewed birth as natural and normal is because it was so common. There were many pregnancies and births in colonial times, as well as many deaths. Speert (1980) explained that "The early Americans tried valiantly to fulfill the Biblical command: 'Be fruitful and multiply. . .' and indeed they responded all too well to the injunction to 'fill the earth,' as the gravestones of the Colonial cemeteries attest" (p. 6). Many colonial men had three or four wives in succession. Families needed to produce children in quantity because the odds of the children surviving to adulthood were not good. It was not uncommon for half of a family's children to die before their parents (Speert, 1980).
Most births in the 1600s and 1700s were social events. When a women went into labor, her female friends came to attend to her and offer support before, during, and after the birth. The women shared childbirth knowledge with one another (Dye, 1986).








Midwives as the norm. Following European traditions, midwives
attended almost all Colonial births, including the three that occurred during the crossing of the Mayflower (Speert, 1980). Midwives lent moral support and encouragement to the laboring women. They offered herbal remedies for pain, but did not engage in the physicians' typical practices of bloodletting and purging (Litoff, 1978).
Physicians attended few births during this period. Physicians were male and were allowed to attend births only in emergencies. Colonists thought it immoral for a man to attend a woman during childbirth. Indeed, if a man played the midwife role during a normal birth, he could face criminal prosecution (Litoff, 1978; Speert, 1980). Even in emergency situations, families often had a hard time finding physicians. Medical care in general was scant in the early colonial period. There were no resident surgeons in the New World until 1630 and many people who provided medical services did so as a secondary job. These physicians had limited ability to help in childbirths (Speert, 1980). Often, physicians would perform drastic surgery only at problematic births, either cutting the women open to save their babies or cutting up the babies in pieces to save the women (Litoff, 1978; Speert, 1980).
The physician situation did not improve until the early 18th century. Government did not establish regulations for doctors until the late 1700s. New York City was the first governmental agency to regulate medical practice, and this did not occur until 1760 (Speert, 1980). In 1775 the total population in the colonies was 2,743,000 with only 3,500 medical practitioners. Of these, only 200 to 400 were licensed. Indeed, only one in ten medical practitioners had any formal medical training. Many physicians were clergymen who practiced medicine only because no trained doctors were available (Speert,






12
1980). These "physicians" used primitive and haphazard methods. Thomas Jefferson stated that the typical physician of his time

substitutes presumption for knolege [sic. From the scanty field of what is known, he launches into the boundless region of what is unknown..
. I have lived myself to see the disciplines of Hoffman, Boerhaave,
Stahl, Cullen, Brown, succeed one another like the shifting figures of a magic lantern, & their fancies, like the dresses of the annual doll-babies
from Paris, becoming, from their novelty, the vogue of the day, and yeilding [sic to the next novelty their ephemeral favor. The patient, treated on the fashionable theory, sometimes gets well in spite of the
medicine. (Blanton, 1931, p. 199)
Women therefore had little reason to trust physicians, even when they had access to them. Most expectant mothers used the services of midwives. Fortunately, most births were normal and did not require a doctor's surgical skills. As a result, midwives were in high demand, and had more power than did most women at the time. Community members respected midwives' knowledge and skills, and midwives served important educational and social functions in the community (Dye, 1986; Litoff, 1978; Speert, 1980).
Some communities were uncomfortable with the amount of influence that midwives wielded. One prominent Boston midwife, Anne Hutchinson, angered community members when she stepped out of the midwifery role and became a spiritual leader. Women came to her for guidance in religious and pregnancy matters. Her unorthodox religious teachings displeased the religious leaders in the community. Tensions grew and finally peaked when Hutchinson presided at the birth of a malformed baby. Her enemies labeled the midwife a witch, excommunicated her from the church, and banished her from the city (Speert, 1980). Hutchinson's experiences illustrate the conflict that colonialists felt, who needed midwifery services but were uncomfortable seeing women wield too much power and influence.








Groundwork laid for change. Although female midwives attended
most births in early Colonial America, this state of affairs began to change in the late Colonial period. The catalyst for this change started in the early 1600s (Litoff, 1978; Miller, 1979; Mitford, 1992). Litoff explains that at this time technological advances in Europe laid the ground for the rise of the obstetrician (at the time known as "male midwives") and the demise of the female midwife:

Probably the single most important event which prepared the way for
the acceptance of midwifery as a science, and, as a consequence, brought about the displacement of [female] midwives, was the development of
the obstetric forceps by the British surgeon, Peter Chamberlen, the Elder, early in the seventeenth century. For almost 100 years, the
Chamberlens kept the forceps a family secret. In order to insure
secrecy, the parturient woman was blindfolded, and the forceps were carried into the lying-in chamber in a large wooden box covered with gilded carvings. Gradually, physicians either bought "the secret" from
the Chamberlens or developed their own versions of the forceps.
Midwives could not afford to buy the forceps nor could they find
physicians who would instruct them in their proper use. (1978, p. 7) Late Colonial and Early National Period
The late 18th century marked a turning point for societal views of childbirth. The number of physicians increased, and obstetricians took advantage of improved training opportunities. In most cases, female midwives were denied access to the new training institutes. Indeed, the presence of poorly trained midwives located in some parts of the United States caused many in the country to doubt the competency of all midwives. Obstetrical opposition to midwives further damaged midwives' reputations. As a result, people's view of physicians began to improve, while their view of midwives deteriorated. Americans correspondingly began to view childbirth as a potentially problematic occurrence that required trained medical attention.








Improved quality of physicians. Beginning in the late 1700s, male
midwives began to improve their technical skills. Physicians established four medical schools in America in the late 1700s, and in two of these schools doctors from England taught formal courses in midwifery. This increase in technological knowledge helped physicians establish obstetrics as a separate medical practice. Some hospitals instituted lying-in wards where obstetricians could work and medical students could gain experience (Speert, 1980). Admissions committees allowed only men to attend these schools. "That meant," Litoff explains,

that women were being systematically excluded from attaining a
medical education at the precise time when knowledge of the scientific
advances in obstetrics would have enabled them to become more
competent midwives. Once this process had begun, it became
increasingly difficult for midwives to keep up with the medical
discoveries of the nineteenth century which eventually brought about
the development of modem obstetrics. (1978, p. 99)

At the same time that male midwives began to acquire favorable
reputations, some people began to question the skills and abilities of female midwives. Midwives lacked consistent government support in education, training, and licensure (Litoff, 1978; Speert, 1980). As a result, the quality of midwives varied greatly. By the late 18th century, midwives had evolved into two distinct groups, "urban" and "traditional." Urban midwives were better trained, and their peers provided supervision. There were enough of these midwives in the cities that they could call on each other's assistance in emergencies. Initially, urban midwives had very good reputations and the social status of minor city officials (Shorter, 1982).
In contrast, geographical conditions and population patterns caused traditional midwives to be isolated from others of their profession. Located in the West, urban areas in the Northeast, and the rural South, these women,








also known as "granny midwives," were often old and poor. They usually had little training and practiced their craft without fully understanding the reasons behind their actions (Shorter, 1982). Many relied on folklore and superstitions. Documented practices of these midwives included: putting coins stolen from a church in the laboring woman's mattress to ease labor pains; placing a sharp ax under the bed to make labor easier; making the laboring woman sneeze by blowing snuff into her nostrils from a hollow turkey quill; and burning the placenta to prevent postpartum hemorrhage (Speert, 1980).
Although these two groups of midwives were very different in their beliefs and practices, the negative image of the traditional midwives affected people's views of midwives in general The conception of midwives as dirty, ignorant, and superstitious took hold in popular imaginations.

Obstetrical opposition also contributed to the decline in midwives' reputations. Some of the early obstetricians welcomed midwives, giving them support rather than opposition. A small number of obstetricians offered courses to midwives, and attempted to elevate their status (Litoff, 1978; Speert, 1980). Most obstetricians, however, viewed midwives as competitors. Obstetricians began to advertise, maintaining that they provided services superior to those of midwives and general practitioners. Nineteenth Century
In the nineteenth century, the public increasingly came to accept physician childbirth attendants. Advances in medical knowledge and technology made it possible for physicians to manipulate births in previously unknown ways. Increasingly, physicians held the view that childbirth is a pathological condition, and the public began to accept this view.








Increase in male attendants at births. By the early 1800s the medical profession was firmly established in the United States (Litoff, 1978; Speert, 1980). Some physicians still argued against male birth attendants, in the name of health, morality and decency. As late as 1848, Samuel Gregory wrote:

The introduction of men into the lying-in chamber, in place of female
attendants, has increased the sufferings and dangers of childbearing
women, and brought multiplied injuries and fatalities upon mothers
and children; it violates the sensible feelings of husbands and wives
and causes an untold amount of domestic misery; the unlimited
intimacy between a numerous profession and the female population
silently and effectually wears away female delicacy and professional
morality, and tends, probably more than any other cause in existence,
to undermine the foundations of public virtue. (1848, p. 1)

Nevertheless, male midwives gained acceptance from enough of the public to command high fees (Litoff, 1978). As prohibitions against males in the birth chamber relaxed and the number of doctors increased, regular physicians started attending more normal births, in order to build up their practices (Litoff, 1978). Most urban affluent women engaged male physicians for their childbirths (Litoff, 1978; Speert, 1980).
Medical birth technology and education increased dramatically during this period. In the middle of the 1800s, European research, techniques, and instruments introduced the scientific method to the United States (Speert, 1980). Physicians designed childbirth interventions to make birth more controllable, safe, and comfortable. In 1808 obstetricians began to use ergot to induce contractions; in the 1820s researchers invented a stethoscope so doctors could use to hear the fetal heartbeat; and in the 1840s physicians began to use ether to anesthetize women during birth. To educate doctors in using this technology, nearly all medical schools included midwifery in their curriculum (Litoff, 1978). At the same time, state laws forbade female midwives from using medical instruments during births (Speert, 1980).








In the 1850s, several events again occurred to help obstetricians
increase their practices. First, in 1850 "demonstrative midwifery" began to obtain widespread acceptance. Hospitals allowed obstetricians to have medical students observe and participate in the births of poor women (Litoff, 1978). This action enabled medical students to gain valuable practice with childbirth. Second, in 1853 physicians gave Queen Victoria chloroform during her labor (Litoff, 1978). This event made anesthesia fashionable among upper-class British and American women. Third, in 1859 the American Medical Association (AMA) recognized obstetrics as a medical specialty (Litoff, 1978). This recognition gave obstetrics greater status and a new security.
The increased status and business that obstetricians received in the
mid-1800s did not result in better survival rates for mothers. Medical schools gave obstetricians only limited training in the 1860s. Most obstetricians did not know basic principles of asepsis and did not wash their hands before attending women. This omission resulted in high rates of puerperal (childbirth) fever. The rate was particularly high in hospitals because obstetricians attended to multiple women in the same day and spread germs to all of their patients. In the early 1870s, the death rate of mothers from sepsis in New York hospitals ranged from 7.1 percent to 10 percent (CassidyBrinn, Hornstein, & Downer, 1984; Speert, 1980).
By the late 1870s, however, physicians in the United States began to learn about and practice antiseptic methods (Speert, 1980). At the end of the 1800s, the total maternal death rate dropped to 15.3 per 100,000 women (Litoff, 1978). During the same period, obstetricians became better organized, founding journals, societies, and associations (Litoff, 1978). In the 1800s the rise in medical technology for childbirth resulted in an increase in the








obstetricians' prestige. Obstetricians were now concerned about generating enough business. In 1898, there was one physician for every one hundred and fifty women of childbearing age. Physicians argued that with this surplus of doctors, the United States no longer needed the services of midwives (Litoff, 1978).
Educational opportunities for midwives. In the mid-1800s, several physicians and midwives worked together to provide better midwifery education. In 1848, they established the Boston Female Medical College. This college was the first in the United Stated to offer formal schooling for female midwives. The college awarded graduates certificates in midwifery (Litoff, 1978).
Women who wanted to study medicine met with opposition from some obstetricians. These obstetricians claimed that female midwives and female physicians lacked the ability to be competent practitioners. The popular view of women in the 1800s was that they were frail, overly emotional, and intellectually inferior. Physicians warned that women who taxed their minds with study took essential energy away from their reproductive organs, and therefore should not take up medicine. Obstetricians also emphasized the dangers of pregnancy and claimed that even with more training, midwives would be unprepared for problems that might occur during childbirth (Litoff, 1978).
Childbirth viewed as pathology. In the late 1800s the prevailing view of childbirth shifted. Previously, people viewed childbirth as a natural occurrence, and women witnessed the births of their friends, relatives, and neighbors. According to Dye, "Nineteenth-century women frequently regarded their own knowledge of birth as equal or even superior to that of physicians" (1986, p. 42). Even obstetricians of the period favored non-








interference and usually let childbirth proceed without unnecessarily intervening (Leavitt & Walton, 1984; Speert, 1980).
In the 1890s, however, obstetricians began to view childbirth as a
pathological condition and argued that even "normal" births were fraught with danger. The following abstract, from a paper read at the 1895 annual session of the Medical and Chirugical1 Faculty of Maryland, reflects this belief:

No matter how naturally or with what comparative ease a woman may
pass through the confinement, she is in all cases a wounded woman,
presenting to us, not only the extremely sensitive and receptive uterine
wound, but numerous tears, contusions, and abrasions of the genital
tract." (Litoff, 1978, p. 22)
The public soon began to view childbirth in similar terms. Middleclass women followed the lead of the upper-class in choosing obstetricians over midwives and regular physicians. Litoff explains that:

By the late nineteenth century, the middle and upper classes were
beginning to embrace the view that childbirth was a disease that could
most properly be controlled by the use of instruments, drugs, and surgery.... The male-midwifery debate was laid to rest once the
medical profession and the public began to accept the idea that
childbirth was a complicated medical specialty requiring the services of
the highly trained physician. (1978, p. 21) Early and Mid-Twentieth Century

The pathological view of childbirth that emerged in the 1800s
continued to gain strength throughout the early to mid-20th century. The rapid technological advances of this period helped to create the increasingly common belief that people could gain mastery over nature. Americans viewed childbirth as yet another problem that could be improved through human intervention. Doctors became more concerned with research generalizations and less concerned with individual circumstances. At the


1Surgical








same time, increasingly fewer people chose to use midwives' noninterventionist services.
Decline in midwife-attended births. The decline in the number of midwife-attended births began in the 1800s and continued throughout the early 1900s. In 1900, midwives attended only 50 percent of all births (Litoff, 1978). Middle- and upper-class white women used physicians in combination with monthly nurses (nurses who assisted the doctor at the births and helped the women with housework for several weeks after the birth). Black women in the South and immigrants in the North used midwives. Most women, regardless of their caregiver, gave birth at home. Only the very wealthy and the very poor women had their babies in hospitals. Upper-class women went to hospitals to have their babies because it had become the "fashionable" thing to do, and they could afford the high cost. Poor women birthed in hospitals because they could not afford to pay birth attendants to come to their homes. Many poor women tried to avoid having their babies in the charity wards of the hospitals, because they viewed hospitals as places of operations, disease, and death (Litoff, 1978).
Immigrants' midwives in the North were different from the granny midwives in the South. The granny midwives at this time were usually ignorant and superstitious (Litoff, 1978). The Northern midwives were usually immigrants themselves. They came from Europe, where midwifeattended births were still the norm. Immigrants sought out these midwives because the midwives had extensive training and spoke the women's native languages. Also, many immigrant groups, especially those from Lithuania and Italy, still believed that men did not belong in the birth chamber (Litoff, 1978).






21
Midwives of all kinds faced mounting barriers in the early 1900s. The percentage of midwife-attended births dropped sharply at this time, sinking from 50 percent in 1900 to 15 percent in 1925 (Litoff, 1978). Many states established regulations and restrictions for midwives, and Massachusetts abolished midwifery altogether (Speert, 1980).
Lack of adequate training facilities was a consistent problem for
midwives at this time. In most places, there was no affordable education available for midwives. The schools that did exist in some cities were expensive and of low quality; some graduates could not even read or write. Critics termed these schools "diploma mills," since any women who paid the high enrollment fee received a diploma (Litoff, 1978). In 1906, the American Medical Association began a rating system for medical schools. This system favored schools for white men and led to the dosing of the few quality medical schools that serviced women and blacks (Litoff, 1978).
Further increases in medical technology also led to a decrease in the rate of midwife-attended births (Miller, 1979; Mitford, 1992; Webster, 1993). Physicians began to routinely use X-rays on pregnant women to obtain precise pelvic measurements. Obstetricians also began to give "Twilight Sleep" to laboring women. Twilight Sleep consisted of a combination injection of morphine, which created a light sleep, and scopolamine, an amnesiac drug. The drugs did not eliminate the pain of childbirth, but freed from the memory of childbirth, the drugs left women with the illusion that they were "asleep" and pain-free during their childbirths (Litoff, 1978; Mitford, 1992; Speert, 1980).
At first, physicians were reluctant to use Twilight Sleep because the drugs could cause injury or death to the women and their babies. Obstetricians, however, argued that the drugs were safe as long as








obstetricians supervised their administration in hospitals (Litoff, 1978). Popular women's magazines such as Delineator, Good Housekeeping, Ladies' Home Journal, and McClures published articles that promoted the Twilight Sleep experience. At the same time, the same women's magazines published anti-midwifery articles. The authors stated that obstetrician-attended hospital births were safer and more comfortable (Dye, 1986; Litoff, 1978).
Physician debate concerning midwives. Between the 1910s and the 1930s, physicians intensified their debate concerning midwives. Midwifery proponents pointed out that Europe, which had high percentages of midwifeattended births, also had much lower maternal and infant mortality rates. Proponents argued that American women and their infants would benefit if the government established comprehensive midwifery training programs and regulations similar to the European model (Litoff, 1978).
Newark and New York were the only two American cities to provide government-sponsored midwifery training programs (Litoff, 1978; Speert, 1980). Established between 1911 and 1916, these programs were free and were well attended by immigrants (Litoff, 1978). Along with basic midwifery training, the schools helped their graduates establish close links with back-up doctors (Speert, 1980). These two cities boasted maternal and infant mortality rates that were significantly lower than the national average (Litoff, 1978).

Many obstetricians still argued vehemently against midwives, claiming that midwives were incompetent. Obstetrics, they said, was too complicated for midwives to understand, even with training (Litoff, 1978). Obstetricians imposed sanctions on physicians who broke rank and supported midwifery. In 1912, for example, a Philadelphian obstetrician established a childbirth clinic for middle-income women. Midwives attended the women for all normal labors, and the obstetrician intervened only in emergency situations.








The clinic reported a very low maternal mortality rate. The medical board accused the physician of a breach of professional ethics because he was serving women who could afford to pay for private doctors. The board decided to suspend his license and close the clinic (Speert, 1980).
Midwifery opponents also believed that obstetrical education would not improve until midwives were eliminated. The poor state of obstetrical education for general practitioners of the time is illustrated in the results of a 1911 survey. Forty-three professors who taught at four-year medical schools across the country replied to the survey. Several of the professors said that they could not perform a c-section. Only 21 had served in lying-in hospitals before teaching. Twenty-nine said that their hospital equipment was inadequate for teaching obstetrics. One-fourth said that their institutions' curriculums did not prepare the "ordinary graduate" to practice obstetrics. The majority of the professors believed that "general practitioners lose as many and possibly more women from puerperal infection than do midwives" (Litoff, 1978, p. 65).
The maternal death rate reflected this inadequate education. In 1913, the death rate was 15.8 per 100,000 (Litoff, 1978). The authors of a 1917 study, titled Maternal Mortality From All Conditions Connected with Childbirth in the United States and Certain Other Countries, explained that "childbirth caused more deaths among women fifteen to forty-four years old than any disease except tuberculosis" (Litoff, 1978, p. 71).
Midwife opponents argued that the reform of obstetrics occasioned the abolition of midwives (Litoff, 1978; Speert, 1980). For example, at the 1914 meeting of the American Association for the Study and Prevention of Infant Mortality, the obstetrician George W. Kosmack maintained that "most medical faculties regarded obstetrics 'as a sort of side issue' because midwives








were allowed to practice an important branch of medicine with a much too brief and unsatisfactory training" (Litoff, 1978, p. 66). At the same meeting, Joseph B. De Lee, the founder of the Chicago Lying-in Hospital, explained that young doctors would not choose to become obstetricians as long as midwives existed because, "if a delivery requires so little brains and skill that a midwife can conduct it, there is not the place for him" (Litoff, 1978, p. 67).

In the 1930s, physicians voiced concerns that midwives were taking clients away from them. Physicians claimed that the midwives' practices made it difficult to command high enough fees, since midwives usually charged less than half of a doctor's fee. The midwives helped the new mother around the house for several days after her birth, making the midwife a better value. Also, obstetricians stated that they needed the poor women who traditionally used midwives to attend lying-in charities instead so that medical students could have a sufficient supply of laboring women for training purposes (Litoff, 1978).
Further barriers for midwives. During the 1920s, several other factors led to a continuing decrease in the rate of midwife-assisted births. Declining birth rates resulted in less work for all childbirth practitioners. Also, by the 1920s all states had established Bureaus of Child Hygiene. These bureaus helped train and regulate midwives and also set standards of practice, often restricting midwifery activities (Litoff, 1978; Speert, 1980). Some state officials supported midwives, while others argued against them (Litoff, 1978).

Interestingly, the introduction of prenatal care by social reformers also contributed to the midwives' demise. Previously, women usually saw their childbirth attendant only during labor. In the 1920s, however, states paid nurses to provide prenatal care to impoverished patients. These nurses








guided the women to hospital births, and many of the prenatal programs developed formal ties with lying-in programs (Dye, 1986).
Interventionist view of childbirth. The obstetrical view of childbirth became increasingly interventionist in the 1920s. Joseph De Lee, a leading Chicago obstetrician, wanted higher standards for obstetricians and argued that birth should be viewed as essentially pathological. De Lee believed that the obstetrician's role should be to make birth as safe and comfortable as possible, through active interventions by the obstetricians. De Lee explained that obstetricians could lessen psychic trauma and physical exhaustion by giving women narcotics and scopolamine during their first stages of labor. Obstetricians could preserve the perineum from injury by performing routine episiotomies. Mother and child would be spared from injury if obstetricians routinely used low forceps in the second stage of labor. Obstetricians who routinely administered drugs that stimulated uterine contractions and who manually extracted placentas would reduce hemorrhage and infection (Dye, 1986).
All of De Lee's suggestions became standard policy in hospitals by the end of the 1920s (Litoff, 1978). Most women readily submitted to these procedures, attracted by the scientific modernity of the methods and the promise of effortless and pain-free childbirths (Dye, 1986; Litoff, 1978; Shorter, 1982; Speert, 1980). Dye explains that once women started allowing obstetricians to take over the entire birth process, the trend became difficult to stop.

Once birth routinely took place in hospitals... few women had the opportunity to participate in births other than their own, and, given
the widespread adoption of general anesthesia, often did not experience
even their own births. As knowledge of birth became monopolized,
birth itself became mystified. (1986, p. 42)








In the 1930s obstetricians had firmly established the interventionist
model of childbirth. The New York Obstetrical Society recommended that all births should occur in hospitals (Litoff, 1978). The rate of cesarean sections rose from 1 percent in the period between 1900 and 1909 to 3.2 percent in period between 1930 and 1939 (Shorter, 1982). The cesarean rate in the 1930s was much higher than that in European maternity hospitals (Litoff, 1978).
Medicine in the United States made great advances after World War II. Previously, medical education focused on anatomy, pathology, bacteriology, and physiology. New technologies switched the focus to biochemistry, biophysics, and psychopathology. When medicine became more technically advanced, the prevailing medical paradigm became more technologically oriented. According to Fox,

[The medical] way of reasoning is primarily scientific in nature. In its ideal-typical form, it entails the application of logical-rational thought to empirical phenomena that are assumed to have a direct or indirect
relationship to health and illness. (1989, p. 50)

The focus of the medical paradigm shifted from the individual to statistics. Medical schools emphasized research aspects of medicine, and students who entered the medical field tended to be more bioscientifically oriented than their predecessors. Students with more biosocial orientationsthose who had "interpersonal service and social science and psychological interests and abilities"--tended to concentrate in the field of psychiatry (Fox, 1989, p. 90).
The establishment of the nurse-midwife. Nurse-midwifery was the only type of midwifery that experienced an increase in demand during the early 20th century. Nurse-midwives initially train as nurses, and then receive graduate degrees in midwifery. In 1925, the graduate nurse Mary Beckenridge established the Hyden Center in the mountains of Kentucky.








Beckenridge had trained as a nurse-midwife in England, and she staffed the center with other British-trained nurse-midwives. Several other nursing centers soon opened, and together they operated as the Frontier Nursing Service (FNS) (Litoff, 1978).
The FNS was successful in reducing maternal and infant mortality rates. The FNS experienced only 11 maternal deaths in its first 10,000 deliveries. The national mortality rate at the time was 36.3 deaths per 10,000 births. This difference in rate is especially significant since

60 percent of deliveries between 1925 and 1954 were conducted in the
home in an extremely poverty-stricken area, where the main mode of
transportation was by horseback, modern facilities and medical
assistance were difficult to attain, and the percentage of high-risk
mothers and infants was great. (Browne & Isaacs, 1976, p. 16)
Nurse-midwives established similar programs in other parts of the
country, such as Madera County, California and several areas of Mississippi, with corresponding decreases in infant mortality rates (Litoff, 1978). In 1929, enough nurse-midwives were practicing that they could create the American Association of Nurse-Midwives. Nevertheless, nurse-midwives still met with opposition from the medical profession. No state government formally recognized nurse-midwives until 1945, when New Mexico allowed licensing. The next state to offer formal recognition was New York, in 1955 (Litoff, 1978).
Even with the establishment of nurse-midwives, the number of
midwife-attended births continued to decline. In 1933 midwives attended more than 14 percent of births. By 1950, midwives attended only 4.5 percent of births, in 1960 they attended 2 percent, and in 1970 they attended 0.5 percent (Speert, 1980).
Late Twentieth Century
The 1960s and 1970s saw social changes in various settings and
situations, including childbirth. Two views of childbirth were present during








these decades. The prevailing view was a continuation of the technological, interventionist perspective that had been building since the 18th century. The other view, held by a minority of Americans, posited that childbirth is a natural, healthy occurrence that usually does not require medical interventions. Feminists were the main proponents of this second view. Along with demanding equal rights, feminists insisted on maintaining control over their bodies.
Feminist views of childbirth never gained widespread acceptance or meaningfully changed the medical interventionist perspective. Nevertheless, because of the feminist influence, beginning in the 1960s and continuing through the 1990s, the conditions under which women experienced medical-based childbirth improved.
Women work for improved childbirth conditions. During the 1960s and 1970s an increasing number of women began to demand more control over their childbirth conditions and began to organize. The International Childbirth Education Association (ICEA), founded in 1960, was the first organization these women created. The ICEA was a consumer group that worked to make childbirth practices more family-centered and less traumatizing for women (Cassidy-Brinn, et al, 1984).
At the time that activists formed the ICEA, routine hospital practices for childbirth included: administering enemas; shaving women's pubic hair; restricting women to bed during labor; insisting on a lithotomy position with the women's feet in stirrups for delivery; not allowing a woman to eat during labor; not allowing family members or friends to remain with the women; chemical stimulation of labor; episiotomies; and separation of the mother and newborn (Cassidy-Brinn, et al, 1984; Litoff, 1978; Shorter, 1982).








Women were also concerned with the increasing rate of obstetrical interventions. In the 1960s the cesarean rate was 6.8 percent. This rate increased dramatically in the 1970s, reaching 12.8 percent by the end of the decade (Shorter, 1982). Women activists were concerned because many studies revealed that the routine use of technology during labor (i.e., episiotomies, the lithotomy position and chemical stimulation of labor) caused more problems than they solved (Cassidy-Brinn, et al, 1984; Mitford, 1992; Rowland-Serdar & Schwartz-Shea, 1991).
The number of childbirth reform organizations multiplied in the 1970s. In 1976, activists founded the American Cesarean Prevention Movement. Other organizations, such as the Association for Childbirth at Home, International (ACHI); Home Oriented Maternity Experience (HOME); and Homebirth, Inc. worked for the revival of lay midwifery and home births (Cassidy-Brinn, et al, 1984; Litoff, 1978). These organizations published newsletters and provided referrals to home-birth practitioners. Some organizations offered home birth courses for parents and midwives (CassidyBrinn, et al, 1984).
The rise in feminism in the 1970s contributed to women's interest in improved childbirth conditions. Modern feminist concerns included the right of women to maintain control over their own bodies and births (Cassidy-Brinn, et al, 1984; Donnison, 1977; Litoff, 1978). Donnison explains why:

Freed from the prudery which inhibited the early feminists, today's
militants take pride in their female functions, and call for the right to
choose how they exercise them. Along with demands for the abolition
of the "double standard" in sexual morality and for adequate
contraception and abortion services, the movement is fighting for more sensitive health care for women--whose problems, whether
physical or emotional, are, they claim, still not properly understood by
a predominantly male medical profession. (1977, p. 197)






30
Several women's rights organizations founded during the 1970s dealt primarily with women's health control issues. For example, in 1973 the Boston Women's Health Collective published the popular book "Our Bodies, Ourselves," which encouraged women to take an active role in their health care. Also in 1973, activists founded Womencare, the first childbirth program that emphasized self-help prenatal care. Womencare's clients had access to their complete medical records and a medical library. Clients conducted most of their own prenatal screening tests, learned how to determine the position of their babies, and listened to their babies' heartbeats. The feminist healthcare workers who staffed the center encouraged women to learn from each other by hosting group meetings where the clients discussed how pregnancy affected their lives. The group helped women consider problems and risk factors in light of their individual lives.
A physician birth attendant conducted prenatal examinations and attended women's births, either at their homes or at a hospital. Female health workers accompanied women to their physician exams. Although the women who went to the center enjoyed the control they had over their pregnancies, they were frustrated that the physician attendant did not give them greater decision-making power during births. After five years of operation, obstetricians who opposed the center managed to have it closed down (Cassidy-Brinn, et al, 1984).
In 1976, several feminists formed MOTHER (Mothers of the Whole Earth Revolt). Ginnie Cassidy and Carol Downer, two of the founders of MOTHER, explain that "MOTHER's position was that mothers, like all workers, have a right to recognition for their labor and they need to be given the tools and supplies to do their work well" (Cassidy-Brinn, et a, 1984, p. 52) MOTHER was concerned about all aspects of motherhood, but focused first on






31
childbirth conditions. Members conducted inspections of hospital maternity wards and publicized unsatisfactory conditions when they found them. The group met with heavy resistance from hospitals, and after one inspection police arrested and jailed group members (Cassidy-Brinn, et al, 1984).
Despite the failure of feminists to create widespread reassessments of childbirth practices, they did contribute to a few childbirth reforms. During the 1970s, several birth attendants started childbirth education programs. Instructors in these programs educated women about the physical processes involved during labor and delivery. They also taught the pregnant women ways of coping with labor pain so that the women could use less anesthesia during their labor and deliveries (Cassidy-Brinn, et al, 1984; Davis-Floyd, 1992). In addition, "prepared" and "natural" childbirth advocates demanded and received some changes in hospital procedures. For example, hospitals began to allow husbands to stay with their laboring wives and discontinued general anesthesia during labor in favor of epidurals (Davis-Floyd, 1992).
Midwifery revival. The childbirth reformers and feminist activists of the 1970s also contributed to a midwifery revival. In 1971, for example, the American College of Obstetricians and Gynecologists, the Nurses Association of the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives issued a joint statement that nursemidwives and obstetric registered nurses may assume responsibility for pregnancy and childbirth care for low-risk women under the direction of a qualified obstetrician-gynecologist (Donnison, 1977; Speert, 1980). In the same year, nurse-midwives established and ran the Santa Cruz Birth Centre in California. In 1974 the center delivered 10 percent of all births in the area (Donnison, 1977).








Nevertheless, midwifery remained a debated issue. The medical
profession and the public were reluctant to endorse nurse-midwives because they confused them with "granny midwives." At the same time, obstetricians argued that there were enough doctors to serve all pregnant women, so midwives were superfluous (Litoff, 1978). In 1974, two states prohibited nurse-midwives and 12 states restricted their practice (Speert, 1980). In 1975, midwives attended only 1 percent of all births in the United States (Litoff, 1978).
In the 1980s broad economic and policy changes started to affect the medical paradigm. Nationwide changes in health insurance forced physicians to become more concerned about cost containment and drastically shortened hospital stays. The growing incidence of malpractice suits, along with the continuing rapid increase in medical technology caused doctors to rely less on clinical observations and depend more on laboratory tests. This shift in priorities resulted in doctors having less personal contact with patients, a trend that had been growing since the 1960s (Fox, 1989).
In the 1980s, bowing to demand from consumers, doctors started
making hospital births appear more homelike (Clarke, 1997; Davis-Floyd, 1992). Many hospitals set up "alternative birth centers" within the hospital building. In these centers, pregnant women are allowed to labor and deliver in the same room. The rooms are private and resemble small hotel rooms. Many of these rooms have fold-out couches where the support partners can rest, and are equipped with televisions and VCRs. The medical equipment is hidden in cupboards (Davis-Floyd, 1992).
Results of changes. Critics of hospital births argue that the changes that occurred in the 1980s and 1990s merely mask the fact that the underlying interventionist view of childbirth has not changed. Women still have not








been given additional control over their labor and births (Cassidy-Brinn, et al,
1984; Davis-Floyd, 1992). Hospital-sponsored childbirth classes teach women
how to have control over their behavior during birth, not control over the

birth itself (Davis-Floyd, 1992). Cassidy-Brinn and her colleagues explain that
even with reforms, basic power relationships have remained the same:

The modern history of childbirth shows that when physicians pushed
out midwives, the concept of an experienced birth attendant aiding a woman in her task of giving birth changed to an all-powerful expert
controlling a medical event. As long as this fundamental power
relationship remains the same, reforms won by childbirth groups will
not have a lasting effect.... As we have seen in the last fifty years,
mothers are no longer knocked out with general anesthetics, but they
are given other equally dangerous drugs and procedures....

To understand why previous reforms have given way to "new
improved" harmful childbirth practices, it is necessary to realize that
childbirth reform efforts in the past have focused on making the birth
experience more humane and natural without restoring the
information and decision-making power to individual women.
Although physicians have been pressured to change, they still retained
the ultimate control. (1984, p. 182)
The number of midwife-attended births in the United States slowly
increased throughout the 1980s and 1990s. In 1980, midwives attended 2.1
percent of births (Litoff, 1978). In 1990, the number rose to 3.9 percent (Center
for Disease Control, 1995). In 1996, midwives attended 6.5 percent of all births

(National Center for Health Statistics, 1998).2 Although the total percentage
of midwife-assisted births has increased, less than 1 percent of all births in
1996 occurred outside hospitals (National Center for Health Statistics, 1998).


2"Undoubtedly the number of births attended by midwives of all kinds is higher. In some states, nurse-midwives mainly work as employees under physicians and the insurance companies pay more for a physician attended birth. In order to receive the largest monetary compensation for births, and because the midwife is "under physician supervision" by law, the birth certificate is completed as though the doctor were attending, even if this was not the case. Additionally, in states where Direct Entry Midwives are not licensed or Direct Entry Midwifery is prohibited, many births either go unreported or are reported as unattended or the category of midwife is absent from the birth certificate." (Source: Yvonne Lapp Cryns (1995) "Midwives and Homebirth." The Compleat Mother Maeazine)








The majority of midwife-assisted births occurred with nurse-midwives in hospitals (Clarke, 1997). Hospitals hired these nurse-midwives to work in their alternative birth centers to lower costs and to reinforce the perception that natural birth was being encouraged. These nurse-midwives operated under the supervision of obstetricians and have to follow hospital regulations.
Births in alternative birth centers remain similar to births in

conventional hospitals (Davis-Floyd, 1992; Rothman, 1986). Women who worked to establish these birth centers contend that the results are disappointing: "It looks like you're getting something, and what you get is a lot of family-centered Cesarean sections" (Davis-Floyd, 1992, p. 185).

Feminists argue that the advent of "prepared" childbirth did little to make the process an empowering experience for women (Davis-Floyd, 1992; Rothman, 1986). The most popular prepared childbirth methods cause laboring women to lose control of their labors and deliveries by dictating one "correct" way to think, visualize, and breathe during labor. Two of the major prepared childbirth methods-Lamaze and Dick-Read-train women to relax and breathe during labor (Mitford, 1992). Another influential method, the Bradley method, trains husbands to "coach" their wives through the childbirth process (Mitford, 1992). The developers of all three prepared childbirth methods are male who, of course, have not had first-hand experience of giving birth. Nonetheless, these theorists specify in great detail what women should feel and how they should act during labor.
In the obstetrical paradigm of childbirth, "natural" childbirth means
that women try to get through labor and delivery without epidurals. Hospital routines, such as inserting IVs during admissions, and continually monitoring the fetal heartbeat, still are followed. Obstetricians also use






35
routine episiotomies, forceps, and other obstetrical interventions during the labor and delivery (Davis-Floyd, 1992).
Robert Mendelsohn, a physician critical of hospital births, cautions:

Don't kid yourself into thinking that birthing rooms made up to look just like a real (motel) bedroom are going to make any big difference.
Once you allow yourself to be lured onto Modem Medicine's turf,
they've got you.... If you're on the doctor's turf, you play by the
doctor's rules. (1979, p. 139).
Rather than decreasing, medical interventions during birth are
increasing. In 1996, doctors used electronic fetal monitoring in 83 percent of births. Doctors used drugs to stimulate and induce labor in 169 births per 1000 in 1996. Both of these rates have risen steadily for seven consecutive years. Also in 1996, obstetricians performed cesarean sections in 20.7 percent of births and forceps or vacuum extraction in 9.4 percent (National Center for Health Statistics, 1998).
Women who want to have control of their labor and births have few options. There are few free-standing birth centers in the United States, and lay midwives, who work independently of obstetrical supervision, still face determined opposition (Davis-Floyd, 1992). As of May 1999, direct-entry midwives (midwives who have not first completed nursing training) are prohibited in nine states. In seven other states they are legal but licensure is unavailable. Further, Medicaid will reimburse direct-entry midwives in only eight states (Midwife Alliance of North America [MANA], 1999).
Relative Safety of Midwifery and Obstetrical Care
I have reviewed the safety literature because safety is a central theme running through the histories of both the midwifery and the medical paradigms. Proponents of each paradigm justify their beliefs and actions by voicing concern for the safety of mothers and their newborns. Many researchers have compared the outcomes of midwife-assisted births to those








of obstetrician-assisted births. Four researchers have reviewed recent comparative studies and found that in all the studies clients of midwives had fewer complications during labor that required obstetrical interventions. Furthermore, the women who had midwife caregivers had babies who were as healthy, or healthier, as those of women who had doctors as caregivers (Fischler & Harvey, 1995; Hafner-Eaton & Pearce, 1994; Harvey, Jarrell, Brant, Stainton, & Rach, 1996; Spitzer, 1995). I found no published studies that conclude that modern midwifery care is detrimental to either mothers or their babies.
One frequent criticism of the studies that compare midwife-assisted births with physician-assisted births is that perhaps only healthy women choose midwife-assisted births. However, in one study researchers found that even women who statistically are at higher risk of developing complications during pregnancy and childbirth and/or having low birth-weight babies may benefit from midwifery care (Fischler & Harvey, 1995). Fischler and Harvey (1995) limited their sample to low-income women and studied pregnancy outcomes at three different types of care providers: (a) certified nursemidwives in a hospital-sponsored, prenatal clinic; (b) certified nursemidwives in private practice; and (c) medical doctors in private practice. They found that, even in this traditionally "higher-risk" group, women who received prenatal services from midwives in private practice had significantly higher birthweight babies than did the women in either of the other two groups.
Another frequent criticism of the comparative studies is that women who choose midwife caregivers may be psychologically and behaviorally different from women who choose physician caregivers. Critics have noted that women who choose to have midwives as caregivers may do so because






37
the women intend to play a more active role in their pregnancies and births and therefore may not be comparable to those women who choose physicians as caregivers (Harvey, et al, 1996). This more active involvement may lead to midwife-assisted women having less problems with their pregnancies and births. Research partially supports this criticism. For example, Callister (1995), found that women who had certified nurse midwives as caregivers participated more actively in decisions concerning childbirth, and put more emphasis on the quality of the birth experience, than the women who had obstetricians as caregivers. The midwife-assisted women had significantly lower rates of epidural anesthesia for pain management, lower levels of reliance on others, and more active participation in childbirth care decisions.

Callister based her findings on women's perceptions after the actual births, however, so it is hard to draw firm conclusions from this research. It is possible that the women's health-care professionals influenced women's beliefs and perceptions of pregnancy and childbirth during prenatal care and childbirth. The validity of this criticism also has been partially addressed by Harvey and her colleagues (1996). In their study, Harvey et al (1996) selected all of their participants from a pool of women who desired to have midwifery care. The researchers then randomly assigned women to midwives or physicians for their prenatal care and delivery. The researchers found that those in the midwife-assisted group had significantly lower obstetrical intervention rates during prenatal care and labor, had shorter hospital stays, and had fewer newborns admitted to the neonatal intensive care unit.

Obstetrician-Assisted Births
The Obstetrical Paradigm
A search of the general academic literature and a separate search of MEDLINE uncovered only two studies that directly assess the obstetrical








perspective on pregnancy and childbirth. In a recent comprehensive study, Robbie Davis-Floyd (1992) interviewed 100 mothers, most of whom had obstetrician-assisted births, and an unidentified number of birth attendants. Davis-Floyd states that the medical model of birth is "technocratic." She explains that the medical paradigm's mechanistic bent is caused by a larger, societal-level paradigm:

As the mechanical model itself became the conceptual factor "unifying
cosmos, society, and self" (Merchant 1983:192) [in the seventeenth
century], the primary responsibility for the human body, a
responsibility that had once belonged to religion, was assigned to the
medical profession. This developing science had taken the mechanical
model as its philosophical foundation and so was much better
equipped than religion to take on the challenging conceptual task of
transforming the organic human body into a machine--a
transformation that was crucial to the development of Western society.
(1992, p. 45).
According to Davis-Floyd, the medical world views the body as a
machine and doctors as technicians. Throughout Western history, however, societies have also viewed women as imperfect and inferior to males. "So," Davis-Floyd explains,

the men who established the idea of the body as a machine also firmly
established the male body as the prototype of this machine. Insofar as it
deviated from the male standard, the female body was regarded as
abnormal, inherently defective, and dangerously under the influence
of nature, which due to its unpredictability and its occasional
monstrosities, was itself regarded as inherently defective and in need of
constant manipulation by men. (1992, p. 51)
As a result, doctors classified birth as untrustworthy and dangerous.
Davis-Floyd lists characteristics of the technocratic model of birth. These include: viewing the world through a male perspective; having a classifying and separating approach; equating bodies with machines; viewing the fetus as separate from the mother; believing in the supremacy of technology; believing that appropriate prenatal care is objective and scientific;








believing that adherence to time charts during labor is essential for safety; maintaining that environmental ambiance is not relevant; viewing labor pain as problematic; seeing cesareans as the first remedy for many problems; and viewing birth as a service that medicine owns and supplies to society. The Medical-Care Experience
Diana Scully (1980) studied the results of the obstetrical paradigm of childbirth through observations and interviews with obstetricians. Scully spent three years observing the obstetrical and gynecological training programs in two hospitals in the mid-1970s. She concluded that gynecologists and obstetricians are actually "miseducated" about women during the course of their professional training. Through their obstetrical socialization experience they come to view women as weak and ignorant and pregnancy and labor as inherently problematic. Scully (1980) states that obstetrical training focuses on the use of obstetrical interventions during labor, and as a result the residents attempt to get as much practice doing these procedures as they can. One of the residents in Scully's study explained,

You have to look for your surgical procedures, you have to go after
patients, because no one is crazy enough to come and say, "Hey, here I am, I want you to operate on me." You have to sometimes convince
the patient that she is really sick, and that she is better off with a
surgical procedure. (1980, p. 122)
Scully also reports that many of the male doctors who choose
gynecological and obstetrical specialties enter the field with negative and condescending attitudes towards women, and obstetrical training supports these attitudes. Some residents in Scully's study, for example, predicted that as obstetricians they would need to act as father figures to many of their patients.








These observations are disturbing and several researchers have
criticized Diana Scully's work for being shallow and biased. One critic states

that

Scully deals with what she saw and heard in a literal, absolutist way.
The ironic, self-mocking connotations of some of the vocabulary that obstetrician-gynecologist residents use and the emblematic and social
control dimensions of their rituals seem to escape her. Even more
striking and significant is the absence in her work of any allusion to the medical uncertainty, moral ambiguity, ethical conflict, and the physical,
psychological, and social stress that are so prominent in the other
studies of socialization in residency. In the end, Scully's book is
principally interesting as an example of the genre it represents: a thinly
empirical, post-1960s, social movement-oriented work of militant
social criticism. (Fox, 1989, p. 124-125)

Midwifery-Assisted Births
The Midwifery Paradigm
Midwifery care provides a distinct alternative to the obstetrical

paradigm (Bortin, Alzugaray, Dowd, & Kalman, 1994; Eakins, 1986; Jordan,
1980; Kennedy, 1995; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer,
1995; Turkel, 1995). Whereas practitioners who view pregnancy and
childbirth from the obstetrical model see the process as inherently
pathological, midwives view the process as natural and healthy. Rothman

explains:

From the perspective of the midwifery model, childbirth is viewed as a
healthy activity and as an important event in the lives of women and
their families. During pregnancy and birth, women require physical
care involving examination and screening, but they also require social
and emotional support and comfort for this personal event.
Throughout pregnancy and birth, midwives act as teachers and guides for pregnant women. In the midwifery model, birth is something that women do, not something that is done to them. The midwifery model
offers a view of childbirth which is woman-centered. Women give
birth, and midwives assist them in doing so. (1982, p. 53)






41

The Midwife Alliance of North America (MANA) (1999) elaborates on the midwifery paradigm in its position statements. MANA emphasizes the view that birth is natural: "Childbirth is a normal physiological process as well as a social event in the life of a woman and her family." MANA states that part of the midwives' job is to educate people about the midwifery paradigm:

Midwives should promote childbirth practices which enhance the
normal physiological process.... [Midwives should] provide
information to women and their families which enhances the
understanding of birth as a normal life process and enables them to
make informed decisions. (1999, paragraph 33)
This view-that women should be educated and then allowed to make decisions concerning their pregnancy and childbirth-is another aspect of the midwifery paradigm. MANA explains that women should make their own decisions because each woman is unique, "each birthing woman has individual needs, and [MANA] ... recognizes her right to select the care provider and setting for birth that best fits those needs" (1999, paragraph 5).
Proponents of the midwifery paradigm do not rule out the use of technology. Instead, they advocate the careful and thoughtful use of interventions when individual circumstances warrant their use. "Intervention in the process and the application of technology are potentially harmful and are therefore only justified when their use can be shown to enhance well being and improve outcome for a particular mother and her baby" (MANA, 1999, paragraph 32). MANA asserts that interventions are often performed unnecessarily, and therefore midwives need to "continuously evaluate intervention and the use of technology in midwifery practice and take measures to avoid unnecessary interference" (1999, paragraph 35).








The final area where the midwifery paradigm differs from the
obstetrical paradigm is in its view of accreditation. Midwives value formal accreditation, as an acknowledgment of the expert knowledge that they possess, and as a method of ensuring quality and consistency of care (MANA, 1999). This value is similar to that of the medical paradigm, which acknowledges the importance of formal credentials. Physicians have to pass the standards of certification boards to obtain licenses to practice. In 1987, MANA established the North American Registry of Midwives (NARM) to administer certification for the credential "Certified Professional Midwife" (North American Registry of Midwives, 1999).
The differences between the two paradigms occur in reference to what the certification agencies deem necessary and acceptable for licensure. The route to medical certification is fixed, but midwives may obtain their CPM through a variety of methods. Midwifery-paradigm supporters maintain that individual women and communities have different needs, and therefore various midwifery practices and experiences are appropriate. NARM explains:

CPM certification validates entry-level knowledge, skills, and
experience vital to responsible midwifery practice. This international certification process encompasses multiple educational routes of entry
including apprenticeship, self-study, private midwifery schools, college- and university- based midwifery programs, and nursemidwifery.

Certification shall not be construed as defining midwifery in its
entirety. NARM acknowledges that midwifery encompasses attributes that defy measurement. NARM intends CPM certification to sanction and build a foundation to support midwives' work while recognizing
that their individuality of practice best reflects the needs of the
communities they serve. (1999, paragraphs 1 and 3)








The Midwifery-Care Experience

All the research that describes the experiences of women who select midwifery care are qualitative studies. For example, Kennedy (1995) interviewed six women who had midwifery care and asked them to describe those experiences. Participants reported that their relationships with their midwives were built on respect, trust, and alliance. These relationships enabled the women to play an active part in determining and directing their pregnancy and birth care. Kennedy concludes that "midwifery is a profession that does not provide care to women, it provides care with women" (1995, pp. 410).
In a larger study, Pamela Eakins (1986) interviewed 76 women about their out-of-hospital births. She found that two types of women were most likely to choose to have out-of-hospital births: those who believed that hospitals are inappropriate or dangerous places to have babies, and those who could not afford hospital stays. Eighty-seven percent of the women who delivered at a free-standing birth center, and 95 percent of the women who delivered at home felt "positive" or "extremely positive" about their births.

In two other studies, researchers examined women's experiences with their midwives during labor and childbirth (Berg, Lundgren, Hermansson, & Wahlberg, 1996; Walker, Hall, & Thomas, 1995). These researchers found that women recalled positive relationships with their midwives. In a Swedish study, the participants said their midwives treated them as individuals and that they had a trusting relationship with their midwives. By providing their clients with a sense of control, the midwives were able to offer appropriate support and guidance (Berg, et a, 1996). Similarly, Walker and her colleagues (1995) found that their participants reported positive midwife-guided birth








experiences and said they felt informed, supported, and in control of their labor and delivery.
In a fourth study, Callister (1995) compared the childbirth experiences of women who had midwives and others who had obstetricians at their hospital births. Callister found that women who had midwives as caregivers were more actively involved in their childbirth care decisions, were less likely to have used epidural anesthesia during the births, and were more likely to report they enjoyed their birth experiences.
Kathleen Turkel's conducted a case study of a free-standing birth center. Her results support the findings of the other studies:

The birth center has created a birth setting with extremely positive
results for the clients it serves. The needs and concerns of the pregnant woman are the focus of care at the center. The nurse-midwives seek to
empower women by providing them with the information they need to make decisions about their own pregnancy, labor and delivery and
by creating an environment in which women have much more
control over their experience than they do in a hospital setting. The
relationship between nurse-midwives and clients is built on equality,
trust, and a shared belief that childbirth is a unique experience for each
woman. (1995, p. 127)
Turkel's findings suggest that education may play a key role in causing pregnant and laboring women to feel empowered.
Childbirth as a Feminist Issue

Many theorists claim that control over pregnancy and childbirth is a feminist issue (Bortin, et al, 1994; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). Several feminist theorists contend that the move from home-based to hospital-based births has shifted the power in the caregiver/receiver relationship from the mother to the physician and has caused pregnant and laboring women to feel powerless and unconnected to the childbirth process (Bortin, et al, 1994; Cassidy-Brinn, et al,






45

1984; Davis-Floyd, 1992; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Mitford, 1992; Rothman, 1982; Spitzer, 1995; Turkel, 1995).
These theorists assert that the large majority of American women who have obstetrician-caretakers do not have control over their pregnant bodies. During pregnancy, physicians decide how much weight a woman will gain, what she should and should not eat and drink, what activity she should and should not do, what medical tests she and her fetus will undergo, where she will have her baby, and even when she will give birth. When the woman is in labor, the physician decides the birth position she will assume, how long she will be in labor, what nourishment she will receive, who may be present, what these attendees may do, and a myriad other decisions (Davis-Floyd, 1992; Jordan, 1980; Rothman, 1982; Turkel, 1995).
According to several theorists, pregnant women have lost control over their bodies because the obstetrical model of childbirth replaced a more natural view of pregnancy and childbirth (Churchill, 1995a; Churchill, 1995b; Jordan, 1980; Leavitt, 1986; Miller, 1979; Rothman, 1982; Spitzer, 1995; Troutt, 1996; Turkel, 1995). According to Rothman,

An analysis of childbirth and the technologies which have come to
define the medical model of birth serves to demonstrate the
interrelationships among authority, technology, and gender. In the
medical model, physicians and technicians not only have the power to define the birth process and to constrain the availability of options, but they also have appropriated the very experience of giving birth. (1982,
p.27),
Many researchers have concluded that the data show that there are
power imbalances between women and their physician caregivers (Churchill, 1995a; Danzinger, 1986; Davis-Floyd, 1992; Oakley, 1984; Troutt, 1996). Churchill, for example, also has suggested that these "differing views have led to a position where medical knowledge and frames of reference are






46
accepted and legitimated by a system that leaves women feeling alienated and dissatisfied with the conduct of delivery" (1995b, p. 32).
Feminist theorists argue that in the midwifery paradigm of childbirth, in contrast, laboring women control their bodies and the birth process (Churchill, 1995a; Churchill, 1995b; Jordan, 1980; Leavitt, 1986; Rothman, 1982; Spitzer, 1995; Troutt, 19%; Turkel, 1995). These theorists imply that the midwifery paradigm leads to greater empowerment for pregnant and laboring women by providing more education and greater choice during pregnancy and childbirth.
Empowerment
Definitions of Empowerment
The concept of empowerment is a central element of liberal feminist theory (Rowland-Serdar & Schwartz-Shea, 1991). Nevertheless, the meaning of empowerment is different for different groups of feminists. Some feminists subscribe to a "traditional" definition of empowerment that is based on traditionally masculine definitions of "power." In that definition, empowermentt is... viewed as both the possession of control, authority, or influence over others and as the help provided to assist a person to gain control over his or her life" (Browne, 1995, p. 359). Underlying this traditional definition of empowerment are the assumptions that empowerment is an individual experience, attained primarily for the benefit of the individual, and that agency, mastery, and control are its central elements (Browne, 1995; Gilbert, 1995; Riger, 1993). For the liberal feminists who subscribe to this traditional definition,

empowerment has meant extending the options of women beyond the
domestic to the public sphere. This focus sought to extend to women
certain "rights" which typically were assumed to be granted to males, or at least white males. The vehicle for such empowerment was legal and








constitutional action: liberal ideals were to be extended to all individuals. (Rowland-Serdar & Schwartz-Shea, 1991, p. 605)

Recently, some feminist theorists have redefined the meaning of power and empowerment. In their new definition, "power and empowerment have been reconceptualized more as a process than a thing" (Browne, 1995, p. 360). In this reconceptualized definition, empowerment does not consist of obtaining concrete ends such as "rights" or "control" and the search for empowerment does not end when these ends are reached. Instead, empowerment consists of individuals continually developing their attitudes and abilities. People who are empowered adopt a world-view where they constantly strive to become more able to control their own lives and to help others to do the same. Hall asserts that

women's empowerment includes both a personal strengthening and enhancement of life chances, and collective participation in efforts to achieve equality of opportunity and equity between different genders,
ethnic groups, social classes, and age groups. It enhances human
potential at individual and social levels of expressions. Empowerment
is an essential starting point and a continuing process for realizing the
ideals of human liberation and freedom for all. (1992, p. 83)
This definition, like the traditional definition, describes empowerment in political terms. Nevertheless, it often is not until women are empowered on a personal level that they can collectively participate in group efforts to pursue and attain social changes on the political level (Hall, 1992). The Empowerment Process
The process of personal empowerment is complex. Just as there are
many definitions of empowerment, there are many explanations concerning how individuals become empowered (Alcoff, 1988; Bell, 1981; Browne, 1995; Gilbert, 1995; Hall, 1992; Ozer & Bandura, 1990; Riger, 1993; Rowland-Serdar & Schwartz-Shea, 1991; Spitzer, 1995). Underlying all of these explanations is






48
the belief that a feeling of competency, or efficacy, is a necessary precondition of empowerment.
Positive beliefs concerning one's efficacy in a particular domain are a product of knowledge and successful experience. The more knowledge people have in a particular domain, the more efficacious they believe they will be in that domain. Additionally, once people are successful in an area, they often feel efficacious. Education helps ensure success, which often leads to a person seeking more information in an area, which in turn leads to greater success.
Proponents of the midwifery model of pregnancy and childbirth propose that the midwife-client interaction empowers pregnant women (Bortin, et al, 1994; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). These researchers explain that the midwives aid women's empowerment by convincing women to trust their own abilities to birth their babies with little or no intervention.
Women who have midwife-assisted births often say that the birth
process itself was an extraordinarily powerful, and empowering, experience. For example, the following quotes from women in Eakin's study are typical of women's reactions to unmedicated, uninterventioned births:

In general, I felt it was the most high, exciting, wonderful time of my life. I was part of the creation of a new being. It's a miracle.... There
was excitement, I don't know, being absolutely, totally alive, every part
of you is alive, keenly. It was so intense. I was happy, I was joyous. I
was crying at different parts. It was just awe. I felt wonderful. I felt
totally alive and wonderful.

Immediately following the birth, I would say I felt ecstasy.... I felt as if
I had been through the most incredible experience and that I would
probably never feel that good again.

After her shoulders were born.... I was just getting extremely eager and happy, getting elated with a sense of euphoria, and [the midwife]






49
said I could reach down and take her under her arms and pull her out and that was just--I can't explain it! I can't put a good enough word on
it! I was so joyful.

It was a peak experience. I felt a real sense of things being right, a lot of
energy, a lot of love, a lot of joy ... on top of the world.., a feeling of
accomplishment.... All was right with the world.

It was pow-er-ful. My labor was powerful. The delivery was-ecstatic.
It was the kind of ecstasy that comes from knowing that you have
something to do with it-but yet you don't.... I was awestruck.

[I felt] power. Is that an emotion? (Eakins, 1986, p. 230-231)
Eakins explains that the women's reactions to their childbirths resulted from empowerment processes:

The great majority of mothers experiencing out-of-hospital deliveries
emerged from the birth experience exalted. They were awed by the
work their bodies had done, and they experienced a surge of selfconfidence and a "newfound respect for all mothers." The women
took their ability to control the situation for granted, which freed them
to become totally involved in giving birth. The result was a sense of mastery, a sense of satisfaction, and the discovery of inner strengths.
(1986, p. 231)
There are undoubtedly many influences that may cause the
empowerment feelings of a new mother. Reactions of friends, relatives, and, perhaps most importantly, the father of the baby, all may effect the mothers' feelings of empowerment. For example, one researcher (May, 1980) has developed a typology of fathers' involvements in their partners' pregnancies. Some fathers are much more involved than others, and the involvement may take different forms. May (1980) found that the degree and type of paternal involvement affects the mothers' experiences of pregnancy and childbirth.
The Need for More Research
There are several limitations to the research that links childbirth and empowerment. First, while researchers claim that midwife-attended births








empower women, they have not clearly defined empowerment or explored the specific reasons for empowering experiences during childbirth. Feminist theorists have studied the relationship between pregnancy and childbirth and have noted that empowerment has not been adequately studied. They have called for "qualitative exploration[s] of childbirth as a process" (Bortin, et al, 1994, p. 14).
A second limitation of the existing literature is that researchers have neglected the prenatal experience. Most researchers have limited their data collection and analysis to labor and childbirth alone (e.g., Berg, et al, 19%; Callister, 1995; Hallsdorsdottir & Karlsdottir, 19%; Walker, et al, 1995). They have not studied the pregnancy experience itself.
A third limitation is that the obstetrical paradigm of childbirth has not been carefully studied or explicated. In all but one study, the researchers have not studied the obstetrical paradigm first-hand. Instead, they asked women to remember their childbirths, in many cases several years after their experiences.
The research studies that focus on women's experiences with
midwifery care are also few in number and limited in focus. Most researchers only examined the outcomes of the midwifery care. Only one study (Turkel, 1995), focuses on the process that the women go through during pregnancy and childbirth. Turkel (1995) is the only researcher who studied women's experiences of the prenatal period. All other researchers interviewed participants only after their babies were born. These researchers could not measure the changes that occurred in the women during their pregnancies. Thus, even though the researchers claim that prenatal care and birth under the guidance of a midwife is an empowering experience, they do not tell us why or how the experience is empowering. If theorists want to claim that






51
midwifery is a feminist practice that strengthens and empowers women, then they need to define empowerment, and show how it is created.

Theorists claim that the midwifery model of childbirth is more
satisfying for women than the obstetrical model. Few researchers explicitly examine the obstetrical paradigm of pregnancy and childbirth from the viewpoint of the practitioners in that paradigm. In order to understand how the midwifery model differs from the obstetrical model, and the effects of the difference, a more complete and clear understanding of the obstetrical model is needed. This study will add to that understanding.













CHAPTER 3
METHODOLOGY
Research Method
Researchers have infrequently studied how perceptions of pregnancy and childbirth help shape the birth experience and women's definitions of empowerment. Therefore, the questions this study asked were exploratory. For this reason, a qualitative methodology was an appropriate methodology for this research project. In qualitative research, in contrast to quantitative or "statistical" research, researchers collect data from small numbers of participants. Qualitative researchers draw from interviews and observations a "thick description" and deep understanding of situations from the participants' points of view.
I was interested in uncovering paradigms, or "ways of perceiving" and therefore I used ethnographic methods in this study. In conducting ethnographic research, researchers look for cultural themes in the data. The study's settings, selection and number of participants, the data collection methods, and the techniques for analyzing the data reflect this study's ethnographic methodology. The two paradigms of childbirth and pregnancy that I study represent different ways that my informants interpret childbirth and pregnancy. I use my data to explain how these paradigms relate to broader societal views.

Settings
I studied the practices and client outcomes at a free-standing birth
center and an obstetrician/ gynecologist's office. There are two birth centers in






53
the city where I conducted this study. The birth center that participated in my study, The Midwife Center, is owned and operated by a certified nursemidwife. The birth center that did not participate in the study, The Birth Building, is owned by a married couple, an obstetrician and a midwife. Women who attend The Birth Building see the midwives for their prenatal care. The women then have the option of having their births in the birth center with the midwives or in a hospital, with the obstetrician in attendance. The Birth Building's staff discourage home births. I chose to base my study in The Midwife Center considering that because it is run solely by midwives, it would present a clearer example of the midwifery paradigm.

The Midwife Center is staffed by the midwife-owner, a second certified nurse-midwife, and a state-licensed midwife. The Center's secretary is careful to schedule the clients' prenatal visits so that each woman has at least one prenatal visit with each midwife. The midwives believe that it is important for each of them to establish a relationship with each woman because the midwives take turns being on call for the births. Also employed at the birth center are several nurses who work as assistants at the births.

The birth center acts as a preceptor to licensed midwifery students.
Frequently, after obtaining permission from the clients, students from a local midwifery school attend prenatal examinations and births at the birth center. Two students attended prenatal visits during the time I conducted my study. Women who receive their prenatal care at the birth center have the option of delivering their babies at the birth center or at home, with a midwife and assistant in attendance at either place.
I had been involved with The Midwife Center before the beginning of my study. Over the course of the ten years prior to my study, I had three children and one miscarriage, and went to The Midwife Center for care for all






54
my pregnancies. Two of my children were born at The Midwife Center, and my last child was born at home, with staff from The Midwife Center assisting. I therefore had a good relationship with the midwives, and they were enthusiastic about participating in my study.
I called several obstetrician offices to find a site for the obstetrical aspect of my study. One obstetrician, Dr. Smith, called me back promptly and readily agreed to participate in my study. The obstetrician is the sole owner and operator of his practice. He provides pregnant women with prenatal care and attends their births. He employs two nurses who assist during prenatal visits. The clients who receive their prenatal care from this obstetrician deliver their babies at a local hospital, with the obstetrician in attendance.

Participants
The study included seven pregnant women, three midwives, an
obstetrician, and six additional individuals who provided services or care for the pregnant women. Four of the women were birth center clients, and three were clients of the obstetrician. I selected clients with similar characteristics: all were between the ages of 20 and 30, were married or living with the baby's father and intending to marry, were pregnant for the first time, had attended at least some college, and were happy that they were pregnant and looking forward to becoming mothers. According to standard medical criteria, all the participants at the beginning of the study were at low risk for developing complications during pregnancy and childbirth. I selected participants to be as homogenous as possible so that I might find differences between the women that emanated from their prenatal care rather than from their individual situations. All the participants were between five to seven months pregnant at the beginning of the study. I chose to limit the study to women who were in at least their second trimester of pregnancy because the risk of miscarriage








is substantially lower after the first trimester. Because I wanted to measure how women's perceptions changed over the course of their pregnancies, I did not include women who were past the seventh month of their pregnancies.

I also conducted interviews with the women's partners. All the partners were between the ages of 20 and 30 and were either working or attending college full-time. All the men were actively involved in the pregnancies, attending at least two prenatal visits, whatever childbirth classes their female partners attended, and the birth itself.
I used different methods to recruit participants. The birth center offers free nutrition and exercise classes to all clients. Many of their clients, especially those that are pregnant for the first time, attend these classes. With the instructor's permission, I attended the classes, explained my study to the women, and asked for volunteers. To partially compensate the women for their time, I offered a small monetary reward ($25.00) to participants. Most of the women in the classes were willing to participate. I had the women fill out short informational forms, and then selected the participants who met the study criteria. Fortunately, most people who attended the classes were experiencing their first pregnancies. Initially, five expectant mothers from the birth center met the criteria and agreed to participate, but I was unable to interview one of the women because of scheduling conflicts, and she was dropped from the study.
The only classes that obstetrician-assisted clients attended were the childbirth classes. The hospital offered these classes to women in their last trimester of pregnancy. These women were too far along in their pregnancies to participate in my study. The obstetrician therefore gave me permission to sit in his waiting room and recruit women as they came in for their prenatal examinations. His office staff assisted by letting me know when likely








candidates would be coming in for their appointments. I approached the women before or after their examinations, explained my study, and asked if they would be willing to participate. If they agreed, I asked them questions to determine whether they met my study criteria. Most of the pregnant women I talked to at the obstetrician's office did not meet my study criteria (it was not their first pregnancy, they were planning on moving before their babies were born, their pregnancies were not low-risk, they were too young or too old, they did not have a stable relationship with the baby's father, or they had not attended at least some college). It was more difficult to find qualified participants at this office, so I offered the women who did qualify a significant amount of money for their participation ($100.00). After visiting the doctor's office ten times, I was able to recruit three women.

Data Collection
I used several qualitative methods to collect data. By using more than one method of data collection, I gained a deeper, more reliable and valid understanding of the study participants' experiences. The methods I used were (a) formal and informal interviewing, (b) observation, (c) artifact review, and (d) photographic self-narrative.
Interviews
Over a seven-month period, I conducted at least five interviews with each pregnant women. For each of these interviews, I developed an interview protocol based on my research questions and findings in the literature. When I developed each succeeding protocol, I used my preliminary data analysis as a guide for additional questions. I used these interview questions as conversational starting points that invited women to tell their stories in their own ways. I conducted a formal interview with the pregnant women at the beginning of the research period and after three of








their prenatal visits. I conducted a formal interview with each woman within one to three weeks after their babies' births. In addition, I interviewed five of the women (four from the birth center, and one from the obstetrician's office) five months after their babies' births. I formally interviewed the women's partners once before the birth of the babies and once afterwards.
I conducted one formal interview with each of the midwives and the obstetrician and spoke with each informally at least three times. In addition, I informally interviewed six individuals who assisted the pregnant women, either by teaching classes or conducting portions of the prenatal visits.

I conducted 38 interviews in person and 20 over the telephone. I audio-taped and transcribed all the interviews I did in person. For the remainder of the interviews, I typed notes into my computer as I conducted the interviews. The typed notes captured as much important information as the transcriptions, although the quotations were shorter. Observations
I attended one prenatal visit with each participant, and several classes offered by the health care professionals. The midwifery practice offered nutrition, exercise, and childbirth classes. I attended all these classes. The obstetrician did not offer any classes of his own, but referred clients to childbirth classes offered by the local hospital. I attended a full set of these classes. During these times, I used an observation methodology (cf. Spradley, 1980). This method consists of the researcher observing interactions of interest to the study and conducting informal interviews, often in the form of conversations, with the participants. The researcher records notes of the situation, both during and immediately after the situation occurs.








Artifact Review
I collected copies of all information that the health care professionals

distributed or made available to the women during prenatal visits and during classes. I obtained 21 handouts and pamphlets from the birth center and 6 from the hospital's childbirth classes. I examined the artifacts for their educational content and for explicit and implicit philosophies of pregnancy and childbirth that they contained. Photographic Self-narrative
I used a photographic self-narrative technique to better measure subtle but empowering effects of childbirth (Ziller, 1990). I provided the participants with cameras and gave them the following written instructions:

I have given you a camera that has 27 exposures. I need you to take
pictures of images that you believe represent womanhood. The
pictures can be of anything you want. Examples of possible pictures
include:
* pictures of people; * pictures of objects; * pictures of scenery;
* pictures of pictures found in magazines, books, etc.; � anything else you believe represents womanhood.
I developed the film and discussed the pictures with the women. I
asked them to explain why they took the pictures and what the images meant to them. I also asked the participants how the photographs reflected their ideas about women.
Initially, I had intended for the women to take two sets of photographs, one during their pregnancies, and one after the birth of their babies. When I asked the women to take the second set of pictures, however, they all said that their views of women had not changed during birth and that the pictures that they took would be identical to the first set. Several of the women also said that the weeks following the births of their babies were hectic and, although






59
they were willing to be interviewed about their births, they did not have the time, energy, or opportunity to take a second set of photographs.

Data Analysis
I entered the interviews, field notes, photographic self-narratives, and descriptions of the artifacts into a computer data base, using FileMaker Pro software. I then analyzed the data according to an ethnographic technique based on Spradley's (1979). The first step in this method is to "decontextualize" each piece of data. To accomplish this, I assigned preliminary classifications to the data as soon as possible after collection and/or transcription. During this analysis, I scrutinized each statement and field note line by line. I then "coded" the data by applying interpretive labels to the sentences and paragraphs. Some of the data applied to more than one domain, and I gave this data multiple codes.
I assigned "subdomain" labels to the data, which clarified how the data fit into the domain. For example, I put the statements that the women made concerning the amount of control that they had over their labors into the domain "Control Over Labor." I then gave each statement a subdomain that more completely described the statement's meaning, such as "doctor determined speed of labor,- or "woman decided when to push."

The analysis process was circular. As I analyzed the data from the first set of interviews, I noted that domains that needed clarification. I worked to clarify these domains in the second set of interviews. As I analyzed the next set of interviews, I further redefined and reorganized the domains. For example, during my first two rounds of interviews, some of the women discussed receiving support from others although I had not asked the women questions about support. I put these comments into the domain "Support from Others." During the next round of interviews, I asked all of the women






60
about the support that they received from others. I put these responses in the "Support from Others" domain, and then assigned subdomains to the data, clarifying who gave the women the support (parents, health care professionals, coworkers, etc.), and what type of support the women received (emotional support, information, etc.).
The next phase was componential analysis. During this phase I examined the contrasts among the data in the different domains. This clarified the relationships among the domains and yielded the organization of the data presentation in the results sections. For example, I looked at the data in the domain "Reason for Selecting Caregiver" and compared the data from the midwife-assisted couples with the data from the obstetrician-assisted couples. The data from the two sets of couples were significantly different, and I discuss these differences in a subsection in Chapter 4.
The final step was theme analysis. I examined the domains for multiple relationships and determined how the different taxonomic categories related to each other. The results of this data analysis guided my research of possible theories for interpreting the data. I conducted a literature search for writings that presented broad cultural frameworks through which my results could be understood. I then applied the theories to my results and developed my conclusions.

Research Bias and Ethics
At the beginning of my study, I was concerned about possible
researcher bias. I knew that research showed that midwife-assisted births were at least as safe, if not safer, than obstetrician-assisted births. I also knew that midwife-assisted natural births could be powerful and exciting.
When it came time for my data analysis, I took precautions to insure that my biases did not unduly effect my data interpretation. I accomplished








this by concentrating on explaining, rather than judging or comparing, each paradigm. For example, to describe the paradigms, I did not look for similarities and differences between the paradigms. Rather, I searched the data for each paradigm separately, and developed two paradigm descriptions that did not include comparisons between them. I discuss further precautions in the "Reliability and Validity" section below.
As a feminist researcher, I was concerned about "using" my subjects. My participants met with me numerous times during their pregnancies and once after their births. Most of the women remarked that they enjoyed having a chance to talk about their pregnancies and caretakers. Still, I made the interview process as easy for them as possible, interviewing them at their homes or other convenient places, and conducting some of the interviews by telephone. I also paid the women for their participation, and bought gifts for their babies.
Another, harder problem to overcome was the urge to offer advice to the women. The women who chose the obstetrician as a caregiver did not appear to be aware of the midwife option. These women also received minimal education from their obstetrician. I was tempted to offer advice several times during the interviews, but I stopped myself. At first, I wondered if it was ethical for me to not give the women potentially helpful information, or share my own childbirth experiences with them. I judged each event separately and concluded that remaining silent would not put the participants in any danger.
I decided not to discuss my births or my beliefs with the women during my study. When I recruited my participants from the birth center, I told the women that I had experienced midwife-assisted births. When participants asked me to give them details about my study I told them that I was studying








the effects of different settings on pregnancy and childbirth. I did not offer advice to the women or make any negative comments about their experiences with their childbirth attendants.

Reliability and Validity
The nature of qualitative research makes it more difficult to establish reliability and validity. In ethnographic research, for example, researchers themselves are the measurement instruments. It may be hard for a researcher to formulate valid results because the researchers' world views and past experiences necessarily effect the research process. Also, because ethnographers enter the field with broad questions to guide their observations, it is hard for them to insure that they are paying attention to the "important" happenings of the culture being studied. It may be difficult for researchers to "objectively" analyze the data and formulate valid conclusions.
It may be hard for a researcher to obtain reliable observations because the phenomena being studied is in constant flux. Ethnographers study people, and people and their cultures constantly change, defining and redefining each other. Another potential problem with reliability is a result of the small sample sizes used in qualitative research. Differences found between groups may be the product of individual variations rather than true group differences.
One way I enhanced both the reliability and validity of the study was by becoming immersed in the field. Ideally, ethnographers should spend a great deal of time in the field, so that they can observe many situations, and find recurring themes. Long-term frequent observations and interviews provide researchers with a wealth of information. Over an eleven-month period, I conducted 58 formal interviews, over 20 informal interviews; and observed 7 prenatal visits and 10 classes.






63

There are several other methods that I used to maximize the validity of my findings. First, I decontextualized the data during early analysis. Removing the specifics (such as the participants' names) from the data helped me concentrate on patterns that could be developed across the data. It is only when the I put the results into domains that I begin to recontextualize the findings, looking for reasons to explain the patterns and the discrepancies in the domains (Spradley, 1979).
Another method I used to insure valid conclusions was that of
triangulation. Triangulation refers to using more than one data source to substantiate any conclusion. I drew on two or three sources to identify each of the paradigms' components. I also used a variety of sources, which are listed and described below.
A third way of maximizing the validity of my research was through the study's presentation. The way that ethnographers present their studies can help readers judge for themselves the reliability and validity of the conclusions. I do this by describing what I, personally, brought to the study. In these first three chapters I discuss my background, world view, and theoretical approach to the issue. I describe the context in which I conducted the research. This allows the reader to better understand variables that may have influenced the results.
Another way that I help readers judge the validity of conclusions was by providing "thick description." Researchers do this by including numerous interview quotes and field note abstracts in their results presentation. I provide thick description throughout the three results chapters.
The final way that I enhanced the validity of this research was by
conducting "member checks" with several of my participants. After the first draft of my conclusions, I called five of my participants and discussed my






64
findings with them. All the participants agreed with my interpretations, and stated that I accurately reported and analyzed their experiences.

In addition to becoming immersed in the field, I maximized the

reliability of my study by ensuring that all the pregnant women were similar in many aspects. I tried to ensure that the only difference between the two groups of women was the health care provider that they chose.

Because of the nature of qualitative research, ethnographers will never be able to state with the same assurance as quantitative researchers that their measuring instruments are reliable and valid. Nevertheless, qualitative researchers can compensate for the subjectivity that permeates all research by taking appropriate precautions.













CHAPTER 4
THE COUPLES
Introduction
Researchers have suggested that there may be psychological and
behavioral differences between women who prefer midwives and women who use obstetricians (Harvey, et al, 1996). These initial variations may cause women to experience childbirth differently. In analyzing the interviews and photographic self-narratives, I noticed several similarities and differences between the two groups in my study. I categorized and analyzed these similarities and differences to see if they helped explain why the two groups selected different caregivers and why the groups had different perceptions of their experiences.
In the following sections, I discuss these similarities and differences in detail. To protect the research participants' confidentiality, I describe the photographs that they took, rather than include the photographs themselves.
The four couples in my study who went to the birth center were: Suzyl and David, Nancy and Christopher, Mary and Steven, and Amanda and Arthur. The three couples in my study who went to the obstetrician's office were: Jane and Charles, Kelly and Mitchell, and Amy and Ronald. All the couples except for Amy and Ronald were married. Amy and Ronald lived together and planned on marrying after their baby's birth. The women's ages were between 20 and 29. All the women worked or attended school during at least the first half of their pregnancies.


1All research participants' names have been changed for the sake of confidentiality.
65








Similarities
The two groups were similar in (a) their reactions to the pregnancies;
(b) physical and emotional changes caused by pregnancy; and (c) some of their views of women.

Reactions to Pregnancy
Four of the couples in my study had planned their pregnancies and were happy at the idea of becoming parents. Two of the midwife-assisted couples and one of the obstetrician-assisted couples had not planned their pregnancies. Once over their initial surprise about their pregnancies, however, these couples were happy at the prospect of becoming parents. Suzy, a midwife-assisted woman, described her initial reaction to the news that she was pregnant:

It was just a state of shock, actually. This was unplanned. We knew
that it was a possibility, but we thought the likelihood was very low....
It was very unreal, for the first.., day and a half to two days. Then it
started to get exciting.
Kelly, an obstetrician-assisted woman, had a similar reaction:

At first it was a little hard because it wasn't planned. So emotionally,
just with school and parents and everything else it was a little hard....
[I was] very surprised.... My whole life was going change, it was going
to be such a big change I didn't really know what to think.
Nancy, another midwife-assisted woman, had not actively planned her pregnancy, either, but was not surprised when it happened.

It wasn't such a shock as I was expecting it to be, actually. I kind of
looked at it and thought, "Yeah, it seems kind of probable." But on the
other hand, up until I took the test I hadn't necessarily been expecting
that it would be positive. So, I guess my subconscious was clued in, but
my conscious hadn't really grasped it yet.
Most of the fathers-in-waiting were less ambivalent about becoming fathers. When I asked Nancy's husband, Christopher, how he felt when he first found out that his wife was pregnant, he said,






67

I was ecstatic. We've wanted ... a child for a while, so it was kind of a
happy surprise. We hadn't really tried, we hadn't said, "Well, if we
start now we can have a child here at this time." We didn't do
anything like that, but when it happened it was a happy surprise. I asked Kelly's husband, Mitchell, the same question:

Janet: How did you feel when you first found out that Kelly was
pregnant?

Mitchell: I was happy.

Janet: Were you surprised?

Mitchell: A little bit.

Janet: What were some of the thoughts that went through your
mind?

Mitchell: Happy and nervous, unsure of what to do.
Only one father-in-waiting, Suzy's husband David, was initially uncertain about becoming a parent:

[I was] very shocked at first. I didn't see it coming. Usually I felt like
[when] something that big [happened] I would have heard something from God. I tried to understand what God's will was. At first, you're
not convinced that it's a good idea.
It did not take David long to decide that he was comfortable with the
pregnancy: "It only took less than a day [for me] to start to realize that it was a good idea. I realized that we'd been talking about it before, and it would be OK, we would prepared for it."
Physical and Emotional Changes
Women in both settings experienced the usual physical and emotional pregnancy-associated turmoils. Two women, one in each setting, had particularly difficult first trimesters. Jane, an obstetrician-assisted woman, stated, "my first three months were very hard. It seemed that I was nauseous and tired all the time." Nancy, a midwife-assisted woman, related similar experiences:






68
[The first trimester] was not easy. I found it really hard to get any work
done, to concentrate at all. I felt queasy. There was a period of two to
three hours in the middle of the day that I didn't feel queasy per se, and I got most of my eating done then. But I could only eat certain things..
I couldn't sleep, I was getting up to go to the bathroom all the time..
It was awful.
All the women in the study noticed an increase in mood swings and emotional irrationality. Suzy, who went to the birth center, explained that during her pregnancy her emotions were

definitely more tumultuous than normal. I broke a glass and went
into tears and was inconsolable for ten minutes. And the whole time, I'm thinking, this is ridiculous, why am I so upset about this glass? It's
just a glass. But I couldn't stop. And once I start crying, I can't stop.
Even if I feel better, I still can't stop.
Nancy, who went to the obstetrician's office, reported being overwhelmed occasionally with uncontrollable emotions.

I feel I get really irritated sometimes, and I feel like I can't control that.
I've seen more drastic mood changes. Like, sometimes I can get really depressed and cry at nothing, and sometimes I can get really irritated, and sometimes I'm fine. Seems like more of the other emotions than
just a normal everyday.

Views of Women
The photographic self-narratives reflected some similarities among the two groups' perceptions of womanhood. I had asked the women to take photographs of objects that they believed represented womanhood. Women in both groups included pictures that represented (a) motherhood, (b) taking care of others, (c) taking care of one's self, (d) relationships, and (e) differences from men.
Motherhood. Not surprisingly, women in both groups took pictures representing motherhood. Suzy, a midwife-assisted woman, explained why she took a picture of a woman playing with a child on a swing set: "Motherhood is a part of being a woman, and it's a part that I'm very






69
sensitive to right now." Amy, an obstetrician-assisted woman, took pictures of a baby because "that's such an important part of my life right now."

Care of others. Women in both groups believed that one of women's roles is to take care of others, especially family members. Amanda, who went to the birth center, took a picture of several food items placed on a table. She explained: "This one with the food--we often think of men as being the "bread-winner" of the family, but it's really the women that provide nourishment and cook, and keep the family strong." Kelly, who went to the obstetrician's office, took a picture of a woman standing in a kitchen, balancing a baby on her hip. The woman is standing in front of a mixing bowl and holding a spoon. Kelly explained that she took this picture because "It seems like we're always busy doing something and taking care of the kids. Cooking, cleaning and everything else, just taking care of our families."

Care of self. Women in both groups agreed that part of being a woman means taking care of one's self. Amanda described one picture that she took, but that did not develop dearly.

I just had a calendar with a box of tampons in front of it, which is a
very practical, obvious thing, but it's a very important part of women's
lives, it's something that we have to [attend to]. [It symbolizes] our reproductive system and taking care of ourselves. So, not the most
glamorous part but definitely [an important part].
Jane took a picture of the care products on her mother's vanity for similar reasons.

I took [a picture] of my mother's vanity, because it's got all of her
makeup and jewelry and a mirror there so she can see herself close-up.
Not that I think that women are vain, but I think those kind of
products are important to most women to take care of themselves.

Relationships. All the women took pictures that represented
relationships. These women believed that concern with relationships is part








of a women's role. The women took pictures showing a variety of relationships, including: (a) with their husbands:

I was taking a picture of this couple down here; just before I took the
picture, they were all snuggled up together, and just as I took the
picture, she turned away .... But they were all snuggled up, watching
ducks swim in the lake .... So, that was just a relationship, a husbandwife relationship; (Suzy)
(b) with their mothers:

This is a picture of my mother. She is... a really interesting person.
We have a really close relationship .... We see each other a lot, and,
especially since I've been pregnant, she gives me a lot of advice; (Amy) and (c) with other family members:

These two pictures are collages of pictures of relatives and their
children. These family relationships are important to me. (Nancy)
Mary did not explicitly discuss relationships as part of womanhood, but she did emphasize the importance of family. Mary explained that she took a picture of her church because "They really teach the importance of families, and the purpose of marriage is so that you can have children, [and you] can have families."
Difference from men. Women from both groups viewed women as having some qualities that are different from men. For example, Amanda took several pictures that represented differences she perceived existing between men and women. Amanda described women as being more (a) sensual and artistic:

This [picture is of] my belly dancing instructors. I... chose them
because I just think of women as being kind of the more sensual and
artistic side of the species. And [they are more] expressive;
(b) concerned with housework:

I [took a picture of] the sink because... [of] the women being the one
that traditionally, or stereotypically, keeps the house in order and keeps
the home going;








(c) interested in family history:

This bed was my grandparents' and the medals are my husband's
grandfather's medals, and I chose to put those together because I think
it's usually the women who are the ones that keep the roots of the
family and are the history keepers of the family, more so than men;
(d) patient:

This is a painting that I made, it's called "Patience." ... I think women ... have a great deal of patience. Just in what we have to accomplish in
our lives as mothers and nurturers, we need that patience;
and (e) interested in communication:

This is the phone book, telephone, stamps, and letters because I think the women is often the correspondent in relationships. Like I know I
probably talk to my husband's mother more than he does. And I think that's really pretty common that the women keep the ties between the
family, and keep the communications going.
Jane also took several pictures that she believed represented differences

that exist between men and women. Jane described women as (a) having
different tastes in art:

This picture here I took because my grandmother actually painted that
[painting].... I just thought that it reflected my grandmother's point of
view of appreciating the flowers on the windowsill there, that she had
picked. Those were probably from our backyard, and I just thought that
represented womanhood because it was feminine and well-thoughtout;

(b) interested in collecting things:

That's my Girl Scout uniform from when I was a girl, and ... I thought
that represented womanhood because my mother was a Girl Scout
leader and ... I went to Girl Scout camp and it was obviously
something that a boy couldn't do.... It was just sitting around [during]
... weekly meetings with all the girls. I thought [it] represented
womanhood because we'd [chat] and also ... we had looked forward to getting our patches. I think girls tend to collect things, and we'd try for
our patches and you'd have to do certain things to earn your patches,
and it just seemed like a girl thing to do;
(c) concerned with taking care of the family:








I ... took the [picture of] the iron, because my mother solely does the
ironing in the house.... I've never, ever seen my father iron. My
husband will iron occasionally, but I still think that is very much
considered a woman's job, to iron. I think it represents a woman being
neat, and also... wanting to take care of the family, having them all
look good;

(d) meticulous:

This picture of the sewing machine, I thought.., represented
womanhood because... that's something that's passed on from
woman to woman, and definitely I think that women have sewed
more because.., they are more meticulous and they're more crafty in
that sort of way. Also, I think women tend to have more of those
natural instincts of wanting to clothe their children or their family and
make sure that they have all their buttons and everything;

(e) concerned with family connections:

These are all pictures that my mom has out, and my mom likes to
have lots of pictures, and so do I. I think that's kind of a woman-thing.
She's got her grandkids' [pictures] here.., and I think that's a womanthing, because I think she likes to feel like she's surrounded all the
time by her family. Not that I don't think men care about that, but...
especially with cute baby pictures... maybe my husband.., wouldn't
care as much about [them];
(f) sentimental:

That's the card that I gave my mom for Mother's Day, and I had
[written] a special note in there.... My mother had saved [it] all these
years, I think that's probably about ten years old.... I think that
women tend to be a little more sentimental;

(g) willing to be pampered:

This picture I took of the hot tub in my parent's bathroom is because I
think that women like to be pampered, and this is very much a
feminine thing with the candles and the sense of relaxing and escaping.
When I think of that picture I think of the commercial where [the
slogan is] "Calgon, take me away." It's always a woman that they're showing and maybe she did dishes, or laundry, or worked all day, or
was with the kids all day.... I think that's very much a relaxing,
luxurious pampering thing. That's definitely a woman thing;
(h) concerned with taking care of others:








This picture is of my... mother fixing my sister's hair, and I thought
that was very much something that would represent womanhood,
because it not only shows the mother and daughter relationship, and how close that is, but also how the mother and daughter relationship
tends to be very [concerned with] taking care of each other and I
haven't seen really a father try to [style] a girl's hair. Especially
something like my sister's hair, where it's long and you have to take
care of it. But again, I think it's that taking care of somebody else;

and (i) concerned with their appearances:

This picture I took of my mother's vanity, because it's got all of her
makeup and jewelry and a mirror there so she can see herself dose-up.
Not that I think that women are vain, but I think those kind of
products are important to most women to take care of themselves and
they like to see how they look and take the time to do their hair and
make-up. She's got nail polish here and everything, and I just thought that when you compare what my father has on his bathroom shelf and
what my mother has, there's definitely a big difference.
Education and career. Women from both groups took pictures
representing education. Kelly took a picture of an undergraduate catalog and
explained, "I took this picture for education, school." Before Kelly became
pregnant she was pursuing an undergraduate degree, and she viewed
education as being part of her definition of "woman." Similarly, Suzy said
that education, as a prerequisite to a career, figured prominently in her

definition of womanhood and identity.

These are my engineering books, which is a very important part of my womanhood. [They represent] my career and my professionalism. I've spent a great deal of time and money on [my education] so far, and it's a part of my identity that I really draw a lot of confidence from, and a lot
of strength.

Differences
I noted several differences between the groups in the areas of: (a)
reasons for choosing their caregivers; (b) amount of information they sought
during their pregnancies; (c) their expectations for childbirth; and (d) some of

their views of women.








Reasons for Choosing Caregivers
Midwife-assisted couples. The couples who chose The Midwife Center
researched and discussed their options for pregnancy and childbirth before

they chose their caregivers. When I asked Amanda why she chose the birth
center, she replied, "I read books on the subject, and we visited hospitals and

birth centers, and decided that this would be best." Nancy gave similar

reasons for choosing the birth center:

I'd been doing some reading up on labor and giving birth and I was brought up with a very, I don't know, maybe not exactly in a hippie
atmosphere, but certainly very relaxed social atmosphere compared to
some other people I've known, and so a midwife seemed like, really,
the obvious choice for how I wanted to have the baby.
The midwife-assisted couples discovered during their research that
birth centers offered a philosophy of pregnancy and childbirth with which

they felt comfortable. Steven explained,

Mary and I... did research on pros and cons between a hospital and a birth center, and we decided to go for the birth center.., just from the
research, things we read.... It was more family-oriented, it seemed
more natural, [birth] wasn't in a... cold hospital with a bed, and steelrimmed everything.
Amanda felt comfortable with the midwives' attitudes towards birth:

During the tour [of The Midwife Center], I asked about the philosophy
of the midwife. I wanted to make sure that they believed in similar
things. I asked lots of questions, because I didn't know what their
normal practices were. In the hospital certain things are always done,
and I wanted to see if [the midwives] had a set of specific things that
they always did.... For example, their beliefs on episiotomy, I didn't
want them to be strict either way, and [the midwife] said what I wanted
to hear.... They also supported my decision on water birth. I'm not
sure if I will have a water birth.., but I want to have that as an option.

The couples discovered that, with a midwife-assisted birth, there would
be less chance of the women undergoing unnecessary medical interventions.








Nancy explained that she was concerned about the increased possibility of
medical interventions that are present with a hospital birth:

I didn't really want to give birth in a hospital. I don't want to deal with
knives or drugs or anything like that.... I just felt more comfortable
in a more homelike environment with midwives, rather than in a
hospital with a man with a knife.
Steven voiced similar concerns:

I'm ... a pre-med student, and I took a class about medical terminology
and in that class you talk about all kinds of medical procedures and
things, and they talk about c-sections. The teacher said-he works with doctors a lot-he said that in recent years they've done more and more c-sections. He said one of the main reasons is because insurance costs
are so high, and doctors have to be able to pay for that, and he said that 50% of all people that are born today are born with [a] c-section, which I
thought was ridiculous, it shouldn't be that way.

I also spoke to my dad later.., and he said that my mother had all of us
by c-section, and he thought that it shouldn't have been that way, that she probably could have had [us] normally if she didn't have them in
the hospital, and so that was probably one of the biggest things that
worried us.
The couples who chose midwifery care were happy with the safety
backup systems employed by The Midwife Center. David explained that the
most important factor that influenced his decision to agree to use a birth
center was "being reassured that they could transfer Suzy to the hospital if

anything happened." Mary gave similar reasons for her choice of birthing

place:

Mary: We wanted to go somewhere we could trust.

Janet: And why did you think you would be able to trust The
Midwife Center?
Mary: Because the people were really, really nice. They had backup systems for anything that can go wrong. They have plans for.., any problems. They're prepared for anything that can
go wrong.








Amanda and Christopher were the only people who had previous experiences with non-hospital births. Amanda had attended the midwifeassisted births of her friends, "Two of my friends had births with midwives, and I was at their births. I was a birthing coach for one of them.... I really liked the type of care and treatment she received." Christopher had experienced non-hospital births in his immediate family.

I'm comfortable with [midwife-assisted births]. I'm very easy-going about it.... My brother was a home birth, my sister started off as a
home birth, so that's pretty normal for me, it's like I didn't have any
real problems with the idea of being in a birth center at all.
The couples in my study cited several reasons for choosing The

Midwife Center over The Birth Building. Insurance factors played a key role in two of the couples' decisions. For example, when I asked Suzy why she chose The Midwife Center, Suzy replied, "Because it's completely covered under [my] insurance." Nancy, who is covered by the same insurance plan as Suzy, elaborated:

The question was, what do we have in [this city], and will the insurance
pay for it? I called the insurance company and said: "What midwives
in [my city] will you cover?" And they said, "Oh, we cover The
Midwife Center." ... There's a hundred dollar deductible and it's in
the [preferred provider] network so they cover 100%. And that was the
main reason for the specific location.
The two remaining midwife-assisted couples chose The Midwife Center because it looked and felt less medically-oriented than The Birth Building. Amanda explained,

I had been at two births at The Birth Building, but I really liked the
midwife who gave the tour [at The Midwife Center] ... and I felt really
comfortable there. It had more of a homey atmosphere. I just really
liked the home feeling of The Midwife Center. Mary also compared the two birthing centers:

I looked at one other birthing center.... I didn't look on the inside [of
The Birth Building], just looking at the outside was enough for me. I






77
didn't like it.... It looked like a doctor's office. It didn't look as homey
as the other one, the one I wanted.... I decided I didn't want to go
there.
Obstetrician-assisted couples. None of the three obstetrician-assisted couples considered options outside of obstetrical care and hospital births. They also did not mention knowing women who had chosen midwives as caregivers. The obstetrician-assisted couples did not research different options or consider whether the obstetrical paradigm matched their own views. When I asked why they chose their particular caregiver, they did not offer reasons for choosing an obstetrician over a midwife. Instead, they explained why they chose their particular obstetrician.
Each couple had a different reason for selecting their obstetrician, Dr. Smith. Amy chose him because of his reputation among her friends.

I had heard a lot of good things about him. [I heard that] he was really
easy to talk to; really fun, and understanding. There was one other
[doctor] who I had heard about.. . but I had just heard more good
things about [Dr. Smith].
When Kelly discovered that she was pregnant, she was living in a
different city than her husband, Mitchell. Kelly and Mitchell decided to have the baby in the city where Mitchell was living, and it was up to Mitchell to make the initial obstetrical appointment. Mitchell described the randomness in his selection of Dr. Smith.

Janet: Why did you choose Dr. Smith?

Mitchell: I just called people in the phone book, actually.

Janet: And why did you choose him?

Mitchell: Actually, because Kelly was in [another city] at the time,
going to school down there, and it was the only
[obstetrician's office] I could get her into when I could get her
up here.








Jane and her husband, Charles, also knew nothing about Dr. Smith
when they chose him. Jane explained that she had no choice in her selection of doctors:

My insurance company gave him as my only choice. We have military
insurance, and not many doctors accept it. Initially, I was going to a
different ob/gyn practice, but they stopped accepting my insurance and
they dropped me.... It wasn't really a choice. Amount of Information Sought
Written information. All the women in my study read at least one book about pregnancy and labor. Most of the women read several books. Obstetrician-assisted Amy, for example, said that she had "gotten a lot of books, and read a lot about pregnancy and birth." Midwife-assisted Amanda claimed, "I have everything, and I've read everything."
The midwife-assisted women, however, were the only ones who
mentioned spending time actively researching specific topics and problems that arose during their pregnancies. Nancy explained that whenever she had a question or concern, she would research the topic.

My parents sent me all the books they had and I went to the Friends of
the Library book sale and picked up a whole stack of books, and we go to the bookstore and the library and read up on a bunch of stuff. So, I
get a sense of what the general consensus is.
Amanda actively sought information on things that might help her
during labor and delivery: "I've been researching water births, and from what I've been reading it seems that laboring in the tub helps labor." Suzy, who has asthma, said that the results of her research agreed with the advice that the midwives gave her. "[They told me to] continue taking my medication, which is the same thing that I found when I researched it on the Internet."
Information from others. When the obstetrician-assisted women
discussed pregnancy and childbirth with others, they usually received only






79
birth stories from other women. The type of information that Amy received from others was not reassuring:

My mother gives me advice, she had three children. She said that birth will be painful. My mother said that I should definitely do an epidural.
... My coworker had natural childbirth.., because her doctor didn't
believe in using pain medicine.... She didn't have a positive time....
There were complications, and they had to use forceps. When they
were using the forceps, and they pulled baby out, the forceps broke her
tailbone, and she had to lie on her stomach for three months.
The midwife-assisted women received more helpful advice. For example, Nancy explained how her parents helped her find information.

If I have any questions, I email my mother and she does a search on
Medline and tells me things.... My mother's a biochemist and she's
really interested in all this kind of thing. Every time I have a question I
send her an email and she sends me back references and journal
articles and abstracts and things.
Childbirth classes. The midwife-assisted women were more likely to attend classes relating to pregnancy and childbirth. All of the midwifeassisted women in my study attended the exercise, nutrition, and childbirth classes offered at The Midwife Center. Only one of the obstetrician-assisted women, Jane, attended the childbirth classes offered at the hospital. Expectations for Childbirth
The couples who had obstetrician-assisted births had different
expectations for their childbirth experiences than did the midwife-assisted couples. The two groups had different beliefs about their ability to handle labor pain, they wanted different amounts of control over the process, and they had different views of medical interventions.
Ability to handle labor pain. All of the women thought that childbirth would be painful. Jane stated,

Last night [during a childbirth class] we saw a movie where a person delivered a baby. Watching her give birth really freaked me out and






80
scared me. I have a very low tolerance for pain.... I plan on definitely
having an epidural.
Nancy worried about the pain as well:

It did hit me, a week ago, that I'm pregnant enough now that my belly is reaching out a little, and there's definitely something in there that is
not small. And no matter what happens, it's going to be painful.
Women going to The Midwife Center, however, believed that they
would be able to handle the pain. These women knew that the birth center's staff would not offer them pain-killers during their labors. Nevertheless, the midwife-assisted women trusted that the midwives would teach them how to handle the pain.
Only one obstetrician-assisted woman, Amy, stated that she would try to labor without pain-killers: "I feel that natural is the way it's supposed to be done. It's a natural way of feeling the birth rather than having scientific medicine pumping through your veins." Nevertheless, Amy was not confident in her ability to control the pain: "I want to try to go natural, but I also want anesthesia there just in case I can't handle it."
Desire for control. One difference was in the amount of control that the women wanted to have over their labors and deliveries. The midwifeassisted women wanted to have a good deal of control over their childbirths. Nancy explained: "That's another reason why I'm comfortable being [at the birth center], because I have more control over what goes on, and I am taking the responsibility for learning enough about what's going on that I can make informed decisions."
The obstetrician-assisted women, on the other hand, were not as
concerned about having control. Amy explained that she trusted her doctor to make any necessary decisions: "I have faith, and my doctor, if something does seem like it will go wrong, he will make the right decision about doing a








c-section or anything else." Jane said that she expected her obstetrician to be in charge of the childbirth, and would be upset if he relinquished his responsibilities.

There were a couple of things that were irritating [in the book given at
the childbirth classes] .... Women were explaining their labors, and
one women said that she delivered her baby by herself; the doctor said that she could just grab down and pull out the head herself. I'm all for
having some experience, but if my doctor's there, he's going to do his
job. I don't need a mirror to experience all of this. If my doctor said [to
deliver my baby myself], I would be upset. If he can't do that for me,
then why do I have him there?
Acceptance of medical interventions. The obstetrician-assisted women were more willing to have medical interventions. They were all happy to have three routine sonograms performed during their pregnancies, and they were all open to having episiotomies and epidurals. Charles explained that he and Jane had no qualms about medically inducing the labor to control the baby's size. Two weeks before Jane's due date, Charles stated:

This is the time when [babies] gain a lot of weight, and [Janel has a
small stature so she doesn't want the baby to be too big. So if we don't
see any marked improvement, like say at 40 weeks, I want to find out..
. if we can induce [the labor] and not go too far with the term. Views of Women
As discussed above, there were some similarities between the two groups' views of women, as reflected in the photographic self-narratives. Nevertheless, there were some important differences as well. These differences occurred in the areas of: (a) sacrifices of motherhood, (b) concern with appearance, and (c) similarities to men.
Sacrifices of motherhood. Only the midwife-assisted women took pictures that represented the sacrifices that motherhood demands. For example, Mary took a picture of her reflection in the mirror. She explained, "This is the first picture I've allowed of myself, with my belly.... I just think








of motherhood as a sacrifice of the body." Mary's view that pregnancy is detrimental to physical appearance was shared by Suzy. Suzy had taken a picture of her wedding and engagement pictures, and explained that, "I look at those pictures to remind me of what I want to look like, instead of what's in the mirror right now. That's the conception of myself I like to have."

Midwife-assisted women believed that they sacrificed their comfort to become mothers. Nancy took a picture of her bathroom and explained that:

I was spending far more time in the bathroom than ever before. I had
no idea early pregnancy was so much like having the flu. I had no idea middle pregnancy involved getting up to go the bathroom every two to
four hours. I'm spending a lot of time in the bathroom.
Nancy also took a picture of her sleeping area to symbolize the discomforts of pregnancy.

This one over here, with pillows everywhere, [represents] just the
whole learning not to lie on one's back while sleeping combined with
not being able to lie on one's front because the breasts are really sore
and the stomach's all queasy and all the rest of it.... That's the main focus of this picture, is just wanting to spend as much time as possible lying down and feeling horrible. And now, again, I'm spending more
time in bed because I'm having trouble sleeping because the kid's
kicking me all the time.
Other sacrifices mentioned by Mary included that of time and tastes. Mary took a picture of a clock because "I also think of womanhood/motherhood as a sacrifice of time, that's why it's a picture of a dock." She took a picture of two cars because "This was kind of a statement about how interest in cars [changes], showing the nice, beautiful, red [sports] car; and the big family car, the ugly family car."
Concern with appearance. Obstetrician-assisted women were the only ones who took pictures that represented a concern with manipulating their outward appearance. Their concern with appearance was different from the midwife-assisted women's belief that part of womanhood means sacrificing






83
one's body. The midwife-assisted women acknowledged that, although they might not like it, changes in body shape are part of being a woman. In contrast, the obstetrician-assisted women believed that being a woman meant purposefully camouflaging and changing the body. This view is apparent in the above quote, where Jane describes how women are more concerned than men with their appearance. Kelly also exhibited this view. She took a picture of a makeup collection and a picture of a woman exercising. Kelly explained how these pictures reflected her ideas of womanhood:

This [picture] with all the makeup is [because] when everybody thinks
of a woman we always have to go out of our way to dress ourselves up.
That's the first thing you that you think about, really. I took this one,
the woman working out... [because] like the makeup, in our country
we really put an emphasis on beautiful woman.

Similarities to men. Only midwife-assisted women discussed attributes that they thought women and men held in common. For example, Mary believed that being a parent is part of being a mother, and to represent this she took a picture of a father with his children.
Amanda took a picture of a painted ceramic chameleon and stated that some of the characteristics that define "women" are really characteristics of people in general: "The chameleon is just to show that we're always changing and growing, like the chameleon can change colors and things. I think all people--not just women, either, but men too--are just constantly changing and growing."
Midwife-assisted woman also believed that responsibility for
household maintenance was a characteristic common to both sexes. Suzy took a picture of laundry hanging in a bathroom and explained:

This represents my household responsibilities, which consist of
cleaning the bathroom and doing the laundry. And since I'd just gotten laundry, I got them both in one shot.... I do have other
household responsibilities, although those are my two main ones.






84
Suzy's husband took care of the other household chores, such as washing the dishes.
Women as strong. Only midwife-assisted women described strength as a characteristic of women. Suzy described a picture that she would have liked to have taken, but could not because she did not have her camera with her:

There's a lab in my [school] building, where they test concrete and test
steel and ... they were testing this huge concrete slab. And it's like
twelve feet up in the air. And there was a girl sitting on top of it. A
girl from our department, sitting on the concrete, twelve feet up in the
air, with her steel-toed boots on, and that was just a great picture.
Nancy could not find anything to take a picture of that represented her idea of women's strengths, but she discussed how she was raised with the belief that women are strong and capable.

My grandmother, when my dad was growing up in the 50s and 60s, ran
her own secretarial business; she supported herself and two kids. My mother's a biochemist, and a professor at a university. My aunt has a Ph.D. in mathematics and works for a computer firm. The women in my family generally are pretty self-sufficient and do whatever the hell
they want to do.

Summary
The two groups of couples were alike in many ways. All the women were happy that they were pregnant, and some women in each group endured difficult physical and emotional changes during pregnancy. The groups held some views of women in common, believing that motherhood, taking care of others, taking care of one's self, relationships, and differences from men are all important parts of being a woman. I had selected participants who were similar in several demographic categories, and this may explain why the groups exhibited several similarities.

Nevertheless, I also found significant differences between the two groups. Midwife-assisted women were more careful in selecting their pregnancy and childbirth caregivers, researching their options and touring






85
facilities before they made their choices. They also sought information more aggressively during their pregnancies, were more confident that they could handle labor pains, and wanted control over their labors.

Obstetrician-assisted women were more accepting of medical
interventions and some of their views of women differed from those held by the midwife-assisted women. The obstetrician-assisted women put less emphasis on the sacrifices of motherhood; they believed that women were concerned with manipulating their outward appearance; they did not discuss similarities between women and men; and they did not state that strength is an important characteristic of women.
These differences may indicate that the two groups of women in my
study began pregnancy with different needs and beliefs. Their differences may also have affected the women's interpretations of the significance of their childbirths.













CHAPTER 5
THE MIDWIFERY VIEW OF PREGNANCY AND CHILDBIRTH
The greatest joy is to become a mother; the second greatest is to be a midwife.
- Old Norwegian Proverb
Introduction
Norm paradigms are "taken for granted" in this culture and are thus
self-justifying. In the United States at the present time, most people adopt the obstetrical paradigm and view the midwifery paradigm as a deviation from that norm. The medical paradigm does not explain itself, because it seldom has to. The medical paradigm has explicit methods and an implicit philosophy.
The explanation of alternatives to the taken-for-granted norm
generally includes a clear philosophy statement, an explanation of the norm paradigm, and an effort to delegitimate this norm with anecdotes describing problems with the norm. Midwives are aware that their practice is relegated by many to the edges of the mainstream. Midwives therefore have had to insure that their philosophy is well-formulated and easily explained. Midwives consciously reflect upon their paradigm and explicitly teach it to their clients, taking care to differentiate it from the medical paradigm and give it a privileged position.

The Midwives
The midwives that I interviewed had carefully constructed views of pregnancy and childbirth. In fact, they all had chosen the midwifery








profession precisely because they agreed with its philosophy. Barbara1

explained:

I was a nurse and became attracted to OB during nursing school.... I
went into [psychiatric] nursing and then eventually got into OB when I
knew I really wanted to pursue midwifery. I had been a nurse for
several years and [midwifery] just became my focus. So I worked in labor and delivery and I never really had a medical OB bent. It was
more the midwifery kind of angle right from the beginning. So I was reading and studying and getting the experience by working as a labor
and delivery nurse and then went to midwifery school.
Barbara, a mother of four, was attracted to the midwifery view because
she had negative personal experiences with some medical births. Barbara
learned through these experiences that it is the setting under which a birth
occurs, rather than the ease or difficulty of the birth itself, that determines
how a woman will subjectively experience the birth:

From my own experiences as a woman and as a mother, I had positive experiences and I had negative experiences [of birth] and none of them
depended on the medical risks or outcomes of the births. I had as my
most traumatic birth a normal vaginal delivery that was screwed up by
hospital procedures and policies. It had a normal outcome but it was
very traumatic and is actually what really led me into midwifery.... It made me realize that none of those things needed to happen.... It was
only because of hospital procedures that negative things occurred. I had a placenta previa with a different child, and that's a real medical
emergency and I was hemorrhaging, it was a c-section, it was
premature, it had all the earmarks of... trauma, but it was nowhere
near as traumatic for me emotionally or just even as a whole than the
botched normal birth was.
Liza, who was born and raised in England, was convinced at an early
age that home birth was a safe alternative to the medical model.

My first memory as a child is of being twenty-two months old, standing
outside the bedroom door in my grandparents' house, my father
behind me, my ear glued to the door, waiting to hear the baby cry when

1Throughout this dissertation, I use pseudonames for the midwives' first names and the obstetrician's title and last name. This reflects the way that the clients and the office staffs address the health care professionals. It also reflects the nature of the interactions between the health care professionals and their clients.








my sister was born. I was allowed in immediately and held the baby...
We were allowed.., in even before the placenta even delivered, and
the baby was just wrapped in the first receiving blanket. So, indelibly
in my mind, was this [idea] that babies could be safely born at home,
and that that was part of my experience.
Liza became a midwife because she could not find an acceptable
caregiver for her own first pregnancy, and wanted to ensure that more
women have the opportunity to have a midwife present at their childbirths.

When I was looking for care when I was pregnant with my first child, I
had come from England to America and I was in this rural area, so I went to the health department and walked in and announced that I
was there for prenatal care and to make arrangements to see the
midwife for a home-birth. This was 1974 [and] they all just kind of
looked at me, and their mouths dropped open and they laughed, and
they said, "Oh, no no no, honey, we don't do it like that here." And
then I found out how they did do it... here. And birth was extremely medical. Fathers were not allowed in the delivery room at that time...
Your arms and legs were restrained on the delivery table. The baby
went to the nursery for a full 24 hours, [and there was] no breastfeeding.... It was so different from what I had expected and what I had
anticipated that I started looking for a midwife and found out that
there weren't any available.

As I looked, and as I read more and as I studied what to expect from
birth and what to expect from pregnancy, the more I became convinced
that what I wanted to do was to be a midwife. It took me twelve years
to start training for the midwifery degree from that time on, during
which time I had three more babies. And, by the way, I didn't go to the hospital with that [first] baby. My husband and I stayed home and had her on our own.... We just really couldn't find anybody for the first
one.
Judy also saw problems with the medical view of pregnancy and
childbirth and therefore decided to pursue midwifery:

I was an OB nurse for several years in three different hospitals and
became very frustrated with the kind of maternity care women were
getting. Women were victims of their caregivers instead of being
served by them. And the OBs were very brutal in the 70s and early 80s.

Also, there was a tremendous movement towards alternative birth at
that time and I became very interested in home birth and I really
wanted to learn more so I could help my friends deliver at home. It






89
was what I wanted to do when I went to school--do home births. I like what I'm doing now. I like giving women the alternative to having a
medicalized birth.

The Paradigm
The midwifery paradigm is different from the medical paradigm, and midwives educate their clients about these differences. For example, during the first childbirth class at The Midwife Center, Sandra, the instructor, asked the couples present, "Why did you choose the birth center?" After obtaining several responses, Sandra explained that she felt strongly that women who are pregnant, especially those pregnant for the first time, should know the difference between a hospital birth and a birth center birth.

People who go to the hospital are no different than people who go
here, but the hospitals have a much higher c-section rate. I want you all to understand what are we doing that's different here, and why are
we doing it this way.
Sandra went to a marker board and wrote down the beliefs that underlie the midwifery viewpoint:

" Nature/God directs birth.
" Women's bodies are normal/Birth is normal/healthy.
* Women give birth.
" Women's wishes.
" Family is important.
" Pain is part of being human and OK.
Sandra explicated the midwifery paradigm. I found evidence of these components in my interviews and observations, and I discuss each of these components below. I found three other paradigm components in my interview data: (a) It is important for the midwives to have good personal relationships with the women, (b) Women need to be emotionally prepared for childbirth, and (c) Birth should an empowering experience for women. The midwives and their clients repeated these paradigm components throughout my study and especially during childbirth classes.








Nature / God Directs Birth
The midwifery paradigm includes the belief that birth is a natural
process, directed by a natural force. Sandra explained that there are various names for the power that directs birth, including "God" and "Nature." No matter what name the power is given, however, the concept remains the same--except in unusual circumstances, the power enables women to have healthy births with little or no intervention. The act of intervention is more likely to interfere with the process than assist it. Sandra explained: "Humans can't control birth without messing it up." Sandra said the error of the medical model is that it tries to control what is a natural process. Unnecessary medical interventions may be, and often are, dangerous. Barbara asserted that, "For low-risk, healthy women, a lot of the procedures that are routine in the hospitals can have negative effects as well as helpful effects." During a childbirth class, Sandra illustrated the danger of intervention with the following story.

A woman that I knew who had her baby in the hospital pushed her baby from 10 in the morning.... They did a C-section at 3:30. There
were better positions that she could have gotten into to push the baby
out [but she could not because they had administered] drugs.... An
epidural equals no feeling, and how can you push a baby out if you
have no feeling?
Sandra then explained some of the differences between the procedures that the midwives use during births and the procedures used in hospital births.

Here we do intermittent monitoring of the fetal heartbeat with a [handheld Doppler stethoscope].... At the hospital, they use electronic fetal
monitoring. The woman lies in bed, gets a 3-inch thick elastic belt with
a Doppler device strapped around her stomach, and there's a huge
machine beside her blipping out the heartbeat and measuring
contractions. No study has ever proven it to result in better outcomes for the baby, and the use of it has resulted in 316% more C-sections....
Hospital procedures ... create a disaster out of normality.








The midwives do not rule out the use of medical technology altogether. They do recommend the use of it when warranted by the individual case. Barbara stated, "We're not anti-technology, we're for the appropriate use of technology." Sandra explained to the class that pitocin creates strong and frequent uterine contractions, which can be hard on the baby and difficult for a laboring woman to endure. Sandra explained that epidurals are problematic because they may slow down labor, eliminate the pushing urge, and cause sluggish babies. Nevertheless, she also stated, "There is no one [intervention] that is in and of itself bad. An epidural may be a godsend that makes it possible for you to have a vaginal birth rather than a csection."
The midwives in my study used medical technology when they
thought that it was necessary. For example, they suggested that Nancy should get an ultrasound during her pregnancy. The midwives do not routinely use ultrasounds. They made their recommendation because they believed that it was advisable in this particular situation.

My cycles are generally long. I mean, I don't think in my life I've had a
cycle shorter than thirty days.... So, everyone I've talked to [says],
"Yeah, you'll probably go long, first baby, you know, takes longer... [it
will] probably [be] a week or two late." I'm like, "Okay, I can handle
that." And then at the last [prenatal the midwife said], "Oh, that's funny, I would have thought [you'd deliver] a week early." Just in passing. I'm like, "Wait a minute." I expect that it was because the
uterus was a bit bigger than would normally be expected.... But we're
going for the ultrasound to make sure of the due date. (Nancy)

The midwives also do not hesitate to transfer women to the hospital if they believe that it is medically necessary. In fact, during a childbirth class, Sandra spent an hour discussing complications of pregnancy and birth that would necessitate transfer to a hospital. She stated that one out of every ten women who have their prenatal care at The Midwife Center end up being








transferred to the hospital for various reasons. After a baby is born, the midwives may also refer a woman to the obstetrician. For example, Nancy pushed out her baby quickly, and in the process acquired a bad tear in her perineum. The midwives decided to send Nancy to the hospital to get her tear stitched.

Liza looked at it and said, "I know I'm not capable of mending that one.
I'm going to call Barbara and find out what she thinks." So... Barbara
showed up and did the examination and said, "Oh, this is a thirddegree tear. We're going to send you off to Dr. Brown." Women's Bodies are Normal/Birth is Normal/Healthy

Insurance companies often state in their policies that they provide
pregnancy benefits, "as for any other illness."2 Such statements could convey that pregnancy and childbirth potentially are harmful. The midwifery paradigm, in contrast, includes the belief that birth is a normal and healthy event. They believe, as Sandra stated during a childbirth class, that "Women are strong and capable. Birth is not a disaster waiting to happen. It works. This is a dramatically different way of perceiving birth-It is a way of perceiving women as strong and capable."
Often, pregnant women have to be convinced that this view of birth is realistic. Barbara explained:

I think for women today, . . physically we're told that we can't have babies without medical intervention or interference.... [We try] to help women trust their bodies, and [to believe] that in almost every
case, they will be able to [birth naturally].

Barbara believed that the midwives at The Midwife Center were successful in getting women to trust in the normalness of birth.

They're healthy, normal women and they hopefully are given the
confidence that birth is a normal, healthy, physiological function that 2The Anthem and the Monumental Summary of Benefits pamphlets, states under the heading "Maternity," "Pregnancy benefits shall be provided as for any other illness.








their bodies are made to do and to trust their bodies.... I think that
that sense of belief of birth and the calmness and just the atmosphere
of the birth center and the midwives makes it easier to believe and
trust in the body.

During a childbirth class, Sandra explained how women's bodies are designed to make birth a bearable experience: "Endorphins are your body's natural pain killers. In early labor your body does not release many endorphins. Endorphins are triggered by oxytocin. As your labor progresses, you get more oxytocin, and you also get more endorphins."

The midwives' actions illustrate their conviction that women's bodies usually take care of themselves. For example, during a prenatal visit, Mary's iron level measured a little low. Barbara advised Mary about dietary changes that she could make and supplements that she could take to raise her iron level. Then Barbara reassured Mary, "Your level is not dangerously low, and it probably will go up anyway, even if you did nothing about it." The midwives frequently reassured the women that most births proceed with few complications.

Mary: How often does it happen that a woman wants to push but
she's not fully dilated?

Barbara: Not often. Often if there's a little bit of the cervix left a few
bearing pushes will dilate it the rest of the way. Very rarely
will the cervix get too swollen. Sometimes if the baby is
posterior, the woman will feel the urge to push before she's
fully dilated. It doesn't happen often.
Judy believed that part of her job was to reassure women that birth is natural.

Janet: What do you do to help prepare a woman for childbirth?

Judy: I try to be very, very positive. I [share] with her my trust in
her ability to do it and [connect] her with all the woman who
have done it before. That's really helpful. Connecting her with people she's known so that she's not feeling like her








experience is isolated from every other woman's
experiences.

Janet: How do you connect her with other people?

Judy: Stories. It's an oral thing. Letting her know that people she's
met in classes and in the birth center have had successful
experiences, for example. Talking about my own
experiences, just sharing. Just sharing and letting her know
that she's not alone. I think that's part of it. It's just a
continual positive reinforcement of her ability.

The midwives also worked to help the women expect and accept the bodily changes that occur during pregnancy. In a prenatal visit, Barbara complimented Amanda on the henna design that she had painted on her stomach. Barbara commented that

It's really great that you had that done. A lot of women look at disgust
at their pregnant belly. I like to work on [this concern] with women.
They don't like being big and fat, and it's hard for them to view their
pregnant selves as beautiful.
Objects at The Midwife Center reflected this view of pregnancy as
beautiful. On the coffee table in the birth center's waiting room there was a large book filled with photographs of artistically posed pregnant women. In addition, adorning the birth center's walls were paintings and photographs of pregnant women.
Women Give Birth
The midwives emphasized that it is women, not the health care
professionals, who give birth and who should be in control of the process. Sandra asserted in a class, "Women are in control of the birth. The language of passivity on her part is ridiculous.... She did the delivering, it wasn't the doctor."
The midwives believed that they must convince each client that she can manage control over her labor. Judy explained:




Full Text

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PREGNANCY AND PARADIGMS: POSSIBILITIES FOR EMPOWERMENT By JANET R. MCNELLIS A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1999

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ACKNOWLEDGMENTS This dissertation would not have been possible without the help of many individuals, and I would like to thank these people for all of their assistance. First, I would like to thank the women who graciously agreed to participate in my study. I could not, of course, have done this study without them. 1 truly enjoyed talking to them, watching their pregnancies develop, and meeting their beautiful babies. I am honored that they and their partners let me share in their experiences. I also would like to thank the health care professionals who not only cooperated fully with my study, but who actively took steps to ensure the success of my research, and who maintained interest in my progress. I hope that they find this report accurate and useful. Each of my committee members gave me valuable guidance throughout the proposal and research stages. I would like to thank Bridget Franks, William Marsiglio, Robert Sherman, Rodman Webb, and Robert Ziller for their help and their patience with my numerous proposals. They gave generously of their time and advice, even during their "vacations." They also uncomplainingly read and responded to my dissertation drafts at short notice. Rodman Webb was my "guru" throughout the entire process; encouraging me, guiding me, and pushing me along the way. I would not have been able to complete this dissertation without the help of my husband. Bob, who was an inexhaustible source of encouragement and a valuable font of practical advice.

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r Finally I would like to thank my children, Niall, Molloy, and Aidan, without whom I never would have developed this idea for a dissertation and who also gave me an incentive for finishing. iii

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TABLE OF CONTENTS ptage ACKNOWLEDGEMENTS ii ABSTRACT vii CHAPTERS 1 INTRODUCTION 1 Statement of the Problem 3 Theoretical Framework 3 Purpose of the Study 6 Significance and Limitations of the Study 6 Organization of the Dissertation 7 2 REVIEW OF LITERATURE 9 Introduction 9 The Evolution of Childbirth in America 9 Colonial Times 9 Late Colonial and Early National Period 13 Nineteenth Century 15 Early and Mid-Twentieth Century 19 Late Twentieth Century 27 Relative Safety of Midwifery and Obstetrical Care 35 Obstetrician-Assisted Births 37 The Obstetrical Paradigm 37 The Medical-Care Experience 39 MidwiferyAssisted Births 40 The Midwifery Paradigm 40 The Midwifery-Care Experience 43 Childbirth as a Feminist Issue 44 Empowerment 46 Definitions of Empowerment 46 The Empowerment Process 47 The Need for More Research 49 iv

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3 METHODOLOGY 52 Research Method 52 Settings 52 Participants 54 Data Collection 56 Interviews 56 Observations 57 Artifact Review 58 Photographic Self-narrative 58 Data Analysis 59 Research Bias and Ethics 60 Reliability and Validity 62 4 THE COUPLES 65 Introduction 65 Similarities 66 Reactions to Pregnancy 66 Physical and Emotional Changes 67 Views of Women 68 Differences 73 Reasons for Choosing Caregivers 74 Amount of Information Sought 78 Expectations for Childbirth 79 Views of Women 81 Summary 84 5 THE MIDWIFERY VIEW OF PREGNANCY AND CHILDBIRTH 86 Introduction 86 The Midwives 86 The Paradigm 89 Nature /God Directs Birth 90 Women's Bodies are Normal /Birth is Normal / Healthy 92 Women Give Birth 94 Women's Wishes 102 Family is Important 103 Pain is Part of Being Human and is OK 106 Women Need to Be Emotionally Prepared 108 Importance of the Midwife/ Women Relationship 110 Birth Should Be an Empowering Experience 114 Effects of the Midwifery Paradigm 115 Effects During Pregnancy „.115 Effects During Childbirth 119 Effects After Childbirth 123 Summary 125 v f

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6 THE OBSTETRICAL VIEW OF PREGNANCY AND CHILDBIRTH 127 Introduction 127 The Obstetrician 128 The Paradigm 129 Without Medical Intervention Childbirth is Unpleasant 130 Medical Personnel Can Make Women Comfortable During Childbirth 131 Pregnancy and Childbirth are Potentially Dangerous but Doctors Can Make Them Relatively Safe 133 Medical Personnel are the "Experts" and Have Specialized Roles 138 Effects of the Obstetrical Paradigm on Pregnancy and Childbirth 144 Effects During Pregnancy 144 Effects During Childbirth 148 Effects on the Newborns 154 Summary 155 7 CONCLUSIONS 156 Birth as a Rite of Passage 157 Role of Rituals 158 Role of Myths 159 The Obstetrical Paradigm: Wonders of Technology/ Patriarchy 162 A Technocratic World View 162 Obstetrical Paradigm's Service to Society 164 The Midwifery Paradigm: Wonders of Nature 167 A Holistic World View 168 Transformative Possibilities 169 Initial Differences Between Groups of Women 175 Research Implications 176 Selection of Pregnancy and Childbirth Caregivers 176 Improving Obstetrical Care 176 Suggestions for Further Research 177 Nature of Empowerment 177 Effects on Multiparous Women 178 Effects on Fathers 178 GLOSSARY 180 REFERENCES _ 183 BIOGRAPHICAL SKETCH 189 vi

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CHAPTER 1 INTRODUCTION Pregnancy and childbirth are among the most powerful and memorable experiences in women's lives. For many women, the birth of their first child heralds a new stage of life, a stage of increasing responsibility and maturity. For some women, pregnancy is an enjoyable time and childbirth is an exciting, agreeable experience that becomes a cherished memory. For others, however, pregnancy is an apprehensive time and childbirth a traumatic experience and a painful memory. Several factors contribute to these two different experiences of pregnancy and childbirth. The individual woman's circumstances, such as number of previous pregnancies, personality, age, and general health, constitute some of these factors. For example, women who had high-risk pregnancies or who have major complications during labor or delivery are likely to report that their experiences were negative. Nevertheless, individual circumstances do not adequately explain the differences in women's experiences. Women with similar circumstances often have vastly different pregnancy and childbirth experiences. Several researchers posit that health care professionals may play a large role in determining the effects that pregnancy and childbirth have on women (Berg, Lundgren, Hermansson, «Sc Wahlberg, 1996; Bortin, Alzugaray, Dowd, & Kalman, 1994; Callister, 1995; Kennedy, 1995; Rothman, 1982; Spitzer, 1995; Walker, Hall, & Thomas, 1995). These researchers report that midwifeassisted women are more likely than obstetrician-assisted women to have 1

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2 positive pregnancy and birth experiences. Most midwife-assisted women say that their midwives encouraged them to make important decisions concerning the births, and offered guidance, support, and needed information. These women report that they feel empowered by their pregnancy and childbirth experiences (Berg et al, 1996; Bortin et al, 1994; Callister, 1995; Kennedy, 1995; Rothman, 1982; Spitzer, 1995; Walker et al, 1995). In contrast, the birth stories of obstetrician-assisted women describe medical and technological interventions about which they had little understanding, and over which they had little or no control (Leavitt, 1986; Martin, 1987; Rothman, 1982; Turkel, 1995). Most reports of obstetricalassisted births, however, are contained in studies that support midwifery, and consist of retrospective stories. Researchers have conducted little research that directly measures the psychological effects of pregnancy and childbirth on women who have obstetricians as caretakers. Researchers also have not fully explored reasons why midwifery care appears to yield better physical outcomes for mothers and their babies. Several researchers and theorists argue that obstetricians and midwives view and interpret pregnancy and childbirth differently (Bortin, et al, 1994; Jordan, 1980; Kennedy, 1995; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). These theorists imply that midwives and obstetricians operate under the assumptions of different world views or "paradigms." The existence and nature of the paradigms, however, have not been empirically determined. Also, researchers have not sufficiently explored what consequences alternate paradigms may have on pregnant and laboring women.

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Statement of the Problem We do not know what makes pregnancy and childbirth a positive experience. Pregnancy and childbirth have the potential to be exciting, positive, and empowering events. No other experience offers comparable outcomes or benefits. First childbirths particularly are significant because they signal the woman's transition to motherhood. Subsequent childbirths are important because they can affirm or increase a women's sense of empowerment. Now that most women in the United States become pregnant only two or three times in their lives, it is especially important that each of these pregnancies and childbirths is a positive and meaningful experience. Midwifery supporters claim that midwifery care is more satisfying for women than is obstetrical care. This claim lacks definitive support because we have little data on women's experiences with obstetricians. Furthermore, although many empirical studies have shown that midwifery care often leads to better physical health for both the mother and the newborn than does obstetrical care (Fischler & Harvey, 1995; Hafner-Eaton & Pearce, 1994; Harvey, Jarrell, Brant, Stainton, & Rach, 1996; Spitzer, 1995), the reasons for these differences are not addressed in available studies. Apparently midwifery and obstetrical care affect the psychological and physicd health of mothers differently, but researchers need to further explore the reasons for these differences. Theoretical Framework Obstetricians and midwives may view pregnancy and childbirth through different paradigms. Paradigms are broad theories through which practitioners in a field view the problems and occurrences in that field. Applied to scientific fields, for example, "the shared paradigm [is] a

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4 fundamental unit for the student of scientific development" (Kuhn, 1970, p. 11). Paradigms influence how a person will define and interpret events. If obstetricians and midwives work under the assumptions of different paradigms, they will interpret the same information in different ways. For although paradigms are based upon facts, "scientific fact and theory are not categorically separable, except perhaps within a single tradition of normalscientific practice" (Kuhn, 1970, p. 7). Indeed, the interrelationship between facts and paradigms is bi-directional. In one direction, scientific paradigms are built upon empirical facts. In the other direction, scientific paradigms give meaning to empirical facts. Facts are meaningful only when they are interpreted through paradigms and have no "absolute" value or significance outside of a theoretical framework. Furthermore, the same "fact" can be interpreted through several paradigms simultaneously, and therefore it can hold several different meanings at the same time. Kuhn emphasizes the significance that individual experiences have upon the interpretation of facts: "What a man sees depends both upon what he looks at and also upon what his previous visual-conceptual experience has taught him to see" (1970, p. 113). Therefore, if midwives and obstetricians hold differing views of pregnancy and childbirth, they will act differently toward pregnant and laboring women and will propose different ways of dealing with identical pregnancy and childbirth situations. Midwives and obstetricians expose their clients to their paradigms through actions, words, and education. Pregnant women are likely to internalize their caretakers' pregnancy and childbirth paradigms, since these are the primary views that they are exposed to. The existence of two paradigms in one field, such as pregnancy and childbirth, does not necessarily mean that one paradigm is "right" and the

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5 other "wrong." Not only is meaning not absolute, according to Kuhn, it also is impermanent. What determines the particular interpretation of a fact at any particular moment is the problem that needs to be solved, as well as the paradigm under which the researcher works. As science "progresses," problems and paradigms change, and the meanings of facts that were constructed under the old problems and the old paradigms change as well. Nevertheless, change does not necessarily work toward any specific end. According to Kuhn, "Nothing that has been or will be said makes [science] a process of evolution toward anything" (1970, p. 170-171). Few would say, however, that both paradigms of pregnancy and childbirth are equally valid. Many feminists believe that the obstetrical paradigm of childbirth is inherently patriarchal and disempowers women (Bortin, et al, 1994; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). These theorists state that obstetricians view pregnant women as being ignorant about their own bodies and their physical and psychological needs. Women therefore need the attention of medical "experts" to survive pregnancy and childbirth. Historically, medical experts have been male, working, albeit unwittingly, to support the traditional patriarchal society. Even though an increasing number of obstetricians are female, they have been trained and operate in the male-constructed obstetrical paradigm of childbirth, and their practices thereby are guided by this paradigm. In contrast, these same feminist theorists claim that the midwifery paradigm of childbirth rests on a woman-centered model, one of women assisting other women through a natural process (Bortin, et al, 1994; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). In the midwifery model, the pregnant women makes decisions

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6 concerning her body and her pregnancy. If a pregnant woman lacks the necessary information for making informed choices, midwives see it as their responsibility to provide the necessary knowledge, information, and training to the woman. Purpose of the Study The purpose of this study is to determine how pregnancy and childbirth caregivers help make pregnancy and childbirth a positive experience for women. To accomplish this purpose, I examined both the obstetrical and midwifery paradigms. I described what happened during prenatal care, pregnancy, and childbirth in both an obstetrical setting and in a midwifery setting, and developed explanations of the paradigms. I also interpreted the paradigms through a feminist theoretical framework, tracing the paradigms' effects on the women's feelings of empowerment. Si gnificance and Limitations of the Study Researchers and theorists have stated that midwifery care is psychologically more satisfactory for women and may lead to better physical health for both the mother and the newborn. I conducted this study to identify some of the factors that lead to mothers' satisfaction and beneficial physical outcomes. Health care professionals then can use this information to adjust their practices, and perhaps their paradigms, accordingly. Therefore, this study may benefit both pregnant women and their health care professionals. Feminist theorists have decried the lack of comprehensive qualitative studies of the midwifery paradigm. There is a corresponding need for studies on the obstetrical paradigm of pregnancy and childbirth. This research explores the midwifery and obstetrical paradigms, and contributes to the

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7 paradigms' theoretical clarity. The research also describes the paradigms' effects on the involved clients. Furthermore, the results of this study will also add to our understanding of what empowerment is, and if education works as an empowerment tool. The study may yield insights into the necessary ingredients education has to contain in order to become empowering. The main limitation of this study is that I could not recruit my participants until after they became pregnant. 1 may have obtained valuable information about the participants' pre-pregnancy views of their selves and women if I had interviewed the women before they conceived. A second limitation is that I was not present during the labor and births themselves. Direct observation of the women's interactions with their caretakers during these times may have yielded interesting and useful data. Or ganization of the Dissertation In the first chapter I summarize the problem that I address in the study and describe the theoretical framework of my research. I explain the purpose of the research and explain the significance and limitations of the study. In the second chapter, I review the relevant literature that pertains to the study. This chapter contains three sections, one presenting an overview of the history of childbirth in the United States, another that discusses the literature concerning obstetrical and midwifery paradigms, and a third that summarizes research that compares the relative safety of midwifery and obstetrical births. In the third chapter 1 explain the ethnographic methodology that I used to gather and analyze data. In chapter four I discuss similarities and differences between the two groups of women. In chapter five I present the midwifery view of childbirth, and in chapter six I present the obstetrical paradigm.

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Finally, in chapter seven, I present my conclusions, discuss implications this study, and make suggestions for future research.

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CHAPTER 2 REVIEW OF LITERATURE Introduction In this literature review, I explain how different paradigms of pregnancy and childbirth evolved and discuss the ramifications of these views. In doing so, I first briefly review the evolution of pregnancy and childbirth practices in America. I review studies that evaluate the relative safety of midwifery and obstetrical care and discuss the specifics of the current medical and midwifery paradigm. I examine why theorists believe that pregnancy and childbirth are feminist issues. Last, I review two definitions of empowerment most often found in the psychological, educational, medical, and sociological literatures. The Evolution of Childbirth in America The biological processes of labor and childbirth have remained the same throughout recorded history. Nevertheless, the social definition of childbirth in America has undergone several changes. Changes have occurred in the following areas: (a) control over labor and births; (b) interventions during labor and birth; and (c) significance of birth for women. In this section, I trace the history of childbirth in America, and explain how changes in the broader society relate to changes in views of childbirth. Colonial Times Early in United States history, most people viewed birth as a natural event. Women had their babies at home, with perhaps a midwife or a family doctor in attendance. Women assumed that they could bear labor pain, and 9

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10 knew that if they needed, they could turn to folk remedies for alleviating this pain. Midwives in particular were expert in the use of herbs, exercises, and comfort measures that alleviated the discomforts of pregnancy and helped ensure normal labors and deliveries. Midwives held positions of influence and respect, uncommon for women in early colonial times. Laboring women utilized physicians only in exceptional cases when women or their babies were in danger (Miller, 1979; Mitford, 1992; Starr, 1982). Birth as a natural occurrence. In the 17th century, and the first half of the 18th century, American colonists viewed childbirth as a normal occurrence, one that needed little medical intervention (Litoff, 1978; Speert, 1980). This view is reflected in the medical literature of the time, which refers to birth as a "natural state" (Oakley, 1984). Perhaps part of the reason why people viewed birth as natural and normal is because it was so common. There were many pregnancies and births in colonial times, as well as many deaths. Speert (1980) explained that "The early Americans tried valiantly to fulfill the Biblical command: 'Be fruitful and multiply. . .' and indeed they responded all too well to the injunction to 'fill the earth,' as the gravestones of the Colonial cemeteries attest" (p. 6). Many colonial men had three or four wives in succession. Families needed to produce children in quantity because the odds of the children surviving to adulthood were not good. It was not uncommon for half of a family's children to die before their parents (Speert, 1980). Most births in the 1600s and 1700s were social events. When a women went into labor, her female friends came to attend to her and offer support before, during, and after the birth. The women shared childbirth knowledge with one another (Dye, 1986).

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11 Midwives as the norm. Following European traditions, midwives attended almost all Colonial births, including the three that occurred during the crossing of the Mayflower (Speert, 1980). Midwives lent moral support and encouragement to the laboring women. They offered herbal remedies for pain, but did not engage in the physicians' typical practices of bloodletting and purging (Litoff, 1978). Physicians attended few births during this period. Physicians were male and were allowed to attend births only in emergencies. Colonists thought it immoral for a man to attend a woman during childbirth. Indeed, if a man played the midwife role during a normal birth, he could face criminal prosecution (Litoff, 1978; Speert, 1980). Even in emergency situations, families often had a hard time finding physicians. Medical care in general was scant in the early colonial period. There were no resident surgeons in the New World until 1630 and many people who provided medical services did so as a secondary job. These physicians had limited ability to help in childbirths (Speert, 1980). Often, physicians would perform drastic surgery only at problematic births, either cutting the women open to save their babies or cutting up the babies in pieces to save the women (Litoff, 1978; Speert, 1980). The physician situation did not improve until the early 18th century. Government did not establish regulations for doctors until the late 1700s. New York City was the first governmental agency to regulate medical practice, and this did not occur until 1760 (Speert, 1980). In 1775 the total population in the colonies was 2,743,000 with only 3,500 medical practitioners. Of these, only 200 to 400 were licensed. Indeed, only one in ten medical practitioners had any formal medical training. Many physicians were clergymen who practiced medicine only because no trained doctors were available (Speert,

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12 1980). These "physicians" used primitive and haphazard methods. Thomas Jefferson stated that the typical physician of his time substitutes presumption for knolege [sic1. From the scanty field of what is known, he launches into the boundless region of what is unknown. . . . I have lived myself to see the disciplines of Hoffman, Boerhaave, Stahl, Cullen, Brown, succeed one another like the shifting figures of a magic lantern, & their fancies, like the dresses of the annual doll-babies from Paris, becoming, from their novelty, the vogue of the day, and yeilding [ sicl to the next novelty their ephemeral favor. The patient, treated on the fashionable theory, sometimes gets well in spite of the medicine. (Blanton, 1931, p. 199) Women therefore had little reason to trust physicians, even when they had access to them. Most expectant mothers used the services of midwives. Fortunately, most births were normal and did not require a doctor's surgical skills. As a result, midwives were in high demand, and had more power than did most women at the time. Community members respected midwives' knowledge and skills, and midwives served important educational and social functions in the community (Dye, 1986; Litoff, 1978; Speert, 1980). Some communities were uncomfortable with the amount of influence that midwives wielded. One prominent Boston midwife, Anne Hutchinson, angered community members when she stepped out of the midwifery role and became a spiritual leader. Women came to her for guidance in religious and pregnancy matters. Her unorthodox religious teachings displeased the religious leaders in the community. Tensions grew and finally peaked when Hutchinson presided at the birth of a malformed baby. Her enemies labeled the midwife a witch, excommunicated her from the church, and banished her from the city (Speert, 1980). Hutchinson's experiences illustrate the conflict that colonialists felt, who needed midwifery services but were uncomfortable seeing women wield too much power and influence.

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13 Groundwork laid for chang e. Although female midwives attended most births in early Colonial America, this state of affairs began to change in the late Colonial period. The catalyst for this change started in the early 1600s (Litoff, 1978; Miller, 1979; Mitford, 1992). Litoff explains that at this time technological advances in Europe laid the ground for the rise of the obstetrician (at the time known as "male midwives") and the demise of the female midwife: Probably the single most important event which prepared the way for the acceptance of midwifery as a science, and, as a consequence, brought about the displacement of [female] midwives, was the development of the obstetric forceps by the British surgeon, Peter Chamberlen, the Elder, early in the seventeenth century. For almost 100 years, the Chamberlens kept the forceps a family secret. In order to insure secrecy, the parturient woman was blindfolded, and the forceps were carried into the lying-in chamber in a large wooden box covered with gilded carvings. Gradually, physicians either bought "the secret" from the Chamberlens or developed their own versions of the forceps. Midwives could not afford to buy the forceps nor could they find physicians who would instruct them in their proper use. (1978, p. 7) Late Colonial and Early National Period The late 18th century marked a turning point for societal views of childbirth. The number of physicians increased, and obstetricians took advantage of improved training opportunities. In most cases, female midwives were denied access to the new training institutes. Indeed, the presence of poorly trained midwives located in some parts of the United States caused many in the country to doubt the competency of all midwives. Obstetrical opposition to midwives further damaged midwives' reputations. As a result, people's view of physicians began to improve, while their view of midwives deteriorated. Americans correspondingly began to view childbirth as a potentially problematic occurrence that required trained medical attention.

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14 Improved quality of physicians. Beginning in the late 1700s, male midwives began to improve their technical skills. Physicians established four medical schools in America in the late 1700s, and in two of these schools doctors from England taught formal courses in midwifery. This increase in technological knowledge helped physicians establish obstetrics as a separate medical practice. Some hospitals instituted lying-in wards where obstetricians could work and medical students could gain experience (Speert, 1980). Admissions committees allowed only men to attend these schools. "That meant," Litoff explains, that women were being systematically excluded from attaining a medical education at the precise time when knowledge of the scientific advances in obstetrics would have enabled them to become more competent midwives. Once this process had begun, it became increasingly difficult for midwives to keep up with the medical discoveries of the nineteenth century which eventually brought about the development of modem obstetrics. (1978, p. 99) At the same time that male midwives began to acquire favorable reputations, some people began to question the skills and abilities of female midwives. Midwives lacked consistent government support in education, training, and licensure (Litoff, 1978; Speert, 1980). As a result, the quality of midwives varied greatly. By the late 18th century, midwives had evolved into two distinct groups, "urban" and "traditional." Urban midwives were better trained, and their peers provided supervision. There were enough of these midwives in the cities that they could call on each other's assistance in emergencies. Initially, urban midwives had very good reputations and the social status of minor city officials (Shorter, 1982). In contrast, geographical conditions and population patterns caused traditional midwives to be isolated from others of their profession. Located in the West, urban areas in the Northeast, and the rural South, these women.

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15 also known as "granny midwives," were often old and poor. They usually had little training and practiced their craft without fully understanding the reasons behind their actions (Shorter, 1982). Many relied on folklore and superstitions. Documented practices of these midwives included: putting coins stolen from a church in the laboring woman's mattress to ease labor pains; placing a sharp ax under the bed to make labor easier; making the laboring woman sneeze by blowing snuff into her nostrils from a hollow turkey quill; and burning the placenta to prevent postpartum hemorrhage (Speert, 1980). Although these two groups of midwives were very different in their beliefs and practices, the negative image of the traditional midwives affected people's views of midwives in general The conception of midwives as dirty, ignorant, and superstitious took hold in popular imaginations. Obstetrical opposition also contributed to the decline in midwives' reputations. Some of the early obstetricians welcomed midwives, giving them support rather than opposition. A small number of obstetricians offered courses to midwives, and attempted to elevate their status (Litoff, 1978; Speert, 1980). Most obstetricians, however, viewed midwives as competitors. Obstetricians began to advertise, maintaining that they provided services superior to those of midwives and general practitioners. Nineteenth Century In the nineteenth century, the public increasingly came to accept physician childbirth attendants. Advances in medical knowledge and technology made it possible for physicians to manipulate births in previously unknown ways. Increasingly, physicians held the view that childbirth is a pathological condition, and the public began to accept this view.

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16 Increase in male attendants at births. By the early 1800s the medical profession was firmly established in the United States (Li toff, 1978; Speert, 1980). Some physicians still argued against male birth attendants, in the name of health, morality and decency. As late as 1848, Samuel Gregory wrote: The introduction of men into the lying-in chamber, in place of female attendants, has increased the sufferings and dangers of childbearing women, and brought multiplied injuries and fatalities upon mothers and children; it violates the sensible feelings of husbands and wives and causes an untold amount of domestic misery; the unlimited intimacy between a numerous profession and the female population silently and effectually wears away female delicacy and professional morality, and tends, probably more than any other cause in existence, to undermine the foundations of public virtue. (1848, p. 1) Nevertheless, male midwives gained acceptance from enough of the public to command high fees (Litoff, 1978). As prohibitions against males in the birth chamber relaxed and the number of doctors increased, regular physicians started attending more normal births, in order to build up their practices (Litoff, 1978). Most urban affluent women engaged male physicians for their childbirths (Litoff, 1978; Speert, 1980). Medical birth technology and education increased dramatically during this period. In the middle of the 1800s, European research, techniques, and instruments introduced the scientific method to the United States (Speert, 1980). Physicians designed childbirth interventions to make birth more controllable, safe, and comfortable. In 1808 obstetricians began to use ergot to induce contractions; in the 1820s researchers invented a stethoscope so doctors could use to hear the fetal heartbeat; and in the 1840s physicians began to use ether to anesthetize women during birth. To educate doctors in using this technology, nearly all medical schools included midwifery in their curriculum (Litoff, 1978). At the same time, state laws forbade female midwives from using medical instruments during births (Speert, 1980).

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17 In the 1850s, several events again occurred to help obstetricians increase their practices. First, in 1850 "demonstrative midwifery" began to obtain widespread acceptance. Hospitals allowed obstetricians to have medical students observe and participate in the births of poor women (Litoff, 1978). This action enabled medical students to gain valuable practice with childbirth. Second, in 1853 physicians gave Queen Victoria chloroform during her labor (Litoff, 1978). This event made anesthesia fashionable among upper-class British and American women. Third, in 1859 the American Medical Association (AMA) recognized obstetrics as a medical specialty (Litoff, 1978). This recognition gave obstetrics greater status and a new security. The increased status and business that obstetricians received in the mid-1800s did not result in better survival rates for mothers. Medical schools gave obstetricians only limited training in the 1860s. Most obstetricians did not know basic principles of asepsis and did not wash their hands before attending women. This omission resulted in high rates of puerperal (childbirth) fever. The rate was particularly high in hospitals because obstetricians attended to multiple women in the same day and spread germs to all of their patients. In the early 1870s, the death rate of mothers from sepsis in New York hospitals ranged from 7.1 percent to 10 percent (CassidyBrinn, Homstein, & Downer, 1984; Speert, 1980). By the late 1870s, however, physicians in the United States began to learn about and practice antiseptic methods (Speert, 1980). At the end of the 1800s, the total maternal death rate dropped to 15.3 per 100,000 women (Litoff, 1978). During the same period, obstetricians became better organized, founding journals, societies, and associations (Litoff, 1978). In the 1800s the rise in medical technology for childbirth resulted in an increase in the

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18 obstetricians' prestige. Obstetricians were now concerned about generating enough business. In 1898, there was one physician for every one hundred and fifty women of childbearing age. Physicians argued that with this surplus of doctors, the United States no longer needed the services of midwives (Litoff, 1978). Educational opportunities for midwives. In the mid-1 800s, several physicians and midwives worked together to provide better midwifery education. In 1848, they established the Boston Female Medical College. This college was the first in the United Stated to offer formal schooling for female midwives. The college awarded graduates certificates in midwifery (Litoff, 1978). Women who wanted to study medicine met with opposition from some obstetricians. These obstetricians claimed that female midwives and female physicians lacked the ability to be competent practitioners. The popular view of women in the 1800s was that they were frail, overly emotional, and intellectually inferior. Physicians warned that women who taxed their minds with study took essential energy away from their reproductive organs, and therefore should not take up medicine. Obstetricians also emphasized the dangers of pregnancy and claimed that even with more training, midwives would be unprepared for problems that might occur during childbirth (Litoff, 1978). Childbirth viewed as pathology. In the late 1800s the prevailing view of childbirth shifted. Previously, people viewed childbirth as a natural occurrence, and women witnessed the births of their friends, relatives, and neighbors. According to Dye, "Nineteenth-century women frequently regarded their own knowledge of birth as equal or even superior to that of physicians" (1986, p. 42). Even obstetricians of the period favored non-

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interference and usually let childbirth proceed without unnecessarily intervening (Leavitt & Walton, 1984; Speert, 1980). In the 1890s, however, obstetricians began to view childbirth as a pathological condition and argued that even "normal" births were fraught with danger. The following abstract, from a paper read at the 1895 annual session of the Medical and ChirugicaP Faculty of Maryland, reflects this belief: No matter how naturally or with what comparative ease a woman may pass through the confinement, she is in all cases a wounded woman, presenting to us, not only the extremely sensitive and receptive uterine wound, but numerous tears, contusions, and abrasions of the genital tract." (Litoff, 1978, p. 22) The public soon began to view childbirth in similar terms. Middleclass women followed the lead of the upper-class in choosing obstetricians over midwives and regular physicians. Litoff explains that: By the late nineteenth century, the middle and upper classes were beginning to embrace the view that childbirth was a disease that could most properly be controlled by the use of instruments, drugs, and surgery. . . . The male-midwifery debate was laid to rest once the medical profession and the public began to accept the idea that childbirth was a complicated medical specialty requiring the services of the highly trained physician. (1978, p. 21) Early and Mid-Twentieth Century The pathological view of childbirth that emerged in the 1800s continued to gain strength throughout the early to mid-20th century. The rapid technological advances of this period helped to create the increasingly common belief that people could gain mastery over nature. Americans viewed childbirth as yet another problem that could be improved through human intervention. Doctors became more concerned with research generalizations and less concerned with individual circumstances. At the ^Surgical

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20 same time, increasingly fewer people chose to use midwives' noninterventionist services. Decline in midwife-attended births. The decline in the number of midwife-attended births began in the 1800s and continued throughout the early 1900s. In 1900, midwives attended only 50 percent of all births (Litoff, 1978). Middleand upper-class white women used physicians in combination with monthly nurses (nurses who assisted the doctor at the births and helped the women with housework for several weeks after the birth). Black women in the South and immigrants in the North used midwives. Most women, regardless of their caregiver, gave birth at home. Only the very wealthy and the very poor women had their babies in hospitals. Upper-class women went to hospitals to have their babies because it had become the "fashionable" thing to do, and they could afford the high cost. Poor women birthed in hospitals because they could not afford to pay birth attendants to come to their homes. Many poor women tried to avoid having their babies in the charity wards of the hospitals, because they viewed hospitals as places of operations, disease, and death (Litoff, 1978). Immigrants' midwives in the North were different from the granny midwives in the South. The granny midwives at this time were usually ignorant and superstitious (Litoff, 1978). The Northern midwives were usually immigrants themselves. They came from Europe, where midwifeattended births were still the norm. Immigrants sought out these midwives because the midwives had extensive training and spoke the women's native languages. Also, many immigrant groups, especially those from Lithuania and Italy, still believed that men did not belong in the birth chamber (Litoff, 1978).

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21 Midwives of all kinds faced mounting barriers in the early 1900s. The percentage of midwife-attended births dropped sharply at this time, sinking from 50 percent in 1900 to 15 percent in 1925 (Litoff, 1978). Many states established regulations and restrictions for midwives, and Massachusetts abolished midwifery altogether (Speert, 1980). Lack of adequate training facilities was a consistent problem for midwives at this time. In most places, there was no affordable education available for midwives. The schools that did exist in some cities were expensive and of low quality; some graduates could not even read or write. Critics termed these schools "diploma mills," since any women who paid the high enrollment fee received a diploma (Litoff, 1978). In 1906, the American Medical Association began a rating system for medical schools. This system favored schools for white men and led to the closing of the few quality medical schools that serviced women and blacks (Litoff, 1978). Further increases in medical technology also led to a decrease in the rate of midwife-attended births (Miller, 1979; Mitford, 1992; Webster, 1993). Physicians began to routinely use X-rays on pregnant women to obtain precise pelvic measurements. Obstetricians also began to give "Twilight Sleep" to laboring women. Twilight Sleep consisted of a combination injection of morphine, which created a light sleep, and scopolamine, an amnesiac drug. The drugs did not eliminate the pain of childbirth, but freed from the memory of childbirth, the drugs left women with the illusion that they were "asleep" and pain-free during their childbirths (Litoff, 1978; Mitford, 1992; Speert, 1980). At first, physicians were reluctant to use Twilight Sleep because the drugs could cause injury or death to the women and their babies. Obstetricians, however, argued that the drugs were safe as long as

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22 obstetricians supervised their administration in hospitals (Litoff, 1978). Popular women's magazines such as Delineator, Good Housekeeping, Ladies' Home Journal, and McClures published articles that promoted the Twilight Sleep experience. At the same time, the same women's magazines published anti-midwifery articles. The authors stated that obstetrician-attended hospital births were safer and more comfortable (Dye, 1986; Litoff, 1978). Physician debate concerning midwives. Between the 1910s and the 1930s, physicians intensified their debate concerning midwives. Midwifery proponents pointed out that Europe, which had high percentages of midwifeattended births, also had much lower maternal and infant mortality rates. Proponents argued that American women and their infants would benefit if the government established comprehensive midwifery training programs and regulations similar to the European model (Litoff, 1978). Newark and New York were the only two American dties to provide government-sponsored midwifery training programs (Litoff, 1978; Speert, 1980). Established between 1911 and 1916, these programs were free and were well attended by immigrants (Litoff, 1978). Along with basic midwifery training, the schools helped their graduates establish close links with back-up doctors (Speert, 1980). These two cities boasted maternal and infant mortality rates that were significantly lower than the national average (Litoff, 1978). Many obstetricians still argued vehemently against midwives, claiming that midwives were incompetent. Obstetrics, they said, was too complicated for midwives to understand, even with training (Litoff, 1978). Obstetricians imposed sanctions on physicians who broke rank and supported midwifery. In 1912, for example, a Philadelphian obstetrician established a childbirth clinic for middle-income women. Midwives attended the women for all normal labors, and the obstetrician intervened only in emergency situations.

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23 The clinic reported a very low maternal mortality rate. The medical board accused the physician of a breach of professional ethics because he was serving women who could afford to pay for private doctors. The board decided to suspend his license and close the clinic (Speert, 1980). Midwifery opponents also believed that obstetrical education would not improve until midwives were eliminated. The poor state of obstetrical education for general practitioners of the time is illustrated in the results of a 1911 survey. Forty-three professors who taught at four-year medical schools across the country replied to the survey. Several of the professors said that they could not perform a c-section. Only 21 had served in lying-in hospitals before teaching. Twenty-nine said that their hospital equipment was inadequate for teaching obstetrics. One-fourth said that their institutions' curriculums did not prepare the "ordinary graduate" to practice obstetrics. The majority of the professors believed that "general practitioners lose as many and possibly more women from puerperal infection than do midwives" (Litoff, 1978, p. 65) . The maternal death rate reflected this inadequate education. In 1913, the death rate was 15.8 per 100,000 (Litoff, 1978). The authors of a 1917 study, titled Maternal Mortality From All Conditions Connected with Childbirth in the United States and Certain Other Countries, explained that "childbirth caused more deaths among women fifteen to forty-four years old than any disease except tuberculosis" (Litoff, 1978, p. 71). Midwife opponents argued that the reform of obstetrics occasioned the abolition of midwives (Litoff, 1978; Speert, 1980). For example, at the 1914 meeting of the American Association for the Study and Prevention of Infant Mortality, the obstetrician George W. Kosmack maintained that "most medical faculties regarded obstetrics 'as a sort of side issue' because midwives

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24 were allowed to practice an important branch of medicine with a much too brief and unsatisfactory training" (Litoff, 1978, p. 66). At the same meeting, Joseph B. De Lee, the founder of the Chicago Lying-in Hospital, explained that young doctors would not choose to become obstetricians as long as midwives existed because, "if a delivery requires so little brains and skill that a midwife can conduct it, there is not the place for him" (Litoff, 1978, p. 67). In the 1930s, physicians voiced concerns that midwives were taking clients away from them. Physicians claimed that the midwives' practices made it difficult to command high enough fees, since midwives usually charged less than half of a doctor's fee. The midwives helped the new mother around the house for several days after her birth, making the midwife a better value. Also, obstetricians stated that they needed the poor women who traditionally used midwives to attend lying-in charities instead so that medical students could have a sufficient supply of laboring women for training purposes (Litoff, 1978). Further barriers for midwives. During the 1920s, several other factors led to a continuing decrease in the rate of midwife-assisted births. Declining birth rates resulted in less work for all childbirth practitioners. Also, by the 1920s all states had established Bureaus of Child Hygiene. These bureaus helped train and regulate midwives and also set standards of practice, often restricting midwifery activities (Litoff, 1978; Speert, 1980). Some state officials supported midwives, while others argued against them (Litoff, 1978). Interestingly, the introduction of prenatal care by social reformers also contributed to the midwives' demise. Previously, women usually saw their childbirth attendant only during labor. In the 1920s, however, states paid nurses to provide prenatal care to impoverished patients. These nurses

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25 guided the women to hospital births, and many of the prenatal programs developed formal ties with lying-in programs (Dye, 1986). Interventionist view of childbirth. The obstetrical view of childbirth became increasingly interventionist in the 1920s. Joseph De Lee, a leading Chicago obstetrician, wanted higher standards for obstetricians and argued that birth should be viewed as essentially pathological. De Lee believed that the obstetrician's role should be to make birth as safe and comfortable as possible, through active interventions by the obstetricians. De Lee explained that obstetricians could lessen psychic trauma and physical exhaustion by giving women narcotics and scopolamine during their first stages of labor. Obstetricians could preserve the perineum from injury by performing routine episiotomies. Mother and child would be spared from injury if obstetricians routinely used low forceps in the second stage of labor. Obstetricians who routinely administered drugs that stimulated uterine contractions and who manually extracted placentas would reduce hemorrhage and infection (Dye, 1986). All of De Lee's suggestions became standard policy in hospitals by the end of the 1920s (Litoff, 1978). Most women readily submitted to these procedures, attracted by the scientific modernity of the methods and the promise of effortless and pain-free childbirths (Dye, 1986; Litoff, 1978; Shorter, 1982; Speert, 1980). Dye explains that once women started allowing obstetricians to take over the entire birth process, the trend became difficult to stop. Once birth routinely took place in hospitals . . . few women had the opportunity to participate in births other than their own, and, given the widespread adoption of general anesthesia, often did not experience even their own births. As knowledge of birth became monopolized, birth itself became mystified. (1986, p. 42)

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26 In the 1930s obstetricians had firmly established the interventionist model of childbirth. The New York Obstetrical Society recommended that all births should occur in hospitals (Litoff, 1978). The rate of cesarean sections rose from 1 percent in the period between 1900 and 1909 to 3.2 percent in period between 1930 and 1939 (Shorter, 1982). The cesarean rate in the 1930s was much higher than that in European maternity hospitals (Litoff, 1978). Medicine in the United States made great advances after World War H. Previously, medical education focused on anatomy, pathology, bacteriology, and physiology. New technologies switched the focus to biochemistry, biophysics, and psychopathology. When medicine became more technically advanced, the prevailing medical paradigm became more technologically oriented. According to Fox, [The medical] way of reasoning is primarily scientific in nature. In its ideal-typical form, it entails the application of logical-rational thought to empirical phenomena that are assumed to have a direct or indirect relationship to health and illness. (1989, p. 50) The focus of the medical paradigm shifted from the individual to statistics. Medical schools emphasized research aspects of medicine, and students who entered the medical field tended to be more bioscientifically oriented than their predecessors. Students with more biosocial orientationsthose who had "interpersonal service and social science and psychological interests and abilities"~tended to concentrate in the field of psychiatry (Fox, 1989, p. 90). The establishment of the nurse-midwife. Nurse-midwifery was the only type of midwifery that experienced an increase in demand during the early 20th century. Nurse-midwives initially train as nurses, and then receive graduate degrees in midwifery. In 1925, the graduate nurse Mary Beckenridge established the Hyden Center in the mountains of Kentucky.

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'1 27 Beckenridge had trained as a nurse-midwife in England, and she staffed the center with other British-trained nurse-midwives. Several other nursing centers soon opened, and together they operated as the Frontier Nursing Service (FNS) (Litoff, 1978). The FNS was successful in reducing maternal and infant mortality rates. The FNS experienced only 11 maternal deaths in its first 10,000 deliveries. The national mortality rate at the time was 36.3 deaths per 10,000 births. This difference in rate is especially significant since 60 percent of deliveries between 1925 and 1954 were conducted in the home in an extremely poverty-stricken area, where the main mode of transportation was by horseback, modem facilities and medical assistance were difficult to attain, and the percentage of high-risk mothers and infants was great. (Browne & Isaacs, 1976, p. 16) Nurse-midwives established similar programs in other parts of the country, such as Madera County, California and several areas of Mississippi, with corresponding decreases in infant mortality rates (Litoff, 1978). In 1929, enough nurse-midwives were practicing that they could create the American Association of Nurse-Midwives. Nevertheless, nurse-midwives still met with opposition from the medical profession. No state government formally recognized nurse-midwives until 1945, when New Mexico allowed licensing. The next state to offer formal recognition was New York, in 1955 (Litoff, 1978). Even with the establishment of nurse-midwives, the number of midwife-attended births continued to decline. In 1933 midwives attended more than 14 percent of births. By 1950, midwives attended only 4.5 percent of births, in 1960 they attended 2 percent, and in 1970 they attended 0.5 percent (Speert, 1980). Late Twentieth Century The 1960s and 1970s saw social changes in various settings and situations, including childbirth. Two views of childbirth were present during

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28 these decades. The prevailing view was a continuation of the technological, interventionist perspective that had been building since the 18th century. The other view, held by a minority of Americans, posited that childbirth is a natural, healthy occurrence that usually does not require medical interventions. Feminists were the main proponents of this second view. Along with demanding equal rights, feminists insisted on maintaining control over their bodies. Feminist views of childbirth never gained widespread acceptance or meaningfully changed the medical interventionist perspective. Nevertheless, because of the feminist influence, beginning in the 1960s and continuing through the 1990s, the conditions under which women experienced medical-based childbirth improved. Women work for improved childbirth conditions. During the 1960s and 1970s an increasing number of women began to demand more control over their childbirth conditions and began to organize. The International Childbirth Education Association (ICE A), founded in 1960, was the first organization these women created. The ICEA was a consumer group that worked to make childbirth practices more family-centered and less traumatizing for women (Cassidy-Brinn, et al, 1984). At the time that activists formed the ICEA, routine hospital practices for childbirth included: administering enemas; shaving women's pubic hair; restricting women to bed during labor; insisting on a lithotomy position with the women's feet in stirrups for delivery; not allowing a woman to eat during labor; not allowing family members or friends to remain with the women; chemical stimulation of labor; episiotomies; and separation of the mother and newborn (Cassidy-Brinn, et al, 1984; Litoff, 1978; Shorter, 1982).

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29 Women were also concerned with the increasing rate of obstetrical interventions. In the 1960s the cesarean rate was 6.8 percent. This rate increased dramatically in the 1970s, reaching 12.8 percent by the end of the decade (Shorter, 1982). Women activists were concerned because many studies revealed that the routine use of technology during labor (i.e., episiotomies, the lithotomy position and chemical stimulation of labor) caused more problems than they solved (Cassidy-Brinn, et al, 1984; Mitford, 1992; Rowland-Serdar & Schwartz-Shea, 1991). The number of childbirth reform organizations multiplied in the 1970s. In 1976, activists founded the American Cesarean Prevention Movement. Other organizations, such as the Association for Childbirth at Home, International (ACHI); Home Oriented Maternity Experience (HOME); and Homebirth, Inc. worked for the revival of lay midwifery and home births (Cassidy-Brinn, et al, 1984; Litoff, 1978). These organizations published newsletters and provided referrals to home-birth practitioners. Some organizations offered home birth courses for parents and midwives (CassidyBrinn, et al, 1984). The rise in feminism in the 1970s contributed to women's interest in improved childbirth conditions. Modem feminist concerns included the right of women to maintain control over their own bodies and births (Cassidy-Brinn, et al, 1984; Donnison, 1977; Litoff, 1978). Donnison explains why: Freed from the prudery which inhibited the early feminists, today's militants take pride in their female functions, and call for the right to choose how they exercise them. Along with demands for the abolition of the "double standard" in sexual morality and for adequate contraception and abortion services, the movement is fighting for more sensitive health care for women-whose problems, whether physical or emotional, are, they claim, still not properly understood by a predominantly male medical profession. (1977, p. 197)

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30 Several women's rights organizations founded during the 1970s dealt primarily with women's health control issues. For example, in 1973 the Boston Women's Health Collective published the popular book "Our Bodies, Ourselves," which encouraged women to take an active role in their health care. Also in 1973, activists founded Womencare, the first childbirth program that emphasized self-help prenatal care. Womencare's clients had access to their complete medical records and a medical library. Clients conducted most of their own prenatal screening tests, learned how to determine the position of their babies, and listened to their babies' heartbeats. The feminist healthcare workers who staffed the center encouraged women to learn from each other by hosting group meetings where the clients discussed how pregnancy affected their lives. The group helped women consider problems and risk factors in light of their individual lives. A physician birth attendant conducted prenatal examinations and attended women's births, either at their homes or at a hospital. Female health workers accompanied women to their physician exams. Although the women who went to the center enjoyed the control they had over their pregnancies, they were frustrated that the physician attendant did not give them greater decision-making power during births. After five years of operation, obstetricians who opposed the center managed to have it closed down (Cassidy-Brinn, et al, 1984). In 1976, several feminists formed MOTHER (Mothers of the Whole Earth Revolt). Ginnie Cassidy and Carol Downer, two of the founders of MOTHER, explain that "MOTHER'S position was tiiat mothers, like all workers, have a right to recognition for their labor and they need to be given the tools and supplies to do their work well" (Cassidy-Brinn, et al, 1984, p. 52) MOTHER was concerned about all aspects of motherhood, but focused first on

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31 childbirth conditions. Members conducted inspections of hospital maternity wards and publicized unsatisfactory conditions when they found them. The group met with heavy resistance from hospitals, and after one inspection police arrested and jailed group members (Cassidy-Brinn, et al, 1984). Despite the failure of feminists to create widespread reassessments of childbirth practices, they did contribute to a few childbirth reforms. During the 1970s, several birth attendants started childbirth education programs. Instructors in these programs educated women about the physical processes involved during labor and delivery. They also taught the pregnant women ways of coping with labor pain so that the women could use less anesthesia during their labor and deliveries (Cassidy-Brinn, et al, 1984; Davis-Floyd, 1992). In addition, "prepared" and "natural" childbirth advocates demanded and received some changes in hospital procedures. For example, hospitals began to allow husbands to stay with their laboring wives and discontinued general anesthesia during labor in favor of epidurals (Davis-Royd, 1992). Midwifery revival. The childbirth reformers and feminist activists of the 1970s also contributed to a midwifery revival. In 1971, for example, the American College of Obstetricians and Gynecologists, the Nurses Association of the American College of Obstetricians and Gynecologists, and the American College of Nurse-Mid wives issued a joint statement that nursemidwives and obstetric registered nurses may assume responsibility for pregnancy and childbirth care for low-risk women under the direction of a qualified obstetrician-gynecologist (Dormison, 1977; Speert, 1980). In the same year, nurse-midwives established and ran the Santa Cruz Birth Centre in California. In 1974 the center delivered 10 percent of all births in the area (Donnison, 1977).

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Nevertheless, midwifery remained a debated issue. The medical profession and the public were reluctant to endorse nurse-midwives because they confused them with "granny midwives." At the same time, obstetricians argued that there were enough doctors to serve all pregnant women, so midwives were superfluous (Li toff, 1978). In 1974, two states prohibited nurse-midwives and 12 states restricted their practice (Speert, 1980). In 1975, midwives attended only 1 percent of all births in the United States (Litoff, 1978). In the 1980s broad economic tind policy changes started to affect the medical paradigm. Nationwide changes in health insurance forced physicians to become more concerned about cost containment and drastically shortened hospital stays. The growing incidence of malpractice suits, along with the continuing rapid increase in medical technology caused doctors to rely less on clinical observations and depend more on laboratory tests. This shift in priorities resulted in doctors having less personal contact with patients, a trend that had been growing since the 1960s (Fox, 1989). In the 1980s, bowing to demand from consumers, doctors started making hospital births appear more homelike (Clarke, 1997; Davis-Floyd, 1992). Many hospitals set up "alternative birth centers" within the hospital building. In these centers, pregnant women are allowed to labor and deliver in the same room. The rooms are private and resemble small hotel rooms. Many of these rooms have fold-out couches where the support partners can rest, and are equipped with televisions and VCRs. The medical equipment is hidden in cupboards (Davis-Floyd, 1992). Results of chang es. Critics of hospital births argue that the changes that occurred in the 1980s and 1990s merely mask the fact that the underlying interventionist view of childbirth has not changed. Women still have not

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33 been given additional control over their labor and births (Cassidy-Brinn, et al, 1984; Davis-Floyd, 1992). Hospital-sponsored childbirth classes teach women how to have control over their behavior during birth, not control over the birth itself (Davis-Floyd, 1992). Cassidy-Brinn and her colleagues explain that even with reforms, basic power relationships have remained the same: The modern history of childbirth shows that when physicians pushed out midwives, the concept of an experienced birth attendant aiding a woman in her task of giving birth changed to an all-powerful expert controlling a medical event. As long as this fundamental power relationship remains the same, reforms won by childbirth groups will not have a lasting effect. ... As we have seen in the last fifty years, mothers are no longer knocked out with general anesthetics, but they are given other equally dangerous drugs and procedures. . . . To understand why previous reforms have given way to "new improved" harmful childbirth practices, it is necessary to realize that childbirth reform efforts in the past have focused on making the birth experience more humane and natural without restoring the information and decision-making power to individual women. Although physicians have been pressured to change, they still retained the ultimate control. (1984, p. 182) The number of midwife-attended births in the United States slowly increased throughout the 1980s and 1990s. In 1980, midwives attended 2.1 percent of births (Litoff, 1978). In 1990, the number rose to 3.9 percent (Center for Disease Control, 1995). In 1996, midwives attended 6.5 percent of all births (National Center for Health Statistics, 1998).2 Although the total percentage of midwife-assisted births has increased, less than 1 percent of all births in 1996 occurred outside hospitals (National Center for Health Statistics, 1998). ^"Undoubtedly the number of births attended by midwives of all kinds is higher. In some states, nurse-midwives mainly work as employees under physicians and the insurance companies pay more for a physician attended birth. In order to receive the largest monetary compensation for births, and because the midwife is "under physician supervision" by law, the birth certificate is completed as though the doctor were attending, even if this was not the case. Additionally, in states where Direct Entry Midwives are not licensed or Direct Entry Midwifery is prohibited, many births either go unreported or are reported as unattended or the category of midwife is absent from the birth certificate." (Source: Yvonne Lapp Cryns (1995) "Midwives and Homebirth." The Compleat Mother Magazine)

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34 The majority of midwife-assisted births occurred with nurse-midwives in hospitals (Clarke, 1997). Hospitals hired these nurse-midwives to work in their alternative birth centers to lower costs and to reinforce the perception that natural birth was being encouraged. These nurse-midwives operated under the supervision of obstetricians and have to follow hospital regulations. Births in alternative birth centers remain similar to births in conventional hospitals (Davis-Floyd, 1992; Rothman, 1986). Women who worked to establish these birth centers contend that the results are disappointing: "It looks like you're getting something, and what you get is a lot of family-centered Cesarean sections" (Davis-Floyd, 1992, p. 185). Feminists argue that the advent of "prepared" childbirth did little to make the process an empowering experience for women (Davis-Floyd, 1992; Rothman, 1986). The most popular prepared childbirth methods cause laboring women to lose control of their labors and deliveries by dictating one "correct" way to think, visualize, and breathe during labor. Two of the major prepared childbirth methods-Lamaze and Dick-Read~train women to relax and breathe during labor (Mitford, 1992). Another influential method, the Bradley method, trains husbands to "coach" their wives through the childbirth process (Mitford, 1992). The developers of all three prepared childbirth methods are male who, of course, have not had first-hand experience of giving birth. Nonetheless, these theorists specify in great detail what women should feel and how they should act during labor. In the obstetrical paradigm of childbirth, "natural" childbirth means that women try to get through labor and delivery without epidurals. Hospital routines, such as inserting IVs during admissions, and continually monitoring the fetal heartbeat, still are followed. Obstetricians also use

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35 routine episiotomies, forceps, and other obstetrical interventions during the labor and delivery (Davis-Floyd, 1992). Robert Mendelsohn, a physician critical of hospital births, cautions: Don't kid yourself into thinking that birthing rooms made up to look just like a real (motel) bedroom are going to make any big difference. Once you allow yourself to be lured onto Modem Medicine's turf, they've got you. ... If you're on the doctor's turf, you play by the doctor's rules. (1979, p. 139). Rather than decreasing, medical interventions during birth are increasing. In 1996, doctors used electronic fetal monitoring in 83 percent of births. Doctors used drugs to stimulate and induce labor in 169 births per 1000 in 1996. Both of these rates have risen steadily for seven consecutive years. Also in 1996, obstetricians performed cesarean sections in 20.7 percent of births and forceps or vacuum extraction in 9.4 percent (National Center for Health Statistics, 1998). Women who want to have control of their labor and births have few options. There are few free-standing birth centers in the United States, and lay midwives, who work independently of obstetrical supervision, still face determined opposition (Davis-Floyd, 1992). As of May 1999, direct-entry midwives (midwives who have not first completed nursing training) are prohibited in nine states. In seven other states they are legal but licensure is unavailable. Further, Medicaid will reimburse direct-entry midwives in only eight states (Midwife Alliance of North America [MANA], 1999). Relative Safety of Midwifery and Obstetrical Care I have reviewed the safety literature because safety is a central theme running through the histories of both the midwifery and the medical paradigms. Proponents of each paradigm justify their beliefs and actions by voicing concern for the safety of mothers and their newborns. Many researchers have compared the outcomes of midwife-assisted births to those

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of obstetridan-assisted births. Four researchers have reviewed recent comparative studies and found that in all the studies clients of midwives had fewer complications during labor that required obstetrical interventions. Furthermore, the women who had midwife caregivers had babies who were as healthy, or healthier, as those of women who had doctors as caregivers (Fischler & Harvey, 1995; Hafner-Eaton & Pearce, 1994; Harvey, Jarrell, Brant, Stainton, & Rach, 1996; Spitzer, 1995). I found no published studies that conclude that modern midwifery care is detrimental to either mothers or their babies. One frequent criticism of the studies that compare midwife-assisted births with physician-assisted births is that perhaps only healthy women choose midwife-assisted births. However, in one study researchers found that even women who statistically are at higher risk of developing complications during pregnancy and childbirth and/ or having low birth-weight babies may benefit from midwifery care (Fischler & Harvey, 1995). Fischler and Harvey (1995) limited their sample to low-income women and studied pregnancy outcomes at three different types of care providers: (a) certified nursemidwives in a hospital-sponsored, prenatal clinic; (b) certified nursemidwives in private practice; and (c) medical doctors in private practice. They found that, even in this traditionally "higher-risk" group, women who received prenatal services from midwives in private practice had significantly higher birthweight babies than did the women in either of the other two groups. Another frequent criticism of the comparative studies is that women who choose midwife caregivers may be psychologically and behaviorally different from women who choose physician caregivers. Critics have noted that women who choose to have midwives as caregivers may do so because

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37 the women intend to play a more active role in their pregnancies and births and therefore may not be comparable to those women who choose physicians as caregivers (Harvey, et al, 1996). This more active involvement may lead to midwife-assisted women having less problems with their pregnancies and births. Research partially supports this criticism. For example, Callister (1995), found that women who had certified nurse midwives as caregivers participated more actively in decisions concerning childbirth, and put more emphasis on the quality of the birth experience, than the women who had obstetricians as caregivers. The midwife-assisted women had significantly lower rates of epidural anesthesia for pain management, lower levels of reliance on others, and more active participation in childbirth care decisions. Callister based her findings on women's perceptions after the actual births, however, so it is hard to draw firm conclusions from this research. It is possible that the women's health-care professionals influenced women's beliefs and perceptions of pregnancy and childbirth during prenatal care and childbirth. The validity of this criticism also has been partially addressed by Harvey and her colleagues (1996). In their study, Harvey et al (1996) selected all of their participants from a pool of women who desired to have midwifery care. The researchers then randomly assigned women to midwives or physicians for their prenatal care and delivery. The researchers found that those in the midwife-assisted group had significantly lower obstetrical intervention rates during prenatal care and labor, had shorter hospital stays, and had fewer newborns admitted to the neonatal intensive care unit. Obstetrician-Assisted Births The Obstetrical Paradigm A search of the general academic literature and a separate search of MEDLINE uncovered only two studies that directly assess the obstetrical

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38 perspective on pregnancy and childbirth. In a recent comprehensive study, Robbie Davis-Floyd (1992) interviewed 100 mothers, most of whom had obstetrician-assisted births, and an unidentified number of birth attendants. Davis-Floyd states that the medical model of birth is "technocratic." She explains that the medical paradigm's mechanistic bent is caused by a larger, societal-level paradigm: As the mechanical model itself became the conceptual factor "unifying cosmos, society, and self (Merchant 1983:192) [in the seventeenth century], the primary responsibility for the human body, a responsibility that had once belonged to religion, was assigned to the medical profession. This developing science had taken the mechanical model as its philosophical foundation and so was much better equipped than religion to take on the challenging conceptual task of transforming the organic human body into a machine—a transformation that was crucial to the development of Western society. (1992, p. 45). According to Davis-Floyd, the medical world views the body as a machine and doctors as technicians. Throughout Western history, however, societies have also viewed women as imperfect and inferior to males. "So," Davis-Floyd explains, the men who established the idea of the body as a machine also firmly established the male body as the prototype of this machine. Insofar as it deviated from the male standard, the female body was regarded as abnormal, inherently defective, and dangerously under the influence of nature, which due to its unpredictability and its occasional monstrosities, was itself regarded as inherently defective and in need of constant manipulation by men. (1992, p. 51) As a result, doctors classified birth as untrustworthy and dangerous. Davis-Floyd lists characteristics of the technocratic model of birth. These include: viewing the world through a male perspective; having a classifying and separating approach; equating bodies with machines; viewing the fetus as separate from the mother; believing in the supremacy of technology; believing that appropriate prenatal care is objective and scientific;

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believing that adherence to time charts during labor is essential for safety; maintaining that environmental ambiance is not relevant; viewing labor pain as problematic; seeing cesareans as the first remedy for many problems; and viewing birth as a service that medicine owns and supplies to society. The Medical-Care Experience Diana Scully (1980) studied the results of the obstetrical paradigm of childbirth through observations and interviews with obstetricians. Scully spent three years observing the obstetrical and gynecological training programs in two hospitals in the mid-1970s. She concluded that gynecologists and obstetricians are actually "miseducated" about women during the course of their professional training. Through their obstetrical socialization experience they come to view women as weak and ignorant and pregnancy and labor as inherently problematic. Scully (1980) states that obstetrical training focuses on the use of obstetrical interventions during labor, and as a result the residents attempt to get as much practice doing these procedures as they can. One of the residents in Scully's study explained. You have to look for your surgical procedures, you have to go after patients, because no one is crazy enough to come and say, "Hey, here I am, I want you to operate on me." You have to sometimes convince the patient that she is really sick, and that she is better off with a surgical procedure. (1980, p. 122) Scully also reports that many of the male doctors who choose gynecological and obstetrical specialties enter the field with negative and condescending attitudes towards women, and obstetrical training supports these attitudes. Some residents in Scully's study, for example, predicted that as obstetricians they would need to act as father figures to many of their patients.

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40 These observations are disturbing and several researchers have criticized Diana Scully's work for being shallow and biased. One critic states that Scully deals with what she saw and heard in a literal, absolutist way. The ironic, self-mocking connotations of some of the vocabulary that obstetrician-gynecologist residents use and the emblematic and social control dimensions of their rituals seem to escape her. Even more striking and significant is the absence in her work of any allusion to the medical uncertainty, moral ambiguity, ethical conflict, and the physical, psychological, and social stress that are so prominent in the other studies of socialization in residency. In the end, Scully's book is principally interesting as an example of the genre it represents: a thinly empirical, post-1960s, social movement-oriented work of militant social criticism. (Fox, 1989, p. 124-125) Midwifery-Assisted Births The Midwifery Paradig m Midwifery care provides a distinct alternative to the obstetrical paradigm (Bortin, Alzugaray, Dowd, & Kalman, 1994; Eakins, 1986; Jordan, 1980; Kennedy, 1995; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). Whereas practitioners who view pregnancy and childbirth from the obstetrical model see the process as inherently pathological, midwives view the process as natural and healthy. Rothman explains: From the perspective of the midwifery model, childbirth is viewed as a healthy activity and as an important event in the lives of women and their families. During pregnancy and birth, women require physical care involving examination and screening, but they also require social and emotional support and comfort for this personal event. Throughout pregnancy and birth, midwives act as teachers and guides for pregnant women. In the midwifery model, birth is something that women do, not something that is done to them. The midwifery model offers a view of childbirth which is woman-centered. Women give birth, and midwives assist them in doing so. (1982, p. 53)

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41 The Midwife Alliance of North America (MANA) (1999) elaborates on the midwifery paradigm in its position statements. MANA emphasizes the view that birth is natural: "Childbirth is a normal physiological process as well as a social event in the life of a woman and her family." MANA states that part of the midwives' job is to educate people about the midwifery paradigm: Midwives should promote childbirth practices which enhance the normal physiological process. . . . [Midwives should] provide information to women and their families which enhances the understanding of birth as a normal life process and enables them to make informed decisions. (1999, paragraph 33) This view— that women should be educated and then allowed to make decisions concerning their pregnancy and childbirth—is another aspect of the midwifery paradigm. MANA explains that women should make their own decisions because each woman is unique, "each birthing woman has individual needs, and [MANA] . . . recognizes her right to select the care provider and setting for birth that best fits those needs" (1999, paragraph 5). Proponents of the midwifery paradigm do not rule out the use of technology. Instead, they advocate the careful and thoughtful use of interventions when individual circumstances warrant their use. "Intervention in the process and the application of technology are potentially harmful and are therefore only justified when their use can be shown to enhance well being and improve outcome for a particular mother and her baby" (MANA, 1999, paragraph 32). MANA asserts that interventions are often performed unnecessarily, and therefore midwives need to "continuously evaluate intervention and the use of technology in midwifery practice and take measures to avoid unnecessary interference" (1999, paragraph 35).

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The final area where the midwifery paradigm differs from the obstetrical paradigm is in its view of accreditation. Midwives value formal accreditation, as an acknowledgment of the expert knowledge that they possess, and as a method of ensuring quality and consistency of care (MANA, 1999). This value is similar to that of the medical paradigm, which acknowledges the importance of formal credentials. Physicians have to pass the standards of certification boards to obtain licenses to practice. In 1987, MANA established the North American Registry of Midwives (NARM) to administer certification for the credential "Certified Professional Midwife" (North American Registry of Midwives, 1999). The differences between the two paradigms occur in reference to what the certification agencies deem necessary and acceptable for licensure. The route to medical certification is fixed, but midwives may obtain their CPM through a variety of methods. Midwifery-paradigm supporters maintain that individual women and communities have different needs, and therefore various midwifery practices and experiences are appropriate. NARM explains: CPM certification validates entry-level knowledge, skills, and experience vital to responsible midwifery practice. This international certification process encompasses multiple educational routes of entry including apprenticeship, self-study, private midwifery schools, collegeand universitybased midwifery programs, and nursemidwifery. Certification shall not be construed as defining midwifery in its entirety. NARM acknowledges that midwifery encompasses attributes that defy measurement. NARM intends CPM certification to sanction and build a foundation to support midwives' work while recognizing that their individuality of practice best reflects the needs of the communities they serve. (1999, paragraphs 1 and 3)

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43 The Midwifery-Care Experience All the research that describes the experiences of women who select midwifery care are qualitative studies. For example, Kennedy (1995) interviewed six women who had midwifery care and asked them to describe those experiences. Participants reported that their relationships with their mid wives were built on respect, trust, and alliance. These relationships enabled the women to play an active part in determining and directing their pregnancy and birth care. Kennedy concludes that "midwifery is a profession that does not provide care to women, it provides care with women" (1995, pp. 410). In a larger study, Pamela Eakins (1986) interviewed 76 women about their out-of-hospital births. She found that two types of women were most likely to choose to have out-of-hospital births: those who believed that hospitals are inappropriate or dangerous places to have babies, and those who could not afford hospital stays. Eighty-seven percent of the women who delivered at a free-standing birth center, and 95 percent of the women who delivered at home felt "positive" or "extremely positive" about their births. In two other studies, researchers examined women's experiences with their midwives during labor and childbirth (Berg, Lundgren, Hermansson, & Wahlberg, 1996; Walker, Hall, & Thomas, 1995). These researchers found that women recalled positive relationships with their midwives. In a Swedish study, the participants said their midwives treated them as individuals and that they had a trusting relationship with their midwives. By providing their clients with a sense of control, the midwives were able to offer appropriate support and guidance (Berg, et al, 1996). Similarly, Walker and her colleagues (1995) found that their participants reported positive midwife-guided birth

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44 experiences and said they felt informed, supported, and in control of their labor and delivery. In a fourth study, Callister (1995) compared the childbirth experiences of women who had midwives and others who had obstetricians at their hospital births. Callister found that women who had midwives as caregivers were more actively involved in their childbirth care decisions, were less likely to have used epidural anesthesia during the births, and were more likely to report they enjoyed their birth experiences. Kathleen Turkel's conducted a case study of a free-standing birth center. Her results support the findings of the other studies: The birth center has created a birth setting with extremely positive results for the clients it serves. The needs and concerns of the pregnant woman are the focus of care at the center. The nurse-midwives seek to empower women by providing them with the information they need to make decisions about their own pregnancy, labor and delivery and by creating an environment in which women have much more control over their experience than they do in a hospital setting. The relationship between nurse-midwives and clients is built on equality, trust, and a shared belief that childbirth is a unique experience for each woman. (1995, p. 127) Turkel's findings suggest that education may play a key role in causing pregnant and laboring women to feel empowered. Childbirth as a Feminist Issue Many theorists claim that control over pregnancy and childbirth is a feminist issue (Bortin, et al, 1994; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). Several feminist theorists contend that the move from home-based to hospital-based births has shifted the power in the caregiver/ receiver relationship from the mother to the physician and has caused pregnant and laboring women to feel powerless and unconnected to the childbirth process (Bortin, et al, 1994; Cassidy-Brinn, et al.

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45 1984; Davis-Royd, 1992; Jordan, 1980; Leavitt, 1986; McLougWin, 1997; Mitford, 1992; Rothman, 1982; Spitzer, 1995; Turkel, 1995). These theorists assert that the large majority of American women who have obstetrician-caretakers do not have control over their pregnant bodies. During pregnancy, physicians decide how much weight a woman will gain, what she should and should not eat and drink, what activity she should and should not do, what medical tests she and her fetus will undergo, where she will have her baby, and even when she will give birth. When the woman is in labor, the physician decides the birth position she will assume, how long she will be in labor, what nourishment she will receive, who may be present, what these attendees may do, and a myriad other decisions (Davis-Floyd, 1992; Jordan, 1980; Rothman, 1982; Turkel, 1995). According to several theorists, pregnant women have lost control over their bodies because the obstetrical model of childbirth replaced a more natural view of pregnancy and childbirth (Churchill, 1995a; Churchill, 1995b; Jordan, 1980; Leavitt, 1986; Miller, 1979; Rothman, 1982; Spitzer, 1995; Troutt, 1996; Turkel, 1995). According to Rothman, An analysis of childbirth and the technologies which have come to define the medical model of birth serves to demonstrate the interrelationships among authority, technology, and gender. In the medical model, physicians and technicians not only have the power to define the birth process and to constrain the availability of options, but they also have appropriated the very experience of giving birth. (1982, p.27). Many researchers have concluded that the data show that there are power imbalances between women and their physician caregivers (Churchill, 1995a; Danzinger, 1986; Davis-Floyd, 1992; Oakley, 1984; Troutt, 19%). Churchill, for example, also has suggested that these "differing views have led to a position where medical knowledge and frames of reference are

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46 accepted and legitimated by a system that leaves women feeling alienated and dissatisfied with the conduct of delivery" (1995b, p. 32). Feminist theorists argue that in the midwifery paradigm of childbirth, in contrast, laboring women control their bodies and the birth process (Churchill, 1995a; Churchill, 1995b; Jordan, 1980; Leavitt, 1986; Rothman, 1982; Spitzer, 1995; Troutt, 1996; Turkel, 1995). These theorists imply that the midwifery paradigm leads to greater empowerment for pregnant and laboring women by providing more education and greater choice during pregnancy and childbirth. Empowerment Definitions of Empowerment The concept of empowerment is a central element of liberal feminist theory (Rowland-Serdar & Schwartz-Shea, 1991). Nevertheless, the meaning of empowerment is different for different groups of feminists. Some feminists subscribe to a "traditional" definition of empowerment that is based on traditionally masculine definitions of "power." In that definition, "empowerment is . . . viewed as both the possession of control, authority, or influence over others and as the help provided to assist a person to gain control over his or her life" (Browne, 1995, p. 359). Underlying this traditional definition of empowerment are the assumptions that empowerment is an individual experience, attained primarily for the benefit of the individual, and that agency, mastery, and control are its central elements (Browne, 1995; Gilbert, 1995; Riger, 1993). For the liberal feminists who subscribe to this traditional definition, empowerment has meant extending the options of women beyond the domestic to the public sphere. This focus sought to extend to women certain "rights" which typically were assumed to be granted to males, or at least white males. The vehicle for such empowerment was legal and

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constitutional action: liberal ideals were to be extended to all individuals. (Rowland-Serdar & Schwartz-Shea, 1991, p. 605) Recently, some feminist theorists have redefined the meaning of power and empowerment. In their new definition, "power and empowerment have been reconceptualized more as a process than a thing " (Browne, 1995, p. 360). In this reconceptualized definition, empowerment does not consist of obtaining concrete ends such as "rights" or "control" and the search for empowerment does not end when these ends are reached. Instead, empowerment consists of individuals continually developing their attitudes and abilities. People who are empowered adopt a world-view where they constantiy strive to become more able to control their own lives and to help others to do the same. Hall asserts that women's empowerment includes both a personal strengthening and enhancement of life chances, and collective participation in efforts to achieve equality of opportunity and equity between different genders, ethnic groups, social classes, and age groups. It enhances human potential at individual and social levels of expressions. Empowerment is an essential starting point and a continuing process for realizing the ideals of human liberation and freedom for all. (1992, p. 83) This definition, like the traditional definition, describes empowerment in political terms. Nevertheless, it often is not until women are empowered on a personal level that they can collectively participate in group efforts to pursue and attain social changes on the political level (Hall, 1992). The Empowerment Process The process of personal empowerment is complex. Just as there are many definitions of empowerment, there are many explanations concerning how individuals become empowered (Alcoff, 1988; Bell, 1981; Browne, 1995; Gilbert, 1995; Hall, 1992; Ozer & Bandura, 1990; Riger, 1993; Rowland-Serdar & Schwartz-Shea, 1991; Spitzer, 1995). Underlying all of these explanations is

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48 the belief that a feeling of competency, or efficacy, is a necessary precondition of empowerment. Positive beliefs concerning one's efficacy in a particular domain are a product of knowledge and successful experience. The more knowledge people have in a particular domain, the more efficacious they believe they will be in that domain. Additionally, once people are successful in an area, they often feel efficacious. Education helps ensure success, which often leads to a person seeking more information in an area, which in turn leads to greater success. Proponents of the midwifery model of pregnancy and childbirth propose that the midwife-client interaction empowers pregnant women (Bortin, et al, 1994; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Rothman, 1982; Spitzer, 1995; Turkel, 1995). These researchers explain that the midwives aid women's empowerment by convincing women to trust their own abilities to birth their babies with little or no intervention. Women who have midwife-assisted births often say that the birth process itself was an extraordinarily powerful, and empowering, experience. For example, the following quotes from women in Eakin's study are typical of women's reactions to unmedicated, uninterventioned births: In general, I felt it was the most high, exciting, wonderful time of my life. I was part of the creation of a new being. If s a miracle. . . . There was excitement, I don't know, being absolutely, totally alive, every part of you is alive, keenly. It was so intense. I was happy, I was joyous. I was crying at different parts. It was just awe. I felt wonderful. I felt totally alive and wonderful. Immediately following the birth, I would say I felt ecstasy. ... I felt as if I had been through the most incredible experience and that I would probably never feel that good again. After her shoulders were bom. ... I was just getting extremely eager and happy, getting elated with a sense of euphoria, and [the midwife]

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49 said I could reach down and take her under her arms and pull her out and that was just~I can't explain it! I can't put a good enough word on it! I was so joyful. It was a peak experience. I felt a real sense of things being right, a lot of energy, a lot of love, a lot of joy ... on top of the world ... a feeling of accomplishment. ... All was right with the world. It was pow-er-ful. My labor was powerful. The delivery was— ecstatic. It was the kind of ecstasy that comes from knowing that you have something to do with it— but yet you don't. ... I was awestruck. [I felt] power. Is that an emotion? (Eakins, 1986, p. 230-231) Eakins explains that the women's reactions to their childbirths resulted from empowerment processes: The great majority of mothers experiencing out-of-hospital deliveries emerged from the birth experience exalted. They were awed by the work their bodies had done, and they experienced a surge of selfconfidence and a "newfound respect for all mothers." The women took their ability to control the situation for granted, which freed them to become totally involved in giving birth. The result was a sense of mastery, a sense of satisfaction, and the discovery of inner strengths. (1986, p. 231) There are undoubtedly many influences that may cause the empowerment feelings of a new mother. Reactions of friends, relatives, and, perhaps most importantly, the father of the baby, all may effect the mothers' feelings of empowerment. For example, one researcher (May, 1980) has developed a typology of fathers' involvements in their partners' pregnancies. Some fathers are much more involved than others, and the involvement may take different forms. May (1980) found that the degree and type of paternal involvement affects the mothers' experiences of pregnancy and childbirth. The Need for More Research There are several limitations to the research that links childbirth and empowerment. First, while researchers claim that midwife-attended births

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50 empower women, they have not dearly defined empowerment or explored the specific reasons for empowering experiences during childbirth. Feminist theorists have studied the relationship between pregnancy and childbirth and have noted that empowerment has not been adequately studied. They have called for "qualitative exploration [s] of childbirth as a process" (Bortin, et al, 1994, p. 14). A second limitation of the existing literature is that researchers have neglected the prenatal experience. Most researchers have limited their data collection and analysis to labor and childbirth alone (e.g.. Berg, et al, 1996; Calhster, 1995; Hallsdorsdottir & Karlsdottir, 1996; Walker, et al, 1995). They have not studied the pregnancy experience itself. A third limitation is that the obstetrical paradigm of childbirth has not been carefully studied or explicated. In all but one study, the researchers have not studied the obstetrical paradigm first-hand. Instead, they asked women to remember their childbirths, in many cases several years after their experiences. The research studies that focus on women's experiences with midwifery care are also few in number and limited in focus. Most researchers only examined the outcomes of the midwifery care. Only one study (Turkel, 1995), focuses on the process that the women go through during pregnancy and childbirth. Turkel (1995) is the only researcher who studied women's experiences of the prenatal period. All other researchers interviewed participants only after their babies were born. These researchers could not measure the changes that occurred in the women during their pregnancies. Thus, even though the researchers claim that prenatal care and birth under the guidance of a midwife is an empowering experience, they do not tell us why or how the experience is empowering. If theorists want to claim that

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51 midwifery is a feminist practice that strengthens and empowers women, then they need to define empowerment, and show how it is created. Theorists claim that the midwifery model of childbirth is more satisfying for women than the obstetrical model. Few researchers explicitly examine the obstetrical paradigm of pregnancy and childbirth from the viewpoint of the practitioners in that paradigm. In order to understand how the midwifery model differs from the obstetrical model, and the effects of the difference, a more complete and clear understanding of the obstetrical model is needed. This study will add to that understanding.

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1 CHAPTER 3 METHODOLOGY Research Method Researchers have infrequently studied how perceptions of pregnancy and childbirth help shape the birth experience and women's definitions of empowerment. Therefore, the questions this study asked were exploratory. For this reason, a qualitative methodology was an appropriate methodology for this research project. In qualitative research, in contrast to quantitative or "statistical" research, researchers collect data from small numbers of participants. Qualitative researchers draw from interviews and observations a "thick description" and deep understanding of situations from the participants' points of view. I was interested in uncovering paradigms, or "ways of perceiving" and therefore I used ethnographic methods in this study. In conducting ethnographic research, researchers look for cultural themes in the data. The study's settings, selection and number of participants, the data collection methods, and the techniques for analyzing the data reflect this study's ethnographic methodology. The two paradigms of childbirth and pregnancy that I study represent different ways that my informants interpret childbirth and pregnancy. I use my data to explain how these paradigms relate to broader societal views. Setting s I studied the practices and client outcomes at a free-standing birth center and an obstetrician /gynecologist's office. There are two birth centers in 52

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53 the city where I conducted this study. The birth center that participated in my study. The Midwife Center, is owned and operated by a certified nursemidwife. The birth center that did not participate in the study. The Birth Building, is owned by a married couple, an obstetrician and a midwife. Women who attend The Birth Building see the midwives for their prenatal care. The women then have the option of having their births in the birth center with the midwives or in a hospital, with the obstetrician in attendance. The Birth Building's staff discourage home births. I chose to base my study in The Midwife Center considering that because it is run solely by midwives, it would present a clearer example of the midwifery paradigm. The Midwife Center is staffed by the midwife-owner, a second certified nurse-midwife, and a state-licensed midwife. The Center's secretary is careful to schedule the clients' prenatal visits so that each woman has at least one prenatal visit with each midwife. The midwives believe that it is important for each of them to establish a relationship with each woman because the midwives take turns being on call for the births. Also employed at the birth center are several nurses who work as assistants at the births. The birth center acts as a preceptor to licensed midwifery students. Frequently, after obtaining permission from the clients, students from a local midwifery school attend prenatal examinations and births at the birth center. Two students attended prenatal visits during the time I conducted my study. Women who receive their prenatal care at the birth center have the option of delivering their babies at the birth center or at home, with a midwife and assistant in attendance at either place. I had been involved with The Midwife Center before the beginning of my study. Over the course of the ten years prior to my study, I had three children and one miscarriage, and went to The Midwife Center for care for all

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54 my pregnancies. Two of my children were born at The Midwife Center, and my last child was born at home, with staff from The Midwife Center assisting. I therefore had a good relationship with the midwives, and they were enthusiastic about participating in my study. I called several obstetrician offices to find a site for the obstetrical aspect of my study. One obstetrician. Dr. Smith, called me back promptly and readily agreed to participate in my study. The obstetrician is the sole owner and operator of his practice. He provides pregnant women with prenatal care and attends their births. He employs two nurses who assist during prenatal visits. The clients who receive their prenatal care from this obstetrician deliver their babies at a local hospital, with the obstetrician in attendance. Participants The study included seven pregnant women, three midwives, an obstetrician, and six additional individuals who provided services or care for the pregnant women. Four of the women were birth center clients, and three were clients of the obstetrician. I selected clients with similar characteristics: all were between the ages of 20 and 30, were married or living with the baby's father and intending to marry, were pregnant for the first time, had attended at least some college, and were happy that they were pregnant and looking forward to becoming mothers. According to standard medical criteria, all the participants at the beginning of the study were at low risk for developing complications during pregnancy and childbirth. I selected participants to be as homogenous as possible so that I might find differences between the women that emanated from their prenatal care rather than from their individual situations. All the participants were between five to seven months pregnant at the beginning of the study. I chose to limit the study to women who were in at least their second trimester of pregnancy because the risk of miscarriage

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is substantially lower after the first trimester. Because I wanted to measure how women's perceptions changed over the course of their pregnancies, I did not include women who were past the seventh month of their pregnancies. I also conducted interviews with the women's partners. All the partners were between the ages of 20 and 30 and were either working or attending college full-time. All the men were actively involved in the pregnancies, attending at least two prenatal visits, whatever childbirth classes their female partners attended, and the birth itself. I used different methods to recruit participants. The birth center offers free nutrition and exercise classes to all clients. Many of their clients, especially those that are pregnant for the first time, attend these classes. With the instructor's permission, I attended the classes, explained my study to the women, and asked for volunteers. To partially compensate the women for their time, I offered a small monetary reward ($25.00) to participants. Most of the women in the classes were willing to participate. I had the women fill out short informational forms, and then selected the participants who met the study criteria. Fortunately, most people who attended the classes were experiencing their first pregnancies. Initially, five expectant mothers from the birth center met the criteria and agreed to participate, but I was unable to interview one of the women because of scheduling conflicts, and she was dropped from the study. The only classes that obstetrician-assisted clients attended were the childbirth classes. The hospital offered these classes to women in their last trimester of pregnancy. These women were too far along in their pregnancies to participate in my study. The obstetrician therefore gave me permission to sit in his waiting room and recruit women as they came in for their prenatal examinations. His office staff assisted by letting me know when likely

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56 candidates would be coming in for their appointments. I approached the women before or after their examinations, explained my study, and asked if they would be willing to participate. If they agreed, I asked them questions to determine whether they met my study criteria. Most of the pregnant women I talked to at the obstetrician's office did not meet my study criteria (it was not their first pregnancy, they were planning on moving before their babies were born, their pregnancies were not low-risk, they were too young or too old, they did not have a stable relationship with the baby's father, or they had not attended at least some college). It was more difficult to find qualified participants at this office, so I offered the women who did qualify a significant amount of money for their participation ($100.00). After visiting the doctor's office ten times, I was able to recruit three women. Data Collection I used several qualitative methods to collect data. By using more than one method of data collection, I gained a deeper, more reliable and valid understanding of the study participants' experiences. The methods I used were (a) formal and informal interviewing, (b) observation, (c) artifact review, and (d) photographic self-narrative. Interviews Over a seven-month period, I conducted at least five interviews with each pregnant women. For each of these interviews, I developed an interview protocol based on my research questions and findings in the literature. When I developed each succeeding protocol, I used my preliminary data analysis as a guide for additional questions. I used these interview questions as conversational starting points that invited women to tell their stories in their own ways. I conducted a formal interview with the pregnant women at the beginning of the research period and after three of

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their prenatal visits. I conducted a formal interview with each woman within one to three weeks after their babies' births. In addition, I interviewed five of the women (four from the birth center, and one from the obstetrician's office) five months after their babies' births. I formally interviewed the women's partners once before the birth of the babies and once afterwards. I conducted one formal interview with each of the midwives and the obstetrician and spoke with each informally at least three times. In addition, I informally interviewed six individuals who assisted the pregnant women, either by teaching classes or conducting portions of the prenatal visits. I conducted 38 interviews in person and 20 over the telephone. I audio-taped and transcribed all the interviews I did in person. For the remainder of the interviews, I typed notes into my computer as I conducted the interviews. The typed notes captured as much important information as the transcriptions, although the quotations were shorter. Observations I attended one prenatal visit with each participant, and several classes offered by the health care professionals. The midwifery practice offered nutrition, exercise, and childbirth classes. I attended all these classes. The obstetrician did not offer any classes of his own, but referred clients to childbirth classes offered by the local hospital. I attended a full set of these classes. EHiring these times, I used an observation methodology (cf. Spradley, 1980). This method consists of the researcher observing interactions of interest to the study and conducting informal interviews, often in the form of conversations, with the participants. The researcher records notes of the situation, both during and immediately after the situation occurs.

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Artifact Review I collected copies of all information that the health care professionals distributed or made available to the women during prenatal visits and during classes. I obtained 21 handouts and pamphlets from the birth center and 6 from the hospital's childbirth classes. I examined the artifacts for their educational content and for explicit and implicit philosophies of pregnancy and childbirth that they contained. Photographic Self-narrative I used a photographic self-narrative technique to better measure subtle but empowering effects of childbirth (Ziller, 1990). I provided the participants with cameras and gave them the following written instructions: I have given you a camera that has 27 exposures. I need you to take pictures of images that you believe represent womanhood. The pictures can be of anything you want. Examples of possible pictures include: • pictures of people; • pictures of objects; • pictures of scenery; • pictures of pictures found in magazines, books, etc.; • anything else you believe represents womanhood. I developed the film and discussed the pictures with the women. I asked them to explain why they took the pictures and what the images meant to them. I also asked the participants how the photographs reflected their ideas about women. Initially, I had intended for the women to take two sets of photographs, one during their pregnancies, and one after the birth of their babies. When I asked the women to take the second set of pictures, however, they all said that their views of women had not changed during birth and that the pictures that they took would be identical to the first set. Several of the women also said that the weeks following the births of their babies were hectic and, although

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59 they were willing to be interviewed about their births, they did not have the time, energy, or opportunity to take a second set of photographs. Data Analysis I entered the interviews, field notes, photographic self-narratives, and descriptions of the artifacts into a computer data base, using FileMaker Pro software. I then analyzed the data according to an ethnographic technique based on Spradley's (1979). The first step in this method is to "decontextualize" each piece of data. To accomplish this, I assigned preliminary classifications to the data as soon as possible after collection and/or transcription. During this analysis, I scrutinized each statement and field note line by line. I then "coded" the data by applying interpretive labels to the sentences and paragraphs. Some of the data applied to more than one domain, and I gave this data multiple codes. I assigned "subdomain" labels to the data, which clarified how the data fit into the domain. For example, I put the statements that the women made concerning the amount of control that they had over their labors into the domain "Control Over Labor." I then gave each statement a subdomain that more completely described the statement's meaning, such as "doctor determined speed of labor," or "woman decided when to push." The analysis process was circular. As I analyzed the data from the first set of interviews, I noted that domains that needed clarification. I worked to clarify these domains in the second set of interviews. As I analyzed the next set of interviews, I further redefined and reorganized the domains. For example, during my first two rounds of interviews, some of the women discussed receiving support fo"om others although I had not asked the women questions about support. I put these comments into the domain "Support from Otiiers." During the next round of interviews, I asked all of the women

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60 about the support that they received from others. I put these responses in the "Support from Others" domain, and then assigned subdomains to the data, clarifying who gave the women the support (parents, health care professionals, coworkers, etc.), and what type of support the women received (emotional support, information, etc.). The next phase was componential analysis. During this phase I examined the contrasts among the data in the different domains. This clarified the relationships among the domains and yielded the organization of the data presentation in the results sections. For example, I looked at the data in the domain "Reason for Selecting Caregiver" and compared the data from the midwife-assisted couples with the data from the obstetrician-assisted couples. The data from the two sets of couples were significantly different, and I discuss these differences in a subsection in Chapter 4. The final step was theme analysis. I examined the domains for multiple relationships and determined how the different taxonomic categories related to each other. The results of this data analysis guided my research of possible theories for interpreting the data. I conducted a literature search for writings that presented broad cultural frameworks through which my results could be understood. I then applied the theories to my results and developed my conclusions. Research Bias and Ethics At the beginning of my study, I was concerned about possible researcher bias. I knew that research showed that midwife-assisted births were at least as safe, if not safer, than obstetrician-assisted births. I also knew that midwife-assisted natural births could be powerful and exciting. When it came time for my data analysis, I took precautions to insure that my biases did not unduly effect my data interpretation. I accomplished

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61 this by concentrating on explaining, rather than judging or comparing, each paradigm. For example, to describe the paradigms, I did not look for similarities and differences between the paradigms. Rather, I searched the data for each paradigm separately, and developed two paradigm descriptions that did not include comparisons between them. I discuss further precautions in the "Reliability and Validity" section below. As a feminist researcher, I was concerned about "using" my subjects. My participants met with me numerous times during their pregnancies and once after their births. Most of the women remarked that they enjoyed having a chance to talk about their pregnancies and caretakers. Still, I made the interview process as easy for them as possible, interviewing them at their homes or other convenient places, and conducting some of the interviews by telephone. I also paid the women for their participation, and bought gifts for their babies. Another, harder problem to overcome was the urge to offer advice to the women. The women who chose the obstetrician as a caregiver did not appear to be aware of the midwife option. These women also received minimal education from their obstetrician. I was tempted to offer advice several times during the interviews, but I stopped myself. At first, I wondered if it was ethical for me to not give the women potentially helpful information, or share my own childbirth experiences with them. I judged each event separately and concluded that remaining silent would not put the participants in any danger. I decided not to discuss my births or my beliefs with the women during my study. When I recruited my participants from the birth center, I told the women that I had experienced midwife-assisted births. When participants asked me to give them details about my study I told them that I was studying

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62 the effects of different settings on pregnancy and childbirth. I did not offer advice to the women or make any negative comments about their experiences with their childbirth attendants. Reliability and Validity The nature of qualitative research makes it more difficult to establish reliability and validity. In ethnographic research, for example, researchers themselves are the measurement instruments. It may be hard for a researcher to formulate valid results because the researchers' world views and past experiences necessarily effect the research process. Also, because ethnographers enter the field with broad questions to guide their observations, it is hard for them to insure that they are paying attention to the "important" happenings of the culture being studied. It may be difficult for researchers to "objectively" analyze the data and formulate valid conclusions. It may be hard for a researcher to obtain reliable observations because the phenomena being studied is in constant flux. Ethnographers study people, and people and their cultures constantly change, defining and redefining each other. Another potential problem with reliability is a result of the small sample sizes used in qualitative research. Differences found between groups may be the product of individual variations rather than true group differences. One way I enhanced both the reliability and validity of the study was by becoming immersed in the field. Ideally, ethnographers should spend a great deal of time in the field, so that they can observe many situations, and find recurring themes. Long-term frequent observations and interviews provide researchers with a wealth of information. Over an eleven-month period, I conducted 58 formal interviews, over 20 informal interviews; and observed 7 prenatal visits and 10 classes.

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63 There are several other methods that I used to maximize the validity of my findings. First, I decontextualized the data during early analysis. Removing the specifics (such as the participants' names) fi-om the data helped me concentrate on patterns that could be developed across the data. It is only when the I put the results into domains that I begin to recontextualize the findings, looking for reasons to explain the patterns and the discrepancies in the domains (Spradley, 1979). Another method I used to insure valid conclusions was that of triangulation. Triangulation refers to using more than one data source to substantiate any conclusion. I drew on two or three sources to identify each of the paradigms' components. I also used a variety of sources, which are listed and described below. A third way of maximizing the validity of my research was through the study's presentation. The way that ethnographers present their studies can help readers judge for themselves the reliability and validity of the conclusions. I do this by describing what I, personally, brought to the study. In these first three chapters I discuss my background, world view, and theoretical approach to the issue. I describe the context in which I conducted the research. This allows the reader to better understand variables that may have influenced the results. Another way that I help readers judge the validity of conclusions was by providing "thick description." Researchers do this by including numerous interview quotes and field note abstracts in their results presentation. I provide thick description throughout the three results chapters. The final way that I enhanced the validity of this research was by conducting "member checks" with several of my participants. After the first draft of my conclusions, I called five of my participants and discussed my

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64 findings with them. All the participants agreed with my interpretations, and stated that I accurately reported and analyzed their experiences. In addition to becoming immersed in the field, I maximized the reliability of my study by ensuring that all the pregnant women were similar in many aspects. I tried to ensure that the only difference between the two groups of women was the health care provider that they chose. Because of the nature of qualitative research, ethnographers will never be able to state with the same assurance as quantitative researchers that their measuring instruments are reliable and valid. Nevertheless, qualitative researchers can compensate for the subjectivity that permeates all research by taking appropriate precautions.

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CHAPTER 4 THE COUPLES Introduction Researchers have suggested that there may be psychological and behavioral differences between women who prefer midwives and women who use obstetricians (Harvey, et al, 1996). These initial variations may cause women to experience childbirth differently. In analyzing the interviews and photographic self-narratives, I noticed several similarities and differences between the two groups in my study. I categorized and analyzed these similarities and differences to see if they helped explain why the two groups selected different caregivers and why the groups had different perceptions of their experiences. In the following sections, I discuss these similarities and differences in detail. To protect the research participants' confidentiality, I describe the photographs that they took, rather than include the photographs themselves. The four couples in my study who went to the birth center were: Suzyi and David, Nancy and Christopher, Mary and Steven, and Amanda and Arthur. The three couples in my study who went to the obstetrician's office were: Jane and Charles, Kelly and Mitchell, and Amy and Ronald. All the couples except for Amy and Ronald were married. Amy and Ronald lived together and planned on marrying after their baby's birth. The women's ages were between 20 and 29. All the women worked or attended school during at least the first half of their pregnancies. ^All research participants' names have been changed for the sake of confidentiality. 65

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66 Similarities The two groups were similar in (a) their reactions to the pregnancies; (b) physical and emotional changes caused by pregnancy; and (c) some of their views of women. Reactions to Pregnancy Four of the couples in my study had planned their pregnancies and were happy at the idea of becoming parents. Two of the midwife-assisted couples and one of the obstetrician-assisted couples had not planned their pregnancies. Once over their initial surprise about their pregnancies, however, these couples were happy at the prospect of becoming parents. Suzy, a midwife-assisted woman, described her initial reaction to the news that she was pregnant: It was just a state of shock, actually. This was unplanned. We knew that it was a possibility, but we thought the likelihood was very low. . . . It was very unreal, for the first . . . day and a half to two days. Then it started to get exciting. Kelly, an obstetrician-assisted woman, had a similar reaction: At first it was a little hard because it wasn't planned. So emotionally, just with school and parents and everything else it was a little hard. . . . [I was] very surprised. . . . My whole life was going change, it was going to be such a big change I didn't really know what to think. Nancy, another midwife-assisted woman, had not actively plarmed her pregnancy, either, but was not surprised when it happened. It wasn't such a shock as I was expecting it to be, actually. I kind of looked at it and thought, "Yeah, it seems kind of probable." But on the other hand, up until I took the test I hadn't necessarily been expecting that it would be positive. So, I guess my subconscious was clued in, but my conscious hadn't really grasped it yet. Most of the fathers-in-waiting were less ambivalent about becoming fathers. When I asked Nancy's husband, Christopher, how he felt when he first found out that his wife was pregnant, he said.

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67 I was ecstatic. We've wanted ... a child for a while, so it was kind of a happy surprise. We hadn't really tried, we hadn't said, "Well, if we start now we can have a child here at this time." We didn't do anything like that, but when it happened it was a happy surprise. I asked Kelly's husband, Mitchell, the same question: Janet: How did you feel when you first found out that Kelly was pregnant? Mitchell: I was happy. Janet: Were you surprised? Mitchell: A little bit. Janet: What were some of the thoughts that went through your mind? Mitchell: Happy and nervous, unsure of what to do. Only one father-in-waiting, Suzy's husband David, was irutially uncertain about becoming a parent: [I was] very shocked at first. I didn't see it coming. Usually I felt like [when] something that big [happened] I would have heard something from God. I tried to understand what God's will was. At first, you're not convinced that if s a good idea. It did not take David long to decide that he was comfortable with the pregnancy: "It only took less than a day [for me] to start to realize that it was a good idea. I realized that we'd been talking about it before, and it would be OK, we would prepared for it." Physical and Emotional Chang es Women in both settings experienced the usual physical and emotional pregnancy-associated turmoils. Two women, one in each setting, had particularly difficult first trimesters. Jane, an obstetrician-assisted woman, stated, "my first three months were very hard. It seemed that I was nauseous and tired all the time." Nancy, a midwife-assisted woman, related similar experiences:

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68 [The first trimester] was not easy. I found it really hard to get any work done, to concentrate at all. I felt queasy. There was a period of two to three hours in the middle of the day that I didn't feel queasy per se, and I got most of my eating done then. But I could only eat certain things. . . . I couldn't sleep, I was getting up to go to the bathroom all the time. . . . It was awful. All the women in the study noticed an increase in mood swings and emotional irrationality. Suzy, who went to the birth center, explained that during her pregnancy her emotions were definitely more tumultuous than normal. I broke a glass and went into tears and was inconsolable for ten minutes. And the whole time, I'm thinking, this is ridiculous, why am I so upset about this glass? If s just a glass. But I couldn't stop. And once I start crying, I can't stop. Even if I feel better, I still can't stop. Nancy, who went to the obstetrician's office, reported being overwhelmed occasionally with uncontrollable emotions. I feel I get really irritated sometimes, and I feel like I can't control that. I've seen more drastic mood changes. Like, sometimes I can get really depressed and cry at nothing, and sometimes I can get really irritated, and sometimes I'm fine. Seems like more of the other emotions than just a normal everyday. Views of Women The photographic self-narratives reflected some similarities among the two groups' perceptions of womanhood. I had asked the women to take photographs of objects that they believed represented womanhood. Women in both groups included pictures that represented (a) motherhood, (b) taking care of others, (c) taking care of one's self, (d) relationships, and (e) differences from men. Motherhood. Not surprisingly, women in both groups took pictures representing motherhood. Suzy, a midwife-assisted woman, explained why she took a picture of a woman playing with a child on a swing set: "Motherhood is a part of being a woman, and if s a part that I'm very

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69 sensitive to right now." Amy, an obstetrician-assisted woman, took pictures of a baby because "thaf s such an important part of my hfe right now." Care of others. Women in both groups believed that one of women's roles is to take care of others, especially family members. Amanda, who went to the birth center, took a picture of several food items placed on a table. She explained: "This one with the food-we often think of men as being the ''bread-winner" of the family, but if s really the women that provide nourishment and cook, and keep the family strong." Kelly, who went to the obstetrician's office, took a picture of a woman standing in a kitchen, balancing a baby on her hip. The woman is standing in front of a mixing bowl and holding a spoon. Kelly explained that she took this picture because "It seems like we're always busy doing something and taking care of the kids. Cooking, cleaning and everything else, just taking care of our families." Care of self. Women in both groups agreed that part of being a woman means taking care of one's self. Amanda described one picture that she took, but that did not develop dearly. I just had a calendar with a box of tampons in front of it, which is a very practical, obvious thing, but if s a very important part of women's lives, ifs something that we have to [attend to]. [It symbolizes] our reproductive system and taking care of ourselves. So, not the most glamorous part but definitely [an important part]. Jane took a picture of the care products on her mother's vanity for similar reasons. I took [a picture] of my mother's vanity, because ifs got all of her makeup and jewelry and a mirror there so she can see herself close-up. Not that I think that women are vain, but I think those kind of products are important to most women to take care of themselves. Relationships. All the women took pictures that represented relationships. These women believed that concern with relationships is part

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of a women's role. The women took pictures showing a variety of relationships, including: (a) with their husbands: I was taking a picture of this couple down here; just before I took the picture, they were all snuggled up together, and just as I took the picture, she turned away. . . . But they were all snuggled up, watching ducks swim in the lake. ... So, that was just a relationship, a husbandwife relationship; (Suzy) (b) with their mothers: This is a picture of my mother. She is ... a really interesting person. We have a really close relationship. . . . We see each other a lot, and, especially since I've been pregnant, she gives me a lot of advice; (Amy) and (c) with other family members: These two pictures are collages of pictures of relatives and their children. These family relationships are important to me. (Nancy) Mary did not explicitly discuss relationships as part of womanhood, but she did emphasize the importance of family. Mary explained that she took a picture of her church because "They really teach the importance of families, and the purpose of marriage is so that you can have children, [and you] can have families." Difference from men. Women from both groups viewed women as having some qualities that are different from men. For example, Amanda took several pictures that represented differences she perceived existing between men and women. Amanda described women as being more (a) sensual and artistic: This [picture is of] my belly dancing instructors. I . . . chose them because I just think of women as being kind of the more sensual and artistic side of the species. And [they are more] expressive; (b) concerned with housework: I [took a picture of] the sink because . . . [of] the women being the one that traditionally, or stereotypically, keeps the house in order and keeps the home going;

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71 (c) interested in family history: This bed was my grandparents' and the medals are my husband's grandfather's medals, and I chose to put those together because I think if s usually the women who are the ones that keep the roots of the family and are the history keepers of the family, more so than men; (d) patient: This is a painting that I made, if s called "Patience." ... I think women . . . have a great deal of patience. Just in what we have to accomplish in our lives as mothers and nurturers, we need that patience; and (e) interested in communication: This is the phone book, telephone, stamps, and letters because I think the women is often the correspondent in relationships. Like I know I probably talk to my husband's mother more than he does. And I think thaf s really pretty common that the women keep the ties between the family, and keep the communications going. Jane also took several pictures that she believed represented differences that exist between men and women. Jane described women as (a) having different tastes in art: This picture here I took because my grandmother actually painted that [painting]. ... I just thought that it reflected my grandmother's point of view of appreciating the flowers on the windowsill there, that she had picked. Those were probably from our backyard, and I just thought that represented womanhood because it was feminine and well-thoughtout; (b) interested in collecting things: Thaf s my Girl Scout uniform from when I was a girl, and ... I thought that represented womanhood because my mother was a Girl Scout leader and ... I went to Girl Scout camp and it was obviously something that a boy couldn't do. . . . It was just sitting around [during] . . . weekly meetings with all the girls. I thought [it] represented womanhood because we'd [chat] and also ... we had looked forward to getting our patches. I think girls tend to collect things, and we'd try for our patches and you'd have to do certain things to earn your patches, and it just seemed like a girl thing to do; (c) concerned with taking care of the family:

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72 I . . . took the [picture of] the iron, because my mother solely does the ironing in the house. . . . I've never, ever seen my father iron. My husband will iron occasionally, but I still think that is very much considered a woman's job, to iron. I think it represents a woman being neat, and also . . . wanting to take care of the family, having them all look good; (d) meticulous: This picture of the sewing machine, I thought . . . represented womanhood because . . . thaf s something thaf s passed on from woman to woman, and definitely I think that women have sewed more because . . . they are more meticulous and they're more crafty in that sort of way. Also, I think women tend to have more of those natural instincts of wanting to clothe their children or their family and make sure that they have all their buttons and everything; (e) concerned with family connections: These are all pictures that my mom has out, and my mom likes to have lots of pictures, and so do I. I think thaf s kind of a woman-thing. She's got her grandkids' [pictures] here . . . and I think thaf s a womanthing, because I think she likes to feel like she's surrounded all the time by her family. Not that I don't think men care about that, but . . . especially with cute baby pictures . . . maybe my husband . . . wouldn't care as much about [themj; (f) sentimental: Thaf s the card that I gave my mom for Mother's Day, and I had [written] a special note in there My mother had saved [it] all these years, I think thaf s probably about ten years old I think that women tend to be a little more sentimental; (g) willing to be pampered: This picture I took of the hot tub in my parenf s bathroom is because I think that women like to be pampered, and this is very much a feminine thing with the candles and the sense of relaxing and escaping. When I think of that picture I think of the commercial where [the slogan is] "Calgon, take me away." If s always a woman that they're showing and maybe she did dishes, or laundry, or worked all day, or was with the kids all day I think thaf s very much a relaxing, luxurious pampering thing. Thaf s definitely a woman thing; (h) concerned with taking care of others:

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73 This picture is of my . . . mother fixing my sister's hair, and I thought that was very much something that would represent womanhood, because it not only shows the mother and daughter relationship, and how close that is, but also how the mother and daughter relationship tends to be very [concerned with] taking care of each other and I haven't seen really a father try to [style] a girl's hair. Especially something like my sister's hair, where it's long and you have to take care of it. But again, I think if s that taking care of somebody else; and (i) concerned with their appearances: This picture I took of my mother's vanity, because if s got all of her makeup and jewelry and a mirror there so she can see herself close-up. Not that I think that women are vain, but I think those kind of products are important to most women to take care of themselves and they like to see how they look and take the time to do their hair and make-up. She's got nail polish here and everything, and I just thought that when you compare what my father has on his bathroom shelf and what my mother has, there's definitely a big difference. Education and career. Women from both groups took pictures representing education. Kelly took a picture of an undergraduate catalog and explained, "I took this picture for education, school." Before Kelly became pregnant she was pursuing an undergraduate degree, and she viewed education as being part of her definition of "woman." Similarly, Suzy said that education, as a prerequisite to a career, figured prominently in her definition of womanhood and identity. These are my engineering books, which is a very important part of my womanhood. [They represent] my career and my professionalism. I've spent a great deal of time and money on [my education] so far, and if s a part of my identity that I really draw a lot of confidence from, and a lot of strength. Differences I noted several differences between the groups in the areas of: (a) reasons for choosing tiieir caregivers; (b) amount of information tiiey sought during tiieir pregnancies; (c) tiieir expectations for childbirth; and (d) some of their views of women.

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\ 74 Reasons for Choosing Caregivers Midwife-assisted couples. The couples who chose The Midwife Center researched and discussed their options for pregnancy and childbirth before they chose their caregivers. When I asked Amanda why she chose the birth center, she replied, "I read books on the subject, and we visited hospitals and birth centers, and decided that this would be best." Nancy gave similar reasons for choosing the birth center: I'd been doing some reading up on labor and giving birth and I was brought up with a very, I don't know, maybe not exactly in a hippie atmosphere, but certainly very relaxed social atmosphere compared to some other people I've known, and so a midwife seemed like, really, the obvious choice for how I wanted to have the baby. The midwife-assisted couples discovered during their research that birth centers offered a philosophy of pregnancy and childbirth with which they felt comfortable. Steven explained, Mary and I . . . did research on pros and cons between a hospital and a birth center, and we decided to go for the birth center . . . just from the research, things we read. ... It was more family-oriented, it seemed more natural, [birth] wasn't in a . . . cold hospital with a bed, and steelrimmed everything. Amanda felt comfortable with the midwives' attitudes towards birth: During the tour [of The Midwife Center], I asked about the philosophy of the midwife. I wanted to make sure that they believed in similar things. I asked lots of questions, because I didn't know what their normal practices were. In the hospital certain things are always done, and I wanted to see if [the midwives] had a set of specific things that they always did. . . . For example, their beliefs on episiotomy, I didn't want them to be strict either way, and [the midwife] said what I wanted to hear They also supported my decision on water birth. I'm not sure if I will have a water birth ... but I want to have that as an option. The couples discovered that, with a midwife-assisted birth, there would be less chance of the women undergoing unnecessary medical interventions.

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75 Nancy explained that she was concerned about the increased possibility of medical interventions that are present with a hospital birth: I didn't really want to give birth in a hospital. I don't want to deal with knives or drugs or anything like that. ... I just felt more comfortable in a more homelike environment with midwives, rather than in a hospital with a man with a knife. Steven voiced similar concerns: I'm ... a pre-med student, and I took a class about medical terminology and in that class you talk about all kinds of medical procedures and things, and they talk about c-sections. The teacher said—he works with doctors a lot—he said that in recent years they've done more and more c-sections. He said one of the main reasons is because insurance costs are so high, and doctors have to be able to pay for that, and he said that 50% of all people that are bom today are bom with [a] c-section, which I thought was ridiculous, it shouldn't be that way. I also spoke to my dad later . . . and he said that my mother had all of us by c-section, and he thought that it shouldn't have been that way, that she probably could have had [us] normally if she didn't have them in the hospital, and so that was probably one of the biggest things that worried us. The couples who chose midwifery care were happy with the safety backup systems employed by The Midwife Center. David explained that the most important factor that influenced his decision to agree to use a birth center was "being reassured that they could transfer Suzy to the hospital if anything happened." Mary gave similar reasons for her choice of birthing place: Mary: We wanted to go somewhere we could trust. Janet: And why did you think you would be able to trust The Midwife Center? Mary: Because the people were really, really nice. They had backup systems for anything that can go wrong. They have plans for . . . any problems. They're prepared for anything that can go wrong.

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76 Amanda and Christopher were the only people who had previous experiences with non-hospital births. Amanda had attended the midwifeassisted births of her friends, "Two of my friends had births with midwives, and I was at their births. I was a birthing coach for one of them. ... I really liked the type of care and treatment she received." Christopher had experienced non-hospital births in his immediate family. I'm comfortable with [midwife-assisted births]. I'm very easy-going about it. . . . My brother was a home birth, my sister started off as a home birth, so thaf s pretty normal for me, it^s like 1 didn't have any real problems with the idea of being in a birth center at all. The couples in my study cited several reasons for choosing The Midwife Center over The Birth Building. Insurance factors played a key role in two of the couples' decisions. For example, when I asked Suzy why she chose The Midwife Center, Suzy replied, "Because if s completely covered under [my] insurance." Nancy, who is covered by the same insurance plan as Suzy, elaborated: The question was, what do we have in [this city], and will the insurance pay for it? I called the insurance company and said: "What midwives in [my city] will you cover?" And they said, "Oh, we cover The Midwife Center." . . . There's a hundred dollar deductible and if s in the [preferred provider] network so they cover 100%. And that was the main reason for the specific location. The two remaining midwife-assisted couples chose The Midwife Center because it looked and felt less medically-oriented than The Birth Building. Amanda explained, I had been at two births at The Birth Building, but I really liked the midwife who gave the tour [at The Midwife Center] . . . and I felt really comfortable there. It had more of a homey atmosphere. I just really liked the home feeling of The Midwife Center. Mary also compared the two birthing centers: I looked at one other birthing center I didn't look on the inside [of The Birth Building], just looking at the outside was enough for me. I

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didn't like it. . . . It looked like a doctor's office. It didn't look as homey as the other one, the one I wanted. ... I decided I didn't want to go there. Obstetrician-assisted couples. None of the three obstetridan-assisted couples considered options outside of obstetrical care and hospital births. They also did not mention knowing women who had chosen midwives as caregivers. The obstetridan-assisted couples did not research different options or consider whether the obstetrical paradigm matched their own views. When I asked why they chose their particular caregiver, they did not offer reasons for choosing an obstetridan over a midwife. Instead, they explained why they chose their particular obstetridan. Each couple had a different reason for selecting their obstetridan. Dr. Smith. Amy chose him because of his reputation among her friends. I had heard a lot of good things about him. [I heard that] he was really easy to talk to; really fun, and understanding. There was one other [doctor] who I had heard about . . . but I had just heard more good things about [Dr. Smith]. When Kelly discovered that she was pregnant, she was living in a different city than her husband, Mitchell. Kelly and Mitchell decided to have the baby in the city where Mitchell was living, and it was up to Mitchell to make the initial obstetrical appointment. Mitchell described the randomness in his selection of Dr. Smith. Janet: Why did you choose Dr. Smith? Mitchell: I just called people in the phone book, actually. Janet: And why did you choose him? Mitchell: Actually, because Kelly was in [another dty] at the time, going to school down there, and it was the only [obstetridan's office] I could get her into when I could get her up here.

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78 Jane and her husband, Charles, also knew nothing about Dr. Smith when they chose him. Jane explained that she had no choice in her selection of doctors: My insurance company gave him as my only choice. We have military insurance, and not many doctors accept it. Initially, I was going to a different ob/ gyn practice, but they stopped accepting my insurance and they dropped me. ... It wasn't really a choice. Amount of Information Soug ht Written information. All the women in my study read at least one book about pregnancy and labor. Most of the women read several books. Obstetridan-assisted Amy, for example, said that she had "gotten a lot of books, and read a lot about pregnancy and birth." Midwife-assisted Amanda claimed, "I have everything, and I've read everything." The midwife-assisted women, however, were the only ones who mentioned spending time actively researching specific topics and problems that arose during their pregnancies. Nancy explained that whenever she had a question or concern, she would research the topic. My parents sent me all the books they had and I went to the Friends of the Library book sale and picked up a whole stack of books, and we go to the bookstore and the library and read up on a bunch of stuff. So, I get a sense of what the general consensus is. Amanda actively sought information on things that might help her during labor and delivery: "I've been researching water births, and from what I've been reading it seems that laboring in the tub helps labor." Suzy, who has asthma, said that the results of her research agreed with the advice that the mid wives gave her. "[They told me to] continue taking my medication, which is the same thing that I found when I researched it on the Internet." Informati on from others . When the obstetrician-assisted women discussed pregnancy and childbirth with others, they usually received only

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79 birth stories from other women. The type of information that Amy received from others was not reassuring: My mother gives me advice, she had three children. She said that birth will be painful. My mother said that I should definitely do an epidural. . . . My coworker had natural childbirth . . . because her doctor didn't believe in using pain medicine. . . . She didn't have a positive time. . . . There were complications, and they had to use forceps. When they were using the forceps, and they pulled baby out, the forceps broke her tailbone, and she had to lie on her stomach for three months. The midwife-assisted women received more helpful advice. For example, Nancy explained how her parents helped her find information. If I have any questions, I email my mother and she does a search on Medline and tells me things. . . . My mother's a biochemist and she's really interested in all this kind of thing. Every time I have a question I send her an email and she sends me back references and journal articles and abstracts and things. Childbirth classes. The midwife-assisted women were more likely to attend classes relating to pregnancy and childbirth. All of the midwifeassisted women in my study attended the exercise, nutrition, and childbirth classes offered at The Midwife Center. Only one of the obstetrician-assisted women, Jane, attended the childbirth classes offered at the hospital. Expectations for Childbirth The couples who had obstetrician-assisted births had different expectations for their childbirth experiences than did the midwife-assisted couples. The two groups had different beliefs about their ability to handle labor pain, they wanted different amounts of control over the process, and they had different views of medical interventions. Ability to handle labor pain. All of the women thought that childbirth would be painful. Jane stated. Last night [during a childbirth class] we saw a movie where a person delivered a baby. Watching her give birth really freaked me out and

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80 scared me. I have a very low tolerance for pain. ... I plan on definitely having an epidural. Nancy worried about the pain as well: It did hit me, a week ago, that I'm pregnant enough now that my belly is reaching out a little, and there's definitely something in there that is not small. And no matter what happens, if s going to be painful. Women going to The Midwife Center, however, believed that they would be able to handle the pain. These women knew that the birth center's staff would not offer them pain-killers during their labors. Nevertheless, the midwife-assisted women trusted that the midwives would teach them how to handle the pain. Only one obstetrician-assisted woman. Amy, stated that she would try to labor without pain-killers: "I feel that natural is the way if s supposed to be done. If s a natural way of feeling the birth rather than having scientific medicine pumping through your veins." Nevertheless, Amy was not confident in her ability to control the pain: "I want to try to go natural, but I also want anesthesia there just in case I can't handle it." Desire for control. One difference was in the amount of control that the women wanted to have over their labors and deliveries. The midwifeassisted women wanted to have a good deal of control over their childbirths. Nancy explained: "Thaf s another reason why I'm comfortable being [at the birth center], because I have more control over what goes on, and I am taking the responsibility for learning enough about whaf s going on that I can make informed decisions." The obstetrician-assisted women, on the other hand, were not as concerned about having control. Amy explained that she trusted her doctor to make any necessary decisions: "I have faith, and my doctor, if something does seem like it will go wrong, he will make the right decision about doing a

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81 c-section or anything else." Jane said that she expected her obstetrician to be in charge of the childbirth, and would be upset if he relinquished his responsibilities. There were a couple of things that were irritating [in the book given at the childbirth classes]. . . . Women were explaining their labors, and one women said that she delivered her baby by herself; the doctor said that she could just grab down and pull out the head herself. I'm all for having some experience, but if my doctor's there, he's going to do his job. I don't need a mirror to experience all of this. If my doctor said [to deliver my baby myself], I would be upset. If he can't do that for me, then why do I have him there? Acceptance of medical interventions . The obstetrician-assisted women were more willing to have medical interventions. They were all happy to have three routine sonograms performed during their pregnancies, and they were all open to having episiotomies and epidurals. Charles explained that he and Jane had no qualms about medically inducing the labor to control the baby's size. Two weeks before Jane's due date, Charles stated: This is the time when [babies] gain a lot of weight, and [Jane] has a small stature so she doesn't want the baby to be too big. So if we don't see any marked improvement, like say at 40 weeks, I want to find out . . . if we can induce [the labor] and not go too far with the term. Views of Women As discussed above, there were some similarities between the two groups' views of women, as reflected in the photographic self-narratives. Nevertheless, there were some important differences as well. These differences occurred in the areas of: (a) sacrifices of motherhood, (b) concern with appearance, and (c) similarities to men. Sacrifices of motherhood. Only the midwife-assisted women took pictures that represented the sacrifices that motherhood demands. For example, Mary took a picture of her reflection in the mirror. She explained, "This is the first picture I've allowed of myself, with my belly I just think

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of motherhood as a sacrifice of the body." Mary's view that pregnancy is detrimental to physical appearance was shared by Suzy. Suzy had taken a picture of her wedding and engagement pictures, and explained that, "I look at those pictures to remind me of what I want to look like, instead of whaf s in the mirror right now. That's the conception of myself I Uke to have." Midwife-assisted women believed that they sacrificed their comfort to become mothers. Nancy took a picture of her bathroom and explained that: I was spending far more time in the bathroom than ever before. I had no idea early pregnancy was so much like having the flu. I had no idea middle pregnancy involved getting up to go the bathroom every two to four hours. I'm spending a lot of time in the bathroom. Nancy also took a picture of her sleeping area to symbolize the discomforts of pregnancy. This one over here, with pillows everywhere, [represents] just the whole learning not to lie on one's back while sleeping combined with not being able to lie on one's front because the breasts are really sore and the stomach's all queasy and all the rest of it. . . . Thaf s the main focus of this picture, is just wanting to spend as much time as possible lying down and feeling horrible. And now, again, I'm spending more time in bed because I'm having trouble sleeping because the kid's kicking me all the time. Other sacrifices mentioned by Mary included that of time and tastes. Mary took a picture of a clock because "I also think of womanhood /motherhood as a sacrifice of time, thafs why if s a picture of a clock." She took a picture of two cars because "This was kind of a statement about how interest in cars [changes], showing the nice, beautiful, red [sports] car; and the big family car, the ugly family car." Concern with appearance. Obstetrician-assisted women were the only ones who took pictures that represented a concern with manipulating their outward appearance. Their concern with appearance was different from the midwife-assisted women's belief that part of womanhood means sacrificing

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83 one's body. The midwife-assisted women acknowledged that, although they might not like it, changes in body shape are part of being a woman. In contrast, the obstetrician-assisted women believed that being a woman meant purposefully camouflaging and changing the body. This view is apparent in the above quote, where Jane describes how women are more concerned than men with their appearance. Kelly also exhibited this view. She took a picture of a makeup collection and a picture of a woman exercising. Kelly explained how these pictures reflected her ideas of womanhood: This [picture] with all the makeup is [because] when everybody thinks of a woman we always have to go out of our way to dress ourselves up. Thaf s the first thing you that you think about, really. I took this one, the woman working out . . . [because] like the makeup, in our country we really put an emphasis on beautiful woman. Similarities to men. Only midwife-assisted women discussed attributes that they thought women and men held in common. For example, Mary believed that being a parent is part of being a mother, and to represent this she took a picture of a father with his children. Amanda took a picture of a painted ceramic chameleon and stated that some of the characteristics that define "women" are really characteristics of people in general: "The chameleon is just to show that we're always changing and growing, like the chameleon can change colors and things. I think all people— not just women, either, but men too—are just constantly changing and growing." Midwife-assisted woman also believed that responsibility for household maintenance was a characteristic common to both sexes. Suzy took a picture of laundry hanging in a bathroom and explained: This represents my household responsibilities, which consist of cleaning the bathroom and doing the laundry. And since I'd just gotten laundry, I got them both in one shot. ... I do have other household responsibilities, although those are my two main ones.

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84 Suzy's husband took care of the other household chores, such as washing the dishes. Women as strong . Only midwife-assisted women described strength as a characteristic of women. Suzy described a picture that she would have liked to have taken, but could not because she did not have her camera with her: There's a lab in my [school] building, where they test concrete and test steel and . . . they were testing this huge concrete slab. And if s like twelve feet up in the air. And there was a girl sitting on top of it. A girl from our department, sitting on the concrete, twelve feet up in the air, with her steel-toed boots on, and that was just a great picture. Nancy could not find anything to take a picture of that represented her idea of women's strengths, but she discussed how she was raised with the belief that women are strong and capable. My grandmother, when my dad was growing up in the 50s and 60s, ran her own secretarial business; she supported herself and two kids. My mother's a biochemist, and a professor at a university. My aunt has a Ph.D. in mathematics and works for a computer firm. The women in my family generally are pretty self-sufficient and do whatever the hell they want to do. Summary The two groups of couples were alike in many ways. All the women were happy that they were pregnant, and some women in each group endured difficult physical and emotional changes during pregnancy. The groups held some views of women in common, believing that motherhood, taking care of others, taking care of one's self, relationships, and differences from men are all important parts of being a woman. I had selected participants who were similar in several demographic categories, and this may explain why the groups exhibited several similarities. Nevertheless, I also found significant differences between the two groups. Midwife-assisted women were more careful in selecting their pregnancy and childbirth caregivers, researching their options and touring

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85 facilities before they made their choices. They also sought information more aggressively during their pregnancies, were more confident that they could handle labor pains, and wanted control over their labors. Obstetrician-assisted women were more accepting of medical interventions and some of their views of women differed from those held by the midwife-assisted women. The obstetrician-assisted women put less emphasis on the sacrifices of motherhood; they believed that women were concerned with manipulating their outward appearance; they did not discuss similarities between women and men; and they did not state that strength is an important characteristic of women. These differences may indicate that the two groups of women in my study began pregnancy with different needs and beliefs. Their differences may also have affected the women's interpretations of the significance of their childbirths.

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CHAPTER 5 THE MIDWIFERY VIEW OF PREGNANCY AND CHILDBIRTH The greatest joy is to become a mother; the second greatest is to be a midwife. Old Norwegian Proverb Introduction Norm paradigms are "taken for granted" in this culture and are thus self-justifying. In the United States at the present time, most people adopt the obstetrical paradigm and view the midwifery paradigm as a deviation from that norm. The medical paradigm does not explain itself, because it seldom has to. The medical paradigm has explicit methods and an implicit philosophy. The explanation of alternatives to the taken-for-granted norm generally includes a clear philosophy statement, an explanation of the norm paradigm, and an effort to delegitimate this norm with anecdotes describing problems with the norm. Midwives are aware that their practice is relegated by many to the edges of the mainstream. Midwives therefore have had to insure that their philosophy is well-formulated and easily explained. Midwives consciously reflect upon their paradigm and explicitly teach it to their clients, taking care to differentiate it from the medical paradigm and give it a privileged position. The Midwives The midwives that I interviewed had carefully constructed views of pregnancy and childbirth. In fact, they all had chosen the midwifery 86

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87 profession precisely because they agreed with its philosophy. Barbara^ explained: I was a nurse and became attracted to OB during nursing school. ... I went into [psychiatric] nursing and then eventually got into OB when I knew I really wanted to pursue midwifery. I had been a nurse for several years and [midwifery] just became my focus. So I worked in labor and delivery and I never really had a medical OB bent. It was more the midwifery kind of angle right from the beginning. So I was reading and studying and getting the experience by working as a labor and delivery nurse and then went to midwifery school. Barbara, a mother of four, was attracted to the midwifery view because she had negative personal experiences with some medical births. Barbara learned through these experiences that it is the setting under which a birth occurs, rather than the ease or difficulty of the birth itself, that determines how a woman will subjectively experience the birth: From my own experiences as a woman and as a mother, I had positive experiences and I had negative experiences [of birth] and none of them depended on the medical risks or outcomes of the births. I had as my most traumatic birth a normal vaginal delivery that was screwed up by hospital procedures and policies. It had a normal outcome but it was very traumatic and is actually what really led me into midwifery. ... It made me realize that none of those things needed to happen. ... It was only because of hospital procedures that negative things occurred. I had a placenta previa with a different child, and thaf s a real medical emergency and I was hemorrhaging, it was a c-section, it was premature, it had all the earmarks of . . . trauma, but it was nowhere near as traumatic for me emotionally or just even as a whole than the botched normal birth was. Liza, who was bom and raised in England, was convinced at an early age that home birth was a safe alternative to the medical model. My first memory as a child is of being twenty-two months old, standing outside the bedroom door in my grandparents' house, my father behind me, my ear glued to the door, waiting to hear the baby cry when ^Throughout this dissertation, I use pseudonames for the midwives' first names cind the obstetrician's title and last name. This reflects the way that the clients and the office staffs address the health care professionals. It also reflects the nature of the interactions between the health care professionals and their clients.

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88 my sister was born. I was allowed in immediately and held the baby. . . . We were allowed ... in even before the placenta even delivered, and the baby was just wrapped in the first receiving blanket. So, indelibly in my mind, was this [idea] that babies could be safely bom at home, and that that was part of my experience. Liza became a midwife because she could not find an acceptable caregiver for her own first pregnancy, and wanted to ensure that more women have the opportunity to have a midwife present at their childbirths. When I was looking for care when I was pregnant with my first child, I had come from England to America and I was in this rural area, so I went to the health department and walked in and announced that I was there for prenatal care and to make arrangements to see the midwife for a home-birth. This was 1974 [and] they all just kind of looked at me, and their mouths dropped open and they laughed, and they said, "Oh, no no no, honey, we don't do it like that here." And then I found out how they did do it . . . here. And birth was extremely medical. Fathers were not allowed in the delivery room at that time. . . . Your arms and legs were restrained on the delivery table. The baby went to the nursery for a full 24 hours, [and there was] no breastfeeding. ... It was so different from what I had expected and what I had anticipated that 1 started looking for a midwife and found out that there weren't any available. As I looked, and as I read more and as I studied what to expect from birth and what to expect from pregnancy, the more I became convinced that what I wanted to do was to be a midwife. It took me twelve years to start training for the midwifery degree from that time on, during which time I had three more babies. And, by the way, I didn't go to the hospital with that [first] baby. My husband and I stayed home and had her on our own. . . . We just really couldn't find anybody for the first one. Judy also saw problems with the medical view of pregnancy and childbirth and therefore decided to pursue midwifery: I was an OB nurse for several years in three different hospitals and became very frustrated with the kind of maternity care women were getting. Women were victims of their caregivers instead of being served by them. And the OBs were very brutal in the 70s and early 80s. Also, there was a tremendous movement towards alternative birth at that time and I became very interested in home birth and I really wanted to learn more so I could help my friends deliver at home. It

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was what I wanted to do when I went to school— do home births. I like what I'm doing now. I like giving women the alternative to having a medicalized birth. The Paradig m The midwifery paradigm is different from the medical paradigm, and midwives educate their clients about these differences. For example, during the first childbirth class at The Midwife Center, Sandra, the instructor, asked the couples present, "Why did you choose the birth center?" After obtaining several responses, Sandra explained that she felt strongly that women who are pregnant, especially those pregnant for the first time, should know the difference between a hospital birth and a birth center birth. People who go to the hospital are no different than people who go here, but the hospitals have a much higher c-section rate. I want you all to understand what are we doing thaf s different here, and why are we doing it this way. Sandra went to a marker board and wrote down the beliefs that underlie the midwifery viewpoint: • Nature/God directs birth. • Women's bodies are normal/Birth is normal/healthy. • Women give birth. • Women's wishes. • Family is important. • Pain is part of being human and OK. Sandra explicated the midwifery paradigm. I found evidence of these components in my interviews and observations, and I discuss each of these components below. I found three other paradigm components in my interview data: (a) It is important for the midwives to have good personal relationships with the women, (b) Women need to be emotionally prepared for childbirth, and (c) Birth should an empowering experience for women. The midwives and their clients repeated these paradigm components throughout my study and especially during childbirth classes.

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Nature /God Directs Birth The midwifery paradigm includes the belief that birth is a natural process, directed by a natural force. Sandra explained that there are various names for the power that directs birth, including "God" and "Nature." No matter what name the power is given, however, the concept remains the same—except in unusual circumstances, the power enables women to have healthy births with little or no intervention. The act of intervention is more likely to interfere with the process than assist it. Sandra explained: "Humans can't control birth without messing it up." Sandra said the error of the medical model is that it tries to control what is a natural process. Unnecessary medical interventions may be, and often are, dangerous. Barbara asserted that, "For low-risk, healthy women, a lot of the procedures that are routine in the hospitals can have negative effects as well as helpful effects." During a childbirth class, Sandra illustrated the danger of intervention with the following story. A woman that I knew who had her baby in the hospital pushed her baby from 10 in the morning. . . . They did a C-section at 3:30. There were better positions that she could have gotten into to push the baby out [but she could not because they had administered] drugs. ... An epidural equals no feeling, and how can you push a baby out if you have no feeling? Sandra then explained some of the differences between the procedures that the midwives use during births and the procedures used in hospital births. Here we do intermittent monitoring of the fetal heartbeat with a [handheld Doppler stethoscope]. ... At the hospital, they use electronic fetal monitoring. The woman lies in bed, gets a 3-inch thick elastic belt with a Doppler device strapped around her stomach, and there's a huge machine beside her blipping out the heartbeat and measuring contractions. No study has ever proven it to result in better outcomes for the baby, and the use of it has resulted in 316% more C-sections Hospital procedures . . . create a disaster out of normality.

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91 The midwives do not rule out the use of medical technology altogether. They do recommend the use of it when warranted by the individual case. Barbara stated, "We're not anti-technology, we're for the appropriate use of technology." Sandra explained to the class that pitocin creates strong and frequent uterine contractions, which can be hard on the baby and difficult for a laboring woman to endure. Sandra explained that epidurals are problematic because they may slow down labor, eliminate the pushing urge, and cause sluggish babies. Nevertheless, she also stated, "There is no one [intervention] that is in and of itself bad. An epidural may be a godsend that makes it possible for you to have a vaginal birth rather than a csection." The midwives in my study used medical technology when they thought that it was necessary. For example, they suggested that Nancy should get an ultrasound during her pregnancy. The midwives do not routinely use ultrasounds. They made their recommendation because they believed that it was advisable in this particular situation. My cycles are generally long. I mean, I don't think in my life I've had a cycle shorter than thirty days. ... So, everyone I've talked to [says], "Yeah, you'll probably go long, first baby, you know, takes longer ... [it will] probably [be] a week or two late." I'm like, "Okay, I can handle that." And then at the last [prenatal the midwife said], "Oh, that's funny, I would have thought [you'd deliver] a week early." Just in passing. I'm like, "Wait a minute." I expect that it was because the uterus was a bit bigger than would normally be expected. . . . But we're going for the ultrasound to make sure of the due date. (Nancy) The midwives also do not hesitate to transfer women to the hospital if they believe that it is medically necessary. In fact, during a childbirth class, Sandra spent an hour discussing complications of pregnancy and birth that would necessitate transfer to a hospital. She stated that one out of every ten women who have their prenatal care at The Midwife Center end up being

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transferred to the hospital for various reasons. After a baby is bom, the midwives may also refer a woman to the obstetrician. For example, Nancy pushed out her baby quickly, and in the process acquired a bad tear in her perineum. The midwives decided to send Nancy to the hospital to get her tear stitched. Liza looked at it and said, "I know I'm not capable of mending that one. I'm going to call Barbara and find out what she thinks." So . . . Barbara showed up and did the examination and said, "Oh, this is a thirddegree tear. We're going to send you off to Dr. Brown." Women's Bodies are Normal /Birth is Normal / Healthy Insurance companies often state in their policies that they provide pregnancy benefits, "as for any other illness."^ Such statements could convey that pregnancy and childbirth potentially are harmful. The midwifery paradigm, in contrast, includes the belief that birth is a normal and healthy event. They believe, as Sandra stated during a childbirth class, that "Women are strong and capable. Birth is not a disaster waiting to happen. It works. This is a dramatically different way of perceiving birth-It is a way of perceiving women as strong and capable." Often, pregnant women have to be convinced that this view of birth is reahstic. Barbara explained: I think for women today, . . physically we're told that we can't have babies without medical intervention or interference. . . . [We try] to help women trust their bodies, and [to believe] that in almost every case, they will be able to [birth naturally]. Barbara believed that the midwives at The Midwife Center were successful in getting women to trust in the normalness of birth. They're healthy, normal women and they hopefully are given the confidence that birth is a normal, healthy, physiological function that •^The Anthem and the Monumental Summary of Benefits pamphlets, states under the heading "Maternity," "Pregnancy benefits shall be provided as for any other illness.

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their bodies are made to do and to trust their bodies. ... I think that that sense of belief of birth and the calmness and just the atmosphere of the birth center and the midwives makes it easier to believe and trust in the body. During a childbirth class, Sandra explained how women's bodies are designed to make birth a bearable experience: "Endorphins are your bod)^s natural pain killers. In early labor your body does not release many endorphins. Endorphins are triggered by oxytocin. As your labor progresses, you get more oxytocin, and you also get more endorphins." The midwives' actions illustrate their conviction that women's bodies usually take care of themselves. For example, during a prenatal visit, Mary's iron level measured a little low. Barbara advised Mary about dietary changes that she could make and supplements that she could take to raise her iron level. Then Barbara reassured Mary, "Your level is not dangerously low, and it probably will go up anyway, even if you did nothing about it." The midwives frequently reassured the women that most births proceed with few complications. Mary: How often does it happen that a woman wants to push but she's not fully dilated? Barbara: Not often. Often if there's a little bit of the cervix left a few bearing pushes will dilate it the rest of the way. Very rarely will the cervix get too swollen. Sometimes if the baby is posterior, the woman will feel the urge to push before she's fully dilated. It doesn't happen often. Judy believed that part of her job was to reassure women that birth is natural. Janet: What do you do to help prepare a woman for childbirth? Judy: I try to be very, very positive. I [share] with her my trust in her ability to do it and [connect] her with all the woman who have done it before. Thaf s really helpful. Connecting her with people she's known so that she's not feeling like her

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94 experience is isolated from every other woman's experiences. Janet: How do you connect her with other people? Judy: Stories. If s an oral thing. Letting her know that people she's met in classes and in the birth center have had successhil experiences, for example. Talking about my own experiences, just sharing. Just sharing and letting her know that she's not alone. I think thaf s part of it. If s just a continual positive reinforcement of her ability. The midwives also worked to help the women expect and accept the bodily changes that occur during pregnancy. In a prenatal visit, Barbara complimented Amanda on the henna design that she had painted on her stomach. Barbara commented that If s really great that you had that done. A lot of women look at disgust at their pregnant belly. I like to work on [this concern] with women. They don't like being big and fat, and if s hard for them to view their pregnant selves as beautiful. Objects at The Midwife Center reflected this view of pregnancy as beautiful. On the coffee table in the birth center's waiting room there was a large book filled with photographs of artistically posed pregnant women. In addition, adorning the birth center's walls were paintings and photographs of pregnant women. Women Give Birth The midwives emphasized that it is women, not the health care professionals, who give birth and who should be in control of the process. Sandra asserted in a class, "Women are in control of the birth. The language of passivity on her part is ridiculous. . . . She did the delivering, it wasn't the doctor." The midwives believed that they must convince each client that she can manage control over her labor. Judy explained:

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When you're in the middle of labor, it has a timeless experience like if s going to last forever. But [it helps to let] her know that if s just a very time-limited experience, and that she can do everything that she needs to do in this very limited amount of time. At the end of it, she'll be a mother. At the end of it, she won't have a bandaged leg, or any other kind of thing. She'll be a mother and she'll have achieved what it is she's waited so long to achieve, thaf s part of what we do, just continually let them know how well they're doing, how well we expect them to do, how normally we expect things to go. So they have a lot of confidence in themselves. One way that the midwives helped their clients assume control of pregnancy and childbirth is by working hard to educate the women. The midwives believe that educated women make better choices during pregnancy and childbirth. Conversely, midwives see lack of education as contributing to unsatisfactory experiences. Janet: What might cause a woman to have negative experiences during childbirth? Liza: Things that take away her choice and her feeling of control. . . . Being in any way confined in her choice of positions and choice of comfort measures and in her choice of who can be with her as support. Also, lack of information about whaf s actually happening to her body. Lack of knowledge and information. The midwives believed that pregnant women need education and that pregnancy is a natural time for learning. Liza explained: [Pregnancy is] a tremendously open time for learning, it really is the teachable moment, because [women are] so open to lots of new information. Women will often make big changes in their lifestyle [during pregnancy and] they seem to be much more open to those kinds of things. The midwives attempted to educate the women through several means. In addition to offering a variety of classes, and providing a lending library, the midwives educated women during prenatal visits. Classes. The Midwife Center offers free classes to its clients and the midwives actively encouraged women to take these classes. Nancy explained.

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96 "[The midwives] have said, 'Are you going to take the classes? Have you signed up yet? Okay, all right, thaf s good.'" The Midwife Center offers nutrition and exercise classes for clients in early pregnancy, and childbirth classes for those in late pregnancy. The information in the childbirth classes covers breastfeeding and postpartum care as well as labor and delivery. For families who already have a child, the birth center offers sibling classes. The birth center also hosts postpartum celebrations every four to six weeks, where the childbirth instructor and new parents gather to discuss their experiences and share advice. One recurring theme of these classes is that the women are in control of their bodies, and the choices that they make are important. Therefore these should be informed choices. The instructor works to give the women a clear understanding of what is happening to their bodies and suggestions for what they can do to make their pregnancies and labors as healthy and easy as possible. For example, at the beginning of the exercise class, the instructor showed the women large posters that contained drawings of cross-sections of a women's body. Different posters corresponded to different stages of pregnancy. The instructor used these charts as well as uterus, pelvis, and fetus models during class discussions to illustrate the pregnancy changes that occur to women's organs, muscles, bones, and hormones. The instructor explained how women can minimize problems that these changes may cause. To alleviate lower back pain, for example, the instructor taught the women an exercise that they could do by themselves, and another exercise that they could do with a partner's assistance. To help motivate the women to actually do the exercises, she gave examples from her own pregnancies: "When I was pregnant and I would exercise, I would come out of it feeling fantastic It is

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97 very helpful, and you will reap the benefits. . . . You will all have minor discomforts during pregnancy, and it will ease these." During the nutrition class, the instructor concentrated on teaching the women how they could modify their diets to maximize their chances of a healthy pregnancy and easy labor. During these classes, the instructor discussed vitamins and minerals, iron, calcium, fats, carbohydrates, and fluids, explaining exactly what benefits the nutrients provide, as well as listing good food sources for them. Instructors talked in everyday language ("It's better to take iron and calcium supplements separately") and in more technical language ("Iron and calcium have the same receptor site [in] the cell. If calcium gets there first, iron can't get there"). The midwives recognized that different people prefer different learning styles. Sandra explained to the couples during the first childbirth class that Not everyone learns by reading, so you may need to find other ways of learning. Other ways include discussing experiences with others, or watching videos. But I will also bring in a crate full of books every week. To provide a variety of experiences in the classes instructors added hands-on activities, videos, guest speakers, and handouts to traditional lecture and discussion periods. During an exercise class, for example, the instructor demonstrated an exercise and then asked women to practice it as she observed and corrected their technique. The instructor also asked women to demonstrate how they lifted objects. She then discussed the proper way that pregnant women should lift. In a nutrition class, the instructor guided the women through an analysis of their own eating habits. The midwives had given each woman a "diet log" during the woman's initial prenatal visit. On this log the women wrote down everything that they ate and drank for a

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98 week. At the nutrition class, the instructor taught the women how to categorize the food into nutritive components, such as iron, calcium, protein, carbohydrates, vitamins and minerals, and fluid. The women calculated the number of servings of each nutrient in their weekly diets. The instructor then gave the women strategies to improve their diets. Sandra used guided relaxations and visualizations during the exercise and childbirth classes as a way to help the women become more comfortable with their bodies and their pregnancies. During these exercises, the women arranged themselves comfortably on large pillows, and Sandra turned down the lights. She started one exercise by leading the women through relaxation of all their muscles. She then told them: "Bring your awareness to your belly. Imagine that you can see inside. You can see your pelvis, your uterus, and then beneath your uterus see your baby, head down, in a sac of dear fluid." Sandra then explained what the fetuses would look like at that stage of pregnancy and what the baby could feel and hear. She told the women to follow the umbilical cord from the baby to the placenta and explained the umbilical cord's functions. Sandra then explained to the women Each of you has body knowledge that knows how to grow and nurture the baby. Just like your body knows full well how to make a baby, it knows how and when to birth. This body knowledge lies deep inside your belly waiting for you when you need it. After the class ended, Sandra explained why she uses these exercises: "I like them because they're internal. Nothing about labor is mental, and if s hard to get at what [labor's] like experientially." During each series of childbirth classes, Sandra showed videos on the philosophy of midwifery, two or three that showed women in labor and childbirth, and one on circumcision. She often chose the videos based on the

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99 women's interests. For example, during one class that 1 observed Sandra explained why she brought in a specific video. "It is on water birth and I wanted to show [it to] you because there are a couple of people in here who are considering [a water birth] pretty seriously." Sandra invited guest speakers to talk to the classes about their childbirth experiences. Sandra recruited couples who had recently had their babies at The Midwife Center to share their birth stories with the "couples-inwaiting." Lending library . The Midwife Center contains a lending library that lines two walls in if s waiting room. Clients may check out books on such topics as contraception, pregnancy and childbirth, breastfeeding, parenting, schooling, and child development. In addition, the midwives maintain a file of articles and pamphlets on topics such as circumcision, breastfeeding, and cord blood donations. Sitting in the waiting room, I observed midwives getting books from the bookcases and information from the files to give to women after prenatal visits. During a childbirth class, Sandra explained that some of the lending library's materials were getting old and out-of-date. She then said she had applied for a grant from the March of Dimes to get new books and to create a video library. "Until these materials come in," Sandra said, "I've brought in some books that you are welcome to borrow." She then brought in a crate of books and discussed the content of each book with the class. The book topics included water births, comfort measures, active birth, and general pregnancy and delivery. Sandra also included some medical reference books because, as she explained to the couples, "I think if s important for you guys to do this research if you're interested in it." Other books that she brought in contained accounts of women's experiences with birth, because "if s good to read about

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100 other's experiences of birth," and other books included good fetus and birth pictures. During the break time in each class, most couples looked through the books, and many borrowed some to take home. Prenatal visits . During prenatal visits, the midwives worked to educate their clients. They gave advice whenever the women asked questions or mentioned problems, and they passed out information brochures on relevant issues. In an interview, Liza said, "We . . . talk a lot in prenatals about what questions women have and what to expect in the next little while." Mary, a client, thought that the midwives offered useful information. She explained: They give you lots of things. They gave me a brochure about early signs of preterm labor . . . and back in the beginning they gave me pamphlets on tests you can have done on the fetus to make sure that there's nothing wrong with the baby. ... If I ever ask any questions they always know where I can get that information. Nancy, another client, concurred: "They're always really happy to answer any questions I might have, and if they've never heard the question then thaf s even more interesting [to the midwives]." The midwives tailored their teaching to the individual women's needs. For example, when Nancy had a bad cold during her eighth month of pregnancy, her Braxton Hicks contractions increased in number and intensity. She went to a prenatal visit at this time: "I brought up the matter of Braxton Hicks. . . . They gave me a sheet about possible signs of preterm labor and how to tell when you are having real contractions." Similarly, Suzy, who has asthma, was worried about her asthma medication affecting the fetus. She worried, "I know it doesn't make me feel that great; it can't make the baby feel real great, and that worries me." She mentioned her concerns to a midwife during her prenatal visit.

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[The midwife] advised me to continue taking my medication . . . because the risk of lack of oxygen to the baby is much worse than the risk of the side effects from the medication. So, [she told me to] pretty much just to keep on as normal and try to stay really on top of it, make sure I don't have any trouble at all. . . . She did give me a sheet from [a local teaching hospital] that she got on . . . the medications that I was taking. (Suzy) The midwives also gave information on topics that were not directly related to the women's health or pregnancies. An example of this occurred during one of Nancy's prenatal visits. Nancy's father, who was a mathematician, attended the visit, along with Nancy's husband. Cara, a midwifery student, was conducting the visit under the supervision of Barbara. At the visit's end, Cara brought Nancy and her retinue into an adjoining room, where there was a centrifuge. Cara collected a few drops of Nancy's blood to check her iron levels. She collected the blood in a pipette and then placed it in the centrifuge to spin. Nancy and her father expressed interest in the centrifuge's operation, so while the blood spun, Cara explained how it worked. After the machine stopped, Cara removed the pipette and explained how to read the results. She described the different blood components, and everyone in the room watched her measure the blood cells. Nancy and her father worked out the mathematical formula necessary for the measurement. Cara then asked Nancy and her father if they would like to examine the centrifuge more closely. By educating women through various methods, and by encouraging women to seek information, the midwives enabled their clients to make informed pregnancy and childbirth decisions. The midwives hoped that the education they provided helps their clients to take control of their pregnancies and childbirths.

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102 Women's Wishes Part of the midwifery paradigm is the belief that the pregnant women should have their wishes respected. The midwives believed that a happy pregnant woman will have an easier labor and delivery and that a woman who is allowed to make choices during labor is more likely to have a successful outcome and will be more satisfied with the birth. When I asked Judy what caused some women to have negative experiences during childbirth, she replied: Not being part of the decision-making processes during the birth. Being treated exactly like every other woman. Not being treated in a personal way. Having to fit into the situation of the institution instead of the institution tailoring itself to her needs and her birth experience. Barbara explained that part of the reason why women have positive experiences during birth is because "they are not disassociated. They are very much a part of the decisions of what happens during their care. They are not on mind-altering drugs and they're really kind of flowing with the moment." Liza concurred, stating that for a woman to have a positive experience she must "feel that she's having her needs met, whatever they might be; and that she's being seen as a person and as important in that; that her wishes and her being are being respected; and that she has some choices." The midwives also believed that the women's wishes correspond to what is best for the baby. Sandra explained in a class that Women know whaf s best for the baby. ... All of the things that women want have been well documented to be best for the baby. For example, if a [pregnant] women is hungry it's because she wants to feed the baby. The midwives encouraged the women to act on their wishes whenever possible. For example, the midwives allowed the women to invite as many people as they wanted to the birth. They also could bring and consume

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103 whatever food and beverage they wished during labor and after the birth. The midwives told the women that they might labor and deliver in any position that they wished. The women might choose to have a water birth and /or have their babies at home. The midwives encouraged the women to trust their instincts when it comes to labor and delivery. Amanda: If my water doesn't break during early labor, when should I call the midwife? Barbara: If you go into early labor in the daytime, call us whenever you like. ... If you start early labor at night, try to sleep through it. But certainly call us whenever you feel like you need to. Family is Important The midwives believed that the women's families should be fully involved in the pregnancies and childbirths. Judy explained that part of her job is to get the women to not . . . see this pregnancy as happening [only] to her uterus. If s happening to her whole family. . . . Are they helping her to do the things that she's not able to do so that she can get enough of what she needs? Liza claimed that "seeing [the partners] as an integral part of the family and as part of the birth, is probably the best thing we can do." Barbara encouraged the partners to attend all classes and prenatal visits: "I think just being in . . . the atmosphere, they also have a much greater opportunity to ask questions, to get their questions answered, to get to know us and to feel part of the whole process." All but one spouse attended the majority of the prenatal visits. The midwives usually directly addressed the partners during the visits, asking them if they had any questions or concerns. The midwives also attempted to draw the partners into participating during the examinations, as the following excerpt from my field notes illustrate:

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104 Mary and Steven sit next to each other beside Barbara's desk. After all three finish discussing Mary's lab results, and Barbara has addressed Mary's concerns, Barbara asks Mary to sit on the examining table. Steven remains in his chair at the other end of the room. Barbara turns to Steven while she takes Mary's blood pressure, and asks, "Did you have tests last week [in your classes]?" Steven stands up and walks closer to the examining table as he discusses his tests. As Barbara continues with Mary's examination, she continues to chat with both Mary and Steven about grades and tests. Barbara feels the baby's position and measures Mary's abdomen. She then puts a hand-held Doppler stethoscope on Mary's stomach, and everyone smiles as they listen to the baby's heartbeat. After Barbara finishes examining Mary, she asks Mary if she has any questions, and answers several. Barbara then turns to Steven and asks him if he has any questions. Steven says, "No." The midwives also included the spouses in the exercise, nutrition, and childbirth classes. The spouses actively participated in these classes, asking questions, taking notes, and trying the exercises and relaxation techniques. The spouses indicated that they enjoyed the prenatal visits and classes. Arthur stated about the prenatal visits, "I enjoyed them. The midwives gave us useful information. They answered questions I had or explained the status of the pregnancy. They discussed how things were going and how the progress should be." The midwives also believed that the family's existing children should be involved in the pregnancy and childbirth process as much as possible. Judy stated: We love the kids to come to the [prenatal] visits, and we often have children come to the visits so they're seeing this abstract idea of a baby in their mother's belly as a person. . . . [We] get the kids touching the mother's belly and listening to the heartbeat. We show them pictures of what the baby looks like inside [the mother] and prepare the children; have them imagine the baby, and [get them] to talk about who they think baby is. They often have real ideas about who the baby is before if s bom. We have a sibling class where they get to see a film and diaper a doll and stuff like that.

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105 The Midwife Center offered classes for children who are about to have a new sibling. Liza explained: There's a sibling class for prospective big brothers and big sisters, and the kids love it. . . . They just come out of that with all kinds of information. They see a video of a birth, they talk a lot about what new babies can and can't do, and we encourage parents to prepare their kids realistically for the changes that will happen. So many people say to the siblings, "Oh good, soon you're going to have a baby brother or sister to play with!" So this child's expecting someone that can play with them. Then the baby's bom and if s this toothless, useless thing they can't even touch, they're not going to hold a toy, they're just no fun. They're totally useless as a playmate. How disappointed can you be? They're telling you you have a baby to play with. [Babies] can't even talk. The midwives also welcomed children at births, as long as they are old enough to not be upset by the sight of their mothers' discomfort. Judy explained: I find most of the kids who come to births are very well-prepared by their parents. Mothers will tell them what kinds of sounds she's going to make and what kinds of fluids and blood there's going to be at the birth. And specifically, what she needs them to do, because kids love to have a job at the birth. A lot of times at the birth, thaf s what we'll do, we'll say, "Well, your job is to put the cloth on your mommy's brow," or "Give her sips of fluid," and the kids really love that, they do a really good job. Or "If s your job to tell us whether if s a girl or a boy." That sort of thing. We love siblings at birth, and they do great. Except, until the age of two and a half, they're too young to know how separate they have to be between their mother and them. And they really don't have a concept of something going to happen. So very small children, it doesn't matter how many times you tell them, they don't really understand. . . . They're so immediate. . . . Very often what happens is that family members or friends will take care of the kids while the mother is in labor and then bring them over immediately afterwards so that they can see the baby right after the birth. If s a lot of fun. They really respond so spontaneously, [they have] so much spontaneous love for the baby, [and] if s really a great time. They say such great stuff, that you couldn't even feed them the words. They say really neat things to the baby. I think they feel connected more.

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'1 106 The midwives also welcomed the involvement of other family members. Parents were welcome at the prenatal visits, and two mothers came to classes I observed. Pain is Part of Being Human and is OK Adherents of the midwifery paradigm view pain, especially labor pain, as natural and not undesirable. Sandra explained during the first childbirth class that "Labor is a doable kind of pain, and there is value to it. . . . Pain can work for you." In one of the videos that Sandra showed, the narrator stated that "Pain is a state of mind, just like pleasure is. The two must exist side by side." The video then showed a woman in the pushing stage of childbirth. The narrator explained that the woman was afraid of losing control. The midwife encouraged the woman, telling her to "Let the power take over. You need to realize that the power is your own. Rather than working against the energy, you can step into it." Pain, midwives tell their clients, is power. Sandra taught the couples that labor pain keeps women focused on the labor process. At the same time, the endorphins that are released in the women's bodies during labor help the women endure the pain. The pain, along with the endorphins, help women concentrate on the muscles that are working and enable women to feel better connected to their bodies. Sandra explained that "During strong contractions, women will often close their eyes and look within themselves. They often have a hard time hearing anyone except for their partners." This concentration and focus on the muscles helps speed up birth. The midwives also believed that the pain helps make the birth experience empowering. Judy explained: For a lot of women the fear of the pain of [labor] really robs them of the empowerment because they'll numb themselves against the pain. . . . I've never had a numbed childbirth, but to me there's something about

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going through it, and then, at the end, having a child and knowing your body did that without [intervention] that really creates empowerment. Although the midwives saw value in pain, they also understood that women want to minimize pain during labor. They therefore taught the women and their partners comfort strategies and breathing techniques that they could use to control labor pain. Because different techniques work for different people and at different stages of labor the midwives described many pain-relief options. During early labor, for example, the midwives encouraged the women to stay at normal activities as long as possible. Sandra explained: If you come in too early, you will be bored and will feel more pain. A major strategy of early labor is to distract yourself. . . . Keep this up until the women absolutely has to concentrate to get through the contractions. You need to have a plan of what to do at home during early labor. If if s nighttime, go to sleep. If you are tired you will feel more pain than if you are not tired. Follow your normal rhythm as much as possible. Make sure that you do what the woman wants to do, not what the man wants to do. Go out somewhere, and think of it as a last date together before you have a baby. Going to a movie is good. . . . You want to make sure you also drink a lot of fluid. This will help your pain tolerance and give you more coordinated contractions. Sandra explained that during active labor, guided relaxation and visuahzation exercises may help women. Sandra stated to the women after leading them through a visualization: "If this is something that works for you, there's a lot you can do using visualization for pain." In a later class, Sandra then described how women can minimize their pain and speed their labor by relaxing during each contraction and visualizing their cervix opening wider. Suzy stated that comfort measures were some of the most helpful things that she learned during the childbirth classes.

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I 108 Suzy: I . . . learned a wonderful trick with a sock. You stick rice in it, and you put it into the microwave and it gets warm and it makes a heating bag. I'd never seen that before and that was pretty cool. I've told all my friends about [the sock]. Janet: And when would you use that sock? Suzy: [Sandra said] it was to relieve labor pains and . . . just to relax. But, I think it just has infinite uses. A nice warm cotton sock. If s very appealing. And using the tennis ball as a massager, we started using that just to use it, because it works well. The birth center provided special equipment that the women could use to help them be more comfortable during labor. In the main birthing room there was a large Jacuzzi tub in which the women could labor. There was also a low, study, backless chair, called a "birthing stool," that some women find comfortable to sit on during labor, and a large inflated latex "birthing ball." Sandra explained to the class the birthing ball's uses. You can sit on it and get into a squat on it. If s good when the baby's head is descending. You can also bounce on it, which sometimes helps alleviate pain. ... It can also help back labor [because] you can slump over it. The instructor also taught the birth partners specific techniques that they could use to help the laboring women. These techniques included simple hand-holding, giving massages, applying wet washcloths, applying counter pressure, bringing fluids, reminding the women of breathing techniques, and giving the women verbal encouragement. Women Need to Be Emotionally Prepared Another part of the midwifery view of pregnancy and childbirth is the belief that emotional preparation for childbirth is as important as physical preparation. According to Barbara, pregnancy can be a trying time emotionally.

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109 I think that [pregnancy] just makes people very attuned to themselves. It makes it harder for people to stuff things down that they've been able to stuff down for years. I think it brings up a lot of issues that they need to deal with because [the issues are] so insistent during pregnancy. [These include] issues about our own parents, about how we were parented, about the way we want to parent, about our relationship with our parents, and about ourselves as being a mother, and are we selfish, or just all sorts of psychological changes or issues that we need to deal with. I think if s just a real . . . prime time where they don't get away with dealing with things the way [they] normally can. The midwives viewed it as their responsibility to help the women become emotionally prepared. Judy explained that part of what she does to prepare women for childbirth is healing up stuff thaf s happening in their relationships. I don't think I facilitate that as much as trying to get them thinking about it so that they're not coming to childbirth with a whole lot of unresolved issues. So if s a whole lot of trying to get them into an optimal state so that when they go into labor they're not poorly nourished and tired and dehydrated, because physically thaf s the worst. Your body can't do hard work when you're not well-nourished and rested and mindful and if you're worried, that reflects in how you do in labor. Liza explained that one thing that contributed to the women being adequately prepared for childbirth was the availability of the midwives to discuss whatever their emotional needs might be, or how they're feeling about things. We're very available and open to that kind of discussion. And [we] always ask at prenatals if they have any questions or concerns. Not just questions, but anything they're concerned about, anything they want to know about. We're willing to give that whatever time and attention it needs, and make referrals to counseling if it sounds serious enough to need outside help or expertise. The midwives also helped women clarify their thoughts and feelings about pregnancy and the impending birth. Liza stated: We also talk a lot in prenatals about what questions women have, what to expect in the next little while. The forms "Profiles of Pregnancy" that everybody gets that they fill out, gives [us] some kind of clue about . . . where their anxieties are centered, what the positives and negatives are to them, and how they're feeling about the

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110 pregnancy. . . . The form asks them questions about their vivid dreams, their fears, the worst thing that they can do during labor and birth, etc. They fill it in themselves, and self-report [the information]. We probably get more spontaneous answers [this way] than if we asked them in [the examining room). The midwifery clients believed that the midwives did a good job handling pregnancy's emotional aspects. Suzy stated: I'm very satisfied with their clinical knowledge, and they seem to have a real handle on the emotional aspects of pregnancy, which is one thing I like. I had two sonograms done by a doctor, and the doctor is male. And he doesn't pay as much attention to the emotional impact. I mean, if I bring up a concern, [the midwives are] very reassuring. They give me the clinical information too, but they're very reassuring to my emotions. . . . [They will say,] "People have babies all the time; it can't be that hard, or so many people wouldn't do it." They seem to have a real handle on the emotional side of things. Importance of the Midwife /Women Relationship The midwives tried to develop positive relationships with their clients and understand their clients on a personal level. They believed that women should birth their babies in a place where they are comfortable and that offering personalized care is one way of helping women feel comfortable. Barbara explained: I think just the atmosphere of keeping things dean and comfortable and getting to know people [helps women]. Personalized care, I think, is one of the main things that makes people feel comfortable. We know them and they know us and they know that we care about them, Liza believed that a good relationship between a laboring woman and her caregiver is essential for good birth experiences: Positive experiences during childbirth [are caused by the woman] being able to feel that she's having her needs met, whatever they might be, and that she's being seen as a person and as important in that; that her wishes and her being is being respected. All the midwife-assisted women in my study stated that they had good relationships with the midwives. The women believed that these

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Ill relationships extended deeper than most caretaker / dient relations. For example, when I asked Amanda to describe her relationship with the midwives, she responded: I think if s a great relationship. I think it is much more personal than with a doctor, and I feel like they really take a lot of time and show a lot of concern, and they talk to me and work with me, so thaf s nice. Nancy also enjoyed her talks with the midwives and stated that the topics of conversations often wandered from pregnancy and childbirth. When I asked her to describe her relationship with the midwives, she replied: "They're very reassiiring and comforting. Liza is more chatty than the rest of them, and our talk is always going off onto tangents. Last time we spent 15 minutes talking about computers." Mary felt a special connection with one midwife in particular because they shared similar schooling experiences. The last one I saw, she seemed to . . . understand me a little more, because she completely understood what I felt when I was going through nursing school and what I'm feeling now. So, I don't think she even knows it, but she gave me encouragement to keep going [to nursing school]. That was really Cool. But all of them are really, really nice and caring and they're excited about what I'm going through. This emphasis on friendly relationships extended throughout the birth center. For example, the secretary/ receptionist at the birth center, Hannah, was informative and friendly. She had her second baby at the birth center and often chatted with the women about pregnancy, birth, children and related matters. The women in my study appreciated her attentiveness. Mary: If s kind of like going home, because of the way it looks, the way it feels there. And, people remember your name. You're not just the person that they have on their chart, there's someone that you get to know. That is important to me. Janet: When you say people, you're talking about the midwives, or

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112 Mary: The midwives and their receptionist. The women felt comfortable with the midwifery students as well. Suzy in particular appreciated talking to one of the students because "she is asthmatic, so that was a great comfort to me because she did a lot of research and I feel very confident that . . . she has a real emotional connection to my problem." Even the bookkeeper, William, who is married to the midwife-owner, knows each birth center client. While sitting in the reception area, I often observed William greeting the clients by their first names and casually chatting with them. One way that the midwives fostered good relationships with their clients was by allowing ample time for each prenatal visit. The midwives reserved a two-hour block of time for the women's initial prenatal visit and allotted a half-hour for each subsequent visit. A second way the midwives helped these relationships develop was by being readily available to the women outside of scheduled visits. Nancy explained: Every time I've called when I haven't had an appointment, when, like, I had really bad morning sickness or when I 'm getting these funny pains in my stomach and I don't know what they are and I call up and I say, "Whaf s going on?" . . . They call back and say, "Tell me about it," "What about this?" "What about that?" "OK, thaf s perfectiy normal, if s just stretching, if s all right." If s very reassuring. And for the morning sickness, every time I called they had a different remedy to try, something new that at least for a few days would help. Suzy also found the midwives willing to help her whenever she needed them, even for non-pregnancy related matters: I caught a cold, and I have allergies. . . . Because of the asthma problems I try to watch it very closely and not let it get out of hand. It likes to settle in my chest, and I went to the infirmary last week and they wouldn't treat me because I was pregnant, so I showed up [at the

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113 birth center] on Tuesday morning without an appointment and begged for drugs. They gave me a prescription for antibiotics. The third way that the midwives encouraged good relations was by treating their cHents with respect. The midwives showed respect for their clients' time by scheduling appointments so that women did not have to wait long in the waiting room. For the prenatal visits that I attended, the midwives saw the women within five minutes of the women's arrivals. This manifestation of respect was important to the women, as Suzy explained: "I was impressed with the birth center when I went for my first check-up. Just their policy about not double-booking and things like that meant a lot to me." The midwives also showed respect for the women's financial circumstances. During one prenatal visit, Barbara discovered that Mary's iron level was slightly low. The midwife took into account Mary's financial situation when she made her recommendations. Barbara: Are you taking vitamins? Mary: I did, but they gave me indigestion. I'm taking calcium supplements now, and I guess I'll start taking iron as well Barbara: How about trying different prenatal vitamins? Mary: Well, I have mixed feelings about that. I heard somewhere that they may not really help. They may just give you expensive urine. Barbara: They're better than nothing. Do you have insurance? Mary: None that will cover this. Barbara: I don't want to order something new for you if it won't help. Mary: I also have a bad gag reflex. Barbara: This is small. I'll write you a prescription, and you can see how much they are. Maybe you can get a sample from the pharmacy. [Writes prescription.] We also have an herbal iron tincture that works really well. ... If s nine dollars a bottle. You can take that with prenatal vitamins.

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I 114 Another way that the midwives showed their respect for the women was by taking the women's concerns seriously. Amanda stated: "I feel they take a genuine interest in me and my concerns. They don't treat anything as petty." The midwives also showed their respect for the women through performing little considerate actions. Nancy related an example: "I was the very first appointment [of the day]. [The midwife] had a metal speculum and warmed it up, and I was like, this is going to be good. If s going to be just fine. It was reassuring, even." Birth Should Be an Empowering Experience The belief that childbirth should be an empowering experience for women is an important part of the midwife paradigm. During one of the videos that Sandra showed the childbirth classes, the narrator claimed that "Birth is a powerful, shaping experience for babies and women. . . . Labor is a rite of passage." This view of childbirth as an empowering occurrence that has the potential to help women view themselves in a different light was echoed by Judy. Some women have [childbirth] experiences that leave them empowered. It leaves them feeling more of a person. And some of them come out of it feeling less of a person, or empty or disempowered. . . . I think that what happens with a lot of women is that birth is very difficult and very challenging and they work through it. And the other side of it, after they've had their baby they realize that they've done some of the most difficult work a woman can ever do and they've done it successfully, and it can't help but make you feel more stronger, more of a woman, more of a person. I think for a lot of women if s a rite of passage into womanhood. Where they recognize their strength as a person. I've seen it a lot. I see it with teenagers, where they're just amazed with the power of childbirth, just how strong it is. If s not anything they could possibly know before they go through it. And they do it successfully, and they come out, "Wow. I can climb Mt. Everest, I can do anything" and it's quite an amazing experience.

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115 Effects of the Midwifery Paradig m As discussed above, the midwifery paradigm appears to consist of nine components. I observed these components in prenatal visits, classes, and other interactions between the birth center staff and the women. In the following section I discuss the effects of the midwifery paradigm on the women's pregnancy and childbirth experiences. During pregnancy, the midwives' actions resulted in women who felt well prepared for childbirth and who were comfortable with the midwives and the birth center. The midwifery paradigm led to the women having positive memories of childbirth, and lasting feelings of empowerment. Effects During Pregnancy Prepared for childbirth . As explained above, one component of the midwifery paradigm is the belief that "women give birth," and should therefore be in control of it. The midwives saw it as their duty to make sure that the women were well educated so that the women could make informed choices. The midwives were apparently successful, for during their last trimester of pregnancy, all of the midwife-assisted women believed that they were well-prepared for childbirth. For example, when I asked Suzy how prepared she felt for childbirth, she replied: I hit 36 weeks tomorrow, and I'm as prepared as I can get. . . . The midwives have done a great job. ... I feel that I'm a lot more prepared than my sisters, who went to OB/GYNs. I feel like I know a lot more about what to expect than they did. The midwife-assisted women and their husbands found the classes to be particularly helpful in preparing them for childbirth. Amanda stated: The teacher is really good at what she does, and the information is presented in a good manner. Some things that she talks about I've already read about, but it sticks better after hearing it first hand. I learn better by talking about things.

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116 Mary stated that she found the exercise class both informational and motivational. I learned about Kegel exercises, and those are supposed to help you far up and down the line, make sure you don't have rectal and uterine prolapse. If s interesting, and thaf s something I learned about. And . . . they talked about all the benefits of exercise. I don't remember what all they were, but it made the impression in my mind where I need to definitely do it. The midwifery belief that "family is important" was apparent in the classes' organization. The midwives encouraged the fathers-in-waiting to attend all of the classes. Usually, only one or two attended the exercise and nutrition classes, but all attended the childbirth classes. The instructor was careful to include the partners in the class, often asking them directly if they had any questions or concerns. The husbands in my study found the classes helpful. David stated, "The classes were really great. I looked forward to them, and felt comfortable in them. The information was fascinating to me. The teacher was really good." The videos helped the husbands gain an understanding of the reality of birth. Steven explained, "The video was kind of graphic, but it did put its point across real well." The women agreed that the classes benefited their husbands. Amanda stated, "The classes have been really great for my husband. I've been reading all the books, but this information is new for him." Suzy explained that the videos helped her husband better understand the reality of childbirth: We've seen two videos, and they've both been very helpful. My husband, after the first video, every time he would look at me that night, he would just shake his head and say, "I'm so sorry. I'm so sorry." I don't think he was quite prepared for it.

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117 Amanda, whose husband was able to attend only three prenatal visits, believed that the classes helped her husband become more familiar with the birth center's environment: I thought it was good for my husband, too, to come and get more familiar with this place because he's come to [only] three or four of my midwife appointments. ... It was good for him to get real comfortable with this place, too. The midwifery paradigm component that asserts that "women's bodies are normal and birth is normal /healthy" helped women build confidence in their ability to have a successful childbirth. Nancy, for example, stated during the last month of her pregnancy that she felt well prepared to deal with any possible discomforts of labor and delivery. She believed that the staff at the birth center had taught her about comfort measures she could use, and she felt confident that she could endure the pain. I'm not worried about back labor, because between the Jacuzzi and a marble rolling pin, and cold packs, I figure if s pain, you deal with it, eventually it goes away or you pass out. You deal with it however you can. It won't kill you. ... I feel very relaxed and mellow. At end of their pregnancies, the women felt empowered, and ready to have their babies. They were aware that the job might be difficult, but they were confident that they would survive the ordeal. In Mary's case, this mindset was different than the one she had near the beginning of her pregnancy. Janet: When I first started talking to you, you said that you were worried about the pain of labor. Have the classes helped you with that fear? Mary: Extremely. They taught me ways to deal with it, and to deal with labor in general. Seeing videos of how other women dealt with it helped a lot. If many others can do it, I can do it also.

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118 Mary's remarks also show that she had internalized the midwifery belief that "pain is part of being human and OK." The couples identified the childbirth videos as being particularly helpful in giving them the mindset that childbirth is normal, natural, and doable. Suzy stated: We saw a video of someone going through a home-birth, and that was really reassuring, because you read all these books and they're like "Oh, the pain! Oh, the tension! Oh, the stress!" And it was really reassuring. It made me feel like I really can do this. Sure if s going to be exhausting and painful, but if s not just painful: if s feasible. And so thaf s reassuring. Nancy agreed: It was comforting to see women doing this, it seemed like it was feasible for me to do. People do this, people have done this, for a long time. There's a good chance that I can do it. Before I was just going to hope and pray that this works out OK. The midwife-assisted women also found the books to be helpful. Nancy said that the book she borrowed was informative: I read it cover to cover. It contained scientific background on procedures associated with labor and delivery. It was good to see that someone had looked at it, and it reinforced my choice to use a birth center rather than a hospital. For example, it showed that there is no need to do an episiotomy in 99% of cases. I had been wondering what research had been done, and this contained lots of papers, and chapters on statistical analysis, so that I could understand what it was saying. Comfortable in the setting . By the last month of their pregnancies, each women had attended at least ten prenatal visits and had met each midwife at least once. They had toured the rooms in which they would labor and deliver, and they had enjoyed numerous conversations with the receptionist. The midwives purposefully made the birth center's atmosphere homelike, and the women appreciated this atmosphere. When I asked why they initially chose the birth center, they replied.

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119 It felt comfortable, and had more of a homey atmosphere. I liked the home feeling. (Amanda) It's kind of like going home, because of the way it looks, and the way it feels there. (Mary) The women continued to feel comfortable in the surroundings, and they also were comfortable with the midwifery paradigm. Nancy explained during her last month of pregnancy: I don't know that I'm exactly looking forward to labor, but I'm certainly looking forward to laboring here with these people a lot more than I would be if I were in a hospital . . . regardless of how well I got on with the doctor. Effects During Childbirth Enjoyable experiences. The women who had their babies at the birth center all had natural vaginal births and healthy babies. Two women had labors that lasted less than six hours. All the women had positive memories of their experiences. Nancy explained, "The birth was great. ... It was a wonderful experience. ... I can't imagine being in a hospital and going through that." Amanda was similarly positive: It was great, it really was. ... All in all, it was a wonderful experience, and I think the most beautiful thing~and the reason I'm so glad I didn't have any pain medication— was feeling her head and then her shoulders as they came out. . . . That was the most incredible feeling I've ever had and just made any pain or discomfort go away. It was really wonderful. Suzy had hard back labor that lasted for seven days. Nevertheless, she still managed to enjoy part of the experience: "(I enjoyed] pushing-pushing was a blast! It didn't hurt-all I felt was a little pinch at the end when I tore. It was the most exhilarating feeling of my life." Even Mary, who during her early pregnancy had asserted that she was apprehensive about labor pain, after her birth testified that, "It wasn't bad."

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120 Minimal birth interventions. The midwives applied the components of their paradigm during the births. For example, the practical application of the component "nature/ God directs birth" was evident when they let the women's labors progress naturally. In Suzy's case, that meant letting her labor for a week. During that time, Suzy came into the birth center several times. The midwives checked her cervical dilation and the baby's heartbeat at each visit, and suggested comfort measures for her to try. Suzy found many of these suggestions, such as laboring in the birth center's Jacuzzi, helpful. Because Suzy and her baby remained healthy, the midwives sent Suzy home after each visit and encouraged her to go about her normal routine as much as possible. Nevertheless, the midwives did resort to a medical intervention when it was apparent that Suzy needed it to be able to continue. Suzy explained that during the fourth day of labor, I began to shake from lack of sleep. The contractions again eased off about 6 or 7 a.m. [The midwives] gave me an injection of a sleeping agent in the morning and sent me home. I slept most of the morning in between contractions. Control over labor and birth. The fact that the midwives honored the women's wishes during birth contributed to the positive experience for the women. Amanda explained: "Judy didn't want to do an episiotomy. She thought about it, but she remembered me saying that I didn't want one and so in that split-second decision she decided not to, which was fine." Mary stated that the midwives supported her wish to be in control of as much of the labor as possible. They were very supportive. I told them [during] a previous visit just a couple days before that that I was very private, so they stood more off. They were really nice about that as far as letting me just [labor] however I wanted it. They were . . . really in the background, just where I wanted them. So ... if I had questions or if I had concerns, they were there to answer the questions.

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121 The midwives also let Mary decide when it was time to push. Mary explained, "I was asking them, 'Am I supposed to be pushing?' and they [answered], 'If you feel like pushing, push.'" Nancy believed that the midwives let her make important decisions many times during her labor. For example, the midwives let Nancy decide: (a) When she should come in and get her dilation checked. "We called the Birth Center, and they said, 'Well, you can come in and get checked if you like.' And I said, 'Yeah, that would be good.'" (b) Where she could labor. [The midwife said], "Well, you can hang around here and stay in the Jacuzzi for a while, or you can go home and labor for a little bit." So I decided to get in the Jacuzzi for a little while. (c) How she could labor. After a little while I was leaning on the big, green, bouncy ball on the bed, because bending over and having Christopher put lots of pressure on my tailbone really helped. I'd kind of lean into him so my abdomen was on his upper leg, and then he put pressure on my tailbone. (d) Whether her amniotic sac should be broken. Nancy: The bag of waters hadn't broken yet, so she broke my waters. Janet: Did you ask to have your water broken, or did Liza suggest that? Nancy: Liza suggested that, because it was bulging out over his head and he was obviously working his way out at that point. I was beginning to feel like I had to push. Janet: And that was okay with you? Nancy: That was fine with me. I was like, "Sure, yeah, no problem." (e) What to eat after the birth. "I stayed in The Midwife Center for a while, and I had Chicken Teriyaki because I was really hxmgry, and that just hit the spot."

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122 (f) In general. "I felt very much that I was in control for the whole process." Prepared for labor. The education that the midwives provided served the women in good stead. For example, Mary explained that: I felt like I was in control [of the labor pain]. I used the [comfort measures] that they talked about [in the classes], like the localizations. I didn't think that I would ever do that because it sounded so strange, but it really helped me get through the contractions. Suzy also found the comfort measures that she learned in the classes to be helpful, and wished that she had started trying them sooner. Hindsight's always 20/20, and I should have tried more comfort measures sooner. . . . Once I did, the bathtub worked the best, with water as hot as I could stand. The other thing that helped was putting the warm rice sock right on my . . . lower back, where it was hurting, and that eased a lot of the back discomfort. Those two things were very helpful, and soft music was real helpful, but I should have started all that earlier. Amanda stated that she felt well prepared for the emotional turmoil of labor. [I knew] that there would be a time [during labor] that you felt like you couldn't go on. I was really glad that I knew that was normal, because I could feel that at one point, that I didn't have enough strength to go on, and it really comforted me to know that many women feel that way and it was a common thing and I wasn't being a wimp or anything. It was something that a lot people feel, so that really comforted me. Spousal involvement in labor and birth. The midwifery belief that "family is important" contributed to the spouses being actively involved in the labors and births. When asked whether they felt adequately involved in the birth, the husbands replied: "Yeah. Absolutely." The husbands explained that they gave their wives support in various ways. Arthur said, "I was pretty much there for Amanda. I gave her whatever support I could offer. This included . . . holding her and talking to her and reassuring her and [giving her] damp washcloths." Christopher also supported his wife by responding to her needs: I pushed where she needed a push I patted the hand, I [talked]

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123 to her, and patted her back when she was fine." Steven helped Mary in similar ways: I helped get her to the birthing center as fast as we could, and then . . . during the contractions, a lot of the time she'd hold my hand and squeeze really tight, or pull on me. I got to bring her water, I got to do things. David mentioned other ways of offering support: I let Suzy support her weight on me, and comforted her a lot when she was having contractions. I would also apply counter pressure sometimes. Before we got to the birth center I timed the contractions, and wrote them all down in a log. I took her to the birth center, and when she was able to push, she was having a good time, and I just held one of her legs for her to push against. The women welcomed their husband's support during labor. Amanda explained; He was great, he was really stronger than I thought he'd be and more reassuring than 1 thought. 1 knew he'd be a real big support system because he always has been, but he just really pleasantiy surprised me on just how supportive he was. At the same time, the women appreciated that the midwifery view "the woman gives birth" encouraged the women and not their husbands to be in control over the process. Mary explained: He was very supportive but he also . . . wasn't in my face. . . . I've seen in hospital births, how the husband's yelling at the wife, trying to direct her in what she should be doing, and 1 didn't want that and he wasn't that way. He was very supportive, but also kind of in the background. He was there, but he wasn't messing with me. . . . Thaf s what I wanted. Effects After Childbirth Willing to do it again. Five months after their birth experiences, the midwife-assisted women still had positive feelings about their births. When I asked Amanda how willing she would be to go through pregnancy and childbirth again, she replied, "I'm ready now. If my midwife and husband

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124 agreed with me, I'd [have another baby] now. [Childbirth] was the most wonderful experience of my life." Mary explained that during her labor, she did not have any misgivings about choosing natural birth: "I'm very willing to go through it again. Even when I was in labor, I was thinking about doing this again soon, thinking about what would happen next time." Even Suzy, who endured seven days of labor, had no qualms about repeating the experience. She was grateful that the midwives allowed her labor to proceed at a slow pace. I'll do it again in a second. I'd do it again in a heartbeat. ... I'd do it the same way, no question. My sister had a very similar labor to mine. She was in labor for over a day, then went into the hospital, had pitocin, and then hemorrhaged. ... I think that long labor runs in my family. . . . Natural childbirth is less traumatic on your body. Empowerment. Midwives believe that "childbirth should be an empowering experience for women." All the midwife-assisted women in my study believed that their experiences empowered them. Amanda said that, because of her birth experience, "I think woman are stronger than I ever realized. ... If s not just myself [feeling] more empowered, if s feeling empowerment for women in general. . . . Birth is an everyday miracle, it happens all the time." Feelings of empowerment took several forms. Nancy stated that she felt more capable after enduring pregnancy and childbirth. It made me feel a little more capable. ... I feel like I did after I spent a year in England by myself when I was 18. After that [year], I felt like I could take care of myself. Now I have that same feeling again. I can handle whatever the world can throw at me. . . . The whole morning sickness thing was horrible. Labor and delivery was fine. It hurt, but [the pain] was bearable. After hearing other women's birth stories about the pain, the pain, I really feel . . . physically competent.

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125 Similarly, Suzy and Amanda believed that their experiences empowered them by making them more confident. I have less of a need to prove myself. I was the youngest of three girls. To my father, I was supposed to be the son he never had. I've always felt the need to prove myself, and excel in lots of things. I don't feel that anymore. I've lost my competitive edge. . . . Some of the not needing to prove myself has to do with my many days in contractions and [not using] pain killers. I have proved myself, and no one can ever said I didn't. (Suzy) [Birth has] given me a little more confidence in my instinct. I think that so many times we have instincts . . . [and] we're taught not to follow that instinct. . . . After the labor I just felt that I had listened to my body and everything worked out great. It taught me to pay attention to when I have this gut feeling. (Amanda) The mothers also felt empowered because they felt stronger after their births. Mary stated, "I can deal with a whole lot of pain without pain medication. I think thaf s empowering. . . . [Empowerment] is being greater than you were before, being stronger." Suzy explained. When you feel that kind of physical power running through your body, if s unbelievable. When I was lying on the bed and I wasn't even pushing, my body was getting the baby out by itself. If s amazing to find that kind of power running through your body. The midwife assisted women believed that their birth experiences had created positive long-term changes in their self-concepts. Suzy summarized this feeling: "It was like a rite of passage going through [childbirth] naturally. Thaf s really the way I felt." Summary In my study, adherents of the midwifery paradigm believed that birth should be an empowering experience for women. They treated childbirth as a normal, natural experience that—given the proper preparation—women can manage by themselves. The midwives believed that proper preparation includes emotional as well as physical aspects. They accomplished this

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126 preparation by offering their clients numerous educational opportunities, by involving the women's family and support network in the pregnancies and births, and by facilitating personal relationships with their clients. By the end of their pregnancies, the midwife-assisted women and their husbands believed that they were well-prepared for childbirth, and felt comfortable having their babies in the birth center. The women enjoyed their births. They all had natural, intervention-free births and they stated that they had sufficient control over their births. Their husbands were involved in the births, and offered support in several ways, but women kept control over their own labors. Reflecting upon their experiences, the midwife-assisted women explained that they gained more than healthy babies. They stated that their experiences were empowering, helping them feel more capable, stronger, and more confident than before. They believed that childbirth was an incredible experience, and looked forward to repeating it.

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CHAPTER 6 THE OBSTETRICAL VIEW OF PREGNANCY AND CHILDBIRTH Introduction The obstetrical paradigm is the "taken for granted" view of pregnancy and childbirth in American culture. Obstetricians do not have to explicitly teach their paradigm's tenets to their clients. Most people in our society consider it to be the "normal" view, and popular media, such as television, movies, and books, reinforce this view. Adherents of the obstetrical paradigm therefore feel no need to either defend or define their view. They do not need to defend it because it is assumed to be the correct view by most people, and as such it is seldom attacked. They do not need to define it because it is so widespread that it is the commonsense view, the view most citizens hold in common. People are exposed to the obstetrical paradigm through primary and secondary socializing agents. The obstetrician-assisted women in my study formed their ideas of what birth would be like through listening to their mothers and friends describe their childbirth stories. I asked Kelly, who did not attend any childbirth classes where she received her information about pregnancy and childbirth, and she replied, "Other people, and books, magazines. ... A lot of my mom's friends." Popular media portrays obstetrician-assisted births almost exclusively. When I asked Kelly's husband Mitchell where he got his information about what birth would be like, he replied, I've watched [labor and childbirth] on TV, and [have] seen it in school and all that. So even though ... I wasn't told exactly "This is going to 127

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128 happen, this is going to happen, this is going to happen," I kind of knew it from seeing it before. None of the obstetrical staff I interviewed volunteered their beliefs and assumptions about what pregnancy and childbirth are, or should be. Nonetheless, I was able to identify common themes through interviews and observations that suggested a paradigmatic view of pregnancy and childbirth. This obstetrical paradigm differed significantly from the midwifery paradigm. The Obstetrician The obstetrician/ gynecologist 1 interviewed did not choose his profession because of personal experiences or out of philosophical convictions. Dr. Smith became an obstetrician before he and his wife had children of their own. His father had been an obstetrician who really enjoyed [obstetrics], and loved it. He had a great office staff and worked hard but seemed to really enjoy it. . . . I'm sure that had some subconscious role [in my career choice], but it certainly didn't have a conscious role. Although Dr. Smith knew that he wanted to be a doctor from a yoimg age, he did not decide on his specialization quickly. He explained, "I didn't know what I was going to do until my third year of medical school, and then I did my rotations and this is what I really liked." When I asked Dr. Smith what, specifically, he liked about the profession, he replied: "It just seemed like fun. I mean, it seemed like going to work every day would be fun." Dr. Smith said that being an obstetrician is enjoyable because he is seldom faced with problems he cannot fix. You're around essentially healthy people. . . . [Pregnancy's] not a chronic thing. Chronic problems in gynecology are certainly the ones that drain the most energy from you, [especially] the pelvic chronic pain, and things like that that you can't fix. I don't know how people who take care of chronic problems get through the day. It would just be so draining. But what I do seems very upbeat and energetic and fun.

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129 Obstetrics also attracted Dr. Smith because its practice involves surgical procedures: "You get to operate, you get to be involved in medical procedures, you're not just looking at colds and sore throats." He appreciated being able to use a wide variety of medical skills. In summary. Dr. Smith became an obstetrician because he wanted to be a doctor, and obstetrics was the medical specialization that he found most interesting. The experiences of his father showed Dr. Smith that obstetrics could be an enjoyable profession. Dr. Smith's own experiences during his residency confirmed and strengthened this belief. The Paradig m The field of obstetrics came into being at a time when many women and babies died during the childbirth process. Physicians formulated and developed obstetrics as a way to make childbirth safer and less painful for all involved. They based their evolving paradigm on the idea that birth is dangerous and needs medical expertise to succeed. The obstetrical paradigm includes the view that with modem methods, birth does not need to be painful or dangerous. Adherents of this view work to ensure that pregnancy and childbirth is accomplished with as much safety, and as little discomfort, as possible. I identified four obstetrical paradigm themes in my interviews and observations: (a) without medical intervention childbirth is unpleasant, (b) medical personnel can make women comfortable during childbirth, (c) pregnancy and childbirth are potentially dangerous but doctors can make them relatively safe, and (d) medical personnel are the "experts" and have specialized roles. I discuss these themes in the following sections, drawing on interviews and field notes to support my categories.

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130 Without Medical Intervention Childbirth is Unpleasant Childbirth is messy. Adherents of the obstetrical paradigm view childbirth as messy and possibly frightening. For these reasons. Dr. Smith discouraged siblings from attending births: I have a lot of trepidation about yoimg children being there for childbirth. . . . Childbirth has a lot of blood associated with it and I think it would be very frightening to see your mother in obvious pain or distress, at least, with a lot of blood. If s this beautiful thing, a childbirth, but ... on the real nitty-gritty, if s not very pretty. Stool comes out with the baby, and everything else and I don't know about that. I tell my women that they can do what they want, but I recommend that [the children] not be in there while mom's actually pushing, and then wait until she's covered up and cleaned up. Then [we can] have the older child come and sit in the bed with mom, and then have the baby brought to them both. The childbirth instructor, Laura, explained to the women that birth might be so messy that the women may want to wait to hold their babies until the nurses cleaned them: "After delivery, the baby goes to mom's abdomen if she wants it. . . . If [moms] want the baby cleaned off first, tell [the nurses]." Pain is negative. Health care professionals working under the obstetrical paradigm assume that labor and delivery pain is needless and negative. "When my wife had our baby," said Dr. Smith, "it was hard for me to watch [during] childbirth. [Childbirth] is hard, and she was hurting." The hospital's childbirth classes echoed this view that pain is negative. During one class, Laura emphasized that women in labor should seek pain relief as soon as possible. Laura: Lef s review. How far dilated do you have to be before you can get your epidural? Woman: Between five to seven centimeters? Laura: You don't have to wait that long! You can get your epidural at four centimeters if your cervix is making changes.

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131 Medical Personnel Can Make Women Comfortable During Childbirth Dr. Smith did not see any benefit in pain, so he worked to diminish it. The medical paradigm includes the belief that pain during labor can and should be safely minimized. Dr. Smith said reducing labor pain is a primary way doctors make childbirth manageable. When I asked him what factors might cause a woman to have positive experiences during childbirth his immediate response was, "An epidural." Working within the obstetrical paradigm, doctors believe women cannot withstand labor pain unless aided by drugs. They help their patients understand that it is common and acceptable for women to need drugs during labor. Throughout the childbirth classes, Laura acknowledged that natural childbirth is acceptable, but stressed that medication may be a more realistic option for most women. Laura explained, "If s good if you're flexible about getting an epidural. Don't feel bad if you don't follow your original birth plan. Don't feel guilty, just enjoy your labor. If s great each way." The instructor warned the couples in the childbirth class about problems that might occur if women have natural births. Laura explained to the couples that during transition, "If you're going natural, this is an important time. Mom[s] may get a little bit hormonal [and may snap at their partners]. . . . This is the worst part of labor as far as losing control." A class video emphasized that women would probably need painrelieving drugs during labor. A narrator begins the video by saying: "Every woman's labor is different. You should stay flexible about pain management. Some women just need a massage, or a shower, others need medicine." The rest of the video describes various analgesics and epidurals, illustrates the administration of an epidural with an animated diagram.

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132 Because Dr. Smith knew he can alleviate severe labor pain, his staff did not offer patients much information on ways that they might deal with the pain themselves. The instructor spent much more childbirth class time discussing medical interventions than discussing alternative comfort measures. Laura did conduct some guided relaxation exercises, but stated that generally they were good only for early labor. During one such exercise she instructed the couples to Stand up, face each other, and hold each other. Rock back and forth slowly. This is a good thing to do if you are trying to hold on until you get your epidural. It gives you something to focus on. One class video showed a woman receiving an epidural. During an epidural administration, a long needle is inserted into a woman's spinal column. The procedure is painful, and the video's narrator stated that, "relaxation techniques are often helpful during epidural administrations." Hospital routines also encourage women in labor to view medication as common and desirable. During a childbirth class, Laura discussed some of the procedures that would take place when the women were admitted to the hospital: Laura: When you come in ... a Hep Lock [intravenous portal] will be put in you. Woman: Is the Hep Lock mandatory if you're healthy? Laura: No, if s just for FV access. Woman: If you're healthy, would you need it? Laura: If s not mandatory, if s for people who plan to have an epidural and if s good [in case] you change your mind about [having urunedicated birth]. Woman: Can you have an epidural placed but not infused so you can walk around? I heard that if s good if you can get into different positions in case of shoulder dystocia.

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133 Laura: Women usually want their epidural pretty soon. The medial staff's concern for comfort extends past childbirth to the nursing period. Laura told the women that they should use pain medicine in order to make their initial breastfeeding experiences more comfortable. If you did a natural birth . . . especially for you multips [multi parous], you'll have after-pains. We will give you Percoset. Multips, your afterpains will be harder. Take the Percoset 15-20 minutes before breastfeeding. The pain will take the enjoyment out of breastfeeding. You can't get hooked on [Percoset] and it is good to take it. Once you get home you can take Tylenol. Pregnancy and Childbirth are Potentially Dangerous but Doctors Can Make Them Relatively Safe Doctors working from the obstetrical paradigm view pregnancy and childbirth as potentially dangerous. Obstetricians make pregnancy safer through careful monitoring and reliance on medical interventions. Measurements and monitoring . Obstetricians spend most of their time measuring and monitoring pregnant women and their fetuses. Normal pregnancies, as defined within the obstetrical paradigm, stay within a narrow range of "normal" measurements. Obstetricians rely on these measurements and attendant statistical probabilities to guide their medical actions and advice. Dr. Smith routinely performed many tests on his pregnant clients. He performed three ultrasounds for each woman during her pregnancy. During each prenatal visit, the nurse weighed the women, evaluated a urine sample, and checked the women's blood pressure and degree of swelling. When any indicators moved out of normal measures. Dr. Smith performed additional tests. When Jane voiced a concern about her baby's movements Dr. Smith quickly prescribed a non-stress test. Jane: I'm concerned that I haven't felt any kicks from the baby, just pushes.

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134 Dr. Smith: Any movement counts as a kick. Now that the baby's bigger it has less room to kick. Is it moving well? Jane: Yes, especially at night, but my book said that it should be moving 10 times an hour, and I'm not feeling that. Dr. Smith: You need to lie quietly on your left side for hour, if you don't feel movements 10 times, then we'll do a non-stress test. Jane: I would like that. Dr. Smith: OK, we'll just do the non-stress test now. Jane's husband, Chris, complained that their obstetrician was sometimes too rigid in promoting norms, at least in the area of weight gain. Dr. Smith said that [pregnant women] should never gain more than 20 pounds. ... He said, "Oh, if s very critical on the weight," and we always say, "Hey, her dief s always very good, her serving sizes appropriate, she never has any junk food, sodas are gone, she just [eats] a very well-rounded meal." And of course she doesn't eat that much because she can't, there isn't much room. . . . He always is so concerned, he's actually pretty rude about the weight. "You've gained so much more weight than I want you to gain." He'd always say that and I'm like, "Wow." But I think she's only gained like 30 poimds total, which isn't bad, but he's never satisfied with the weight. Dr. Smith acknowledged that sometimes relying on norms can be misleading. During her last month of pregnancy, Kelly stated that. Just now [Dr. Smith] told me that I'm at a high risk for a c-section, and I didn't know that before. [Janet: Why is that?] He said, I guess, just because [my pelvis is] very narrow. He said he didn't think [the baby] would come out. But he said that doctors are also really bad at telling, because sometimes they could tell you that it won't work, and then somebody has an 8-pound baby. He said we'd just have to wait and see. Obstetricians' concerns with measurements and averages extends throughout labor and delivery. Laura explained that when women are first admitted to the hospital during labor, they are brought to the triage room. In the triage room you will give a clean-catch urine sample. . . . The nurses will strap on an external monitor. The external monitor shows contractions . . . [and the] baby's heartbeats. If we still can't tell the

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strength of contractions, we may slide in an internal monitor to measure the intensity of contractions. If we can't get the baby's heartbeat with the external monitor, we'll screw on an internal monitor to the baby's scalp. Obstetricians rely on these tests and measures to alert them to possible problems. For example, when Kelly's urine sample showed a slightly high concentration of protein. Dr. Smith sent Kelly to the laboratory to undergo additional tests. The tests came back negative. If the results had been positive, however, it may have meant that Kelly had toxemia, a potentially fatal condition. Use of interventions is necessary to ensure "normal" birth. Physicians' concern with measurements and norms necessitates the use of extensive medical technology. Practitioners in the obstetrical paradigm view this medical technology as beneficial and use all methods available to ensure that baby and mother are as physically healthy as possible. Obstetricians use medical interventions to guarantee that all stages of labor progress within a statistically acceptable length of time. Laura explained that the obstetricians use a couple of different methods to speed up early labor: "We use cytotec pills in the birth canal often rather than pitocin or sometimes we use both." "During [active labor]," Laura told the childbirth class, "if you're in the hospital and your bag of waters is intact, the doctor will break your bag of waters during his dilation check. This may help speed up labor." Once the women's cervix is fully dilated then she has reached the pushing stage of labor. Obstetricians have various means at their disposal to make sure that this stage does not last longer than average. Laura explained. During [the pushing] stage, doctors may use a vacuum extractor to assist with deliveries. If the woman has pushed for a long time, and the baby needs just a little tug, then the doctor will attach the vacuum

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136 to the head of the baby. ... If the first attempt fails, he will take it off, and he may try again. ... If the vacuum doesn't work, then the doctor will use forceps. . . . The only other option to vacuum and forceps is a c-section. This is only used as a last resort. Laura stated that the obstetricians also usually perform episiotomies to speed up the pushing stage. After the baby is bom, the medical staff performs more medical procedures to ensure safety and efficiency. Laura explained: [They will] take the baby to the warmer, and do an assessment on it. They will put ointment on the eyes, and give it a vitamin K shot. . . . At the same time, the doctor will be stitching you up, and cleaning you up They'll [give you] pitocin in an [IV] bag." Prepared for medical interventions. The hospital routines help ensure that everything is ready in case emergency medical interventions are necessary. Nurses attach a Hep Lock when women are admitted to the hospital to make medication administration easier. Once admitted, women are not allowed to eat or drink anything except ice chips. Hospitals established this procedure because anesthesia is safer to administer when the patient's stomach is empty. Laura took the childbirth class participants on a tour of the hospital's labor and delivery areas. These areas were arranged to facilitate medical interventions. The operating room used for cesarean sections was near the combination labor/ delivery rooms. The labor/ delivery rooms looked like small hotel room. Hidden by cabinet doors, however, was an array of medical equipment, such as oxygen tanks. The bed was a regular hospital bed that could be transformed into a delivery table. The bed's foot swung down, giving obstetricians easier access during births. Bright lights swung down from the ceiling to spotlight appropriate areas during delivery. Attached to the walls were outlets where vacuum extractors could be quickly attached.

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137 Items that might provide comfort for the women were not as readily accessible. The ice chips, extra blankets, and wash clothes were kept in a separate room down the hall. Laura explained that women could use mirrors to watch their deliveries, but only at special request. Prepare women for medical interventions. The medical staff prepared women psychologically for the possibility of medical interventions. Participants in the childbirth classes learned that medical interventions were routine even for normal labors. Laura also made sure that class members understood the interventions that would occur in "worst case" scenarios. Jane, the only obstetrical-assisted woman in my study to attend these classes, explained, [The classes] teach you what if s like to go into active labor, to know what to expect at the hospital, what the experience may be like, to discuss what your options are ... as far as epidurals. . . . Basically [to prepare you] so nothing comes as a surprise, which is nice. More important than teaching you the technical aspect [of birth], they make sure that you know what forceps look like. . . . The goal is to [make women] not be afraid of the instruments. . . . Thaf s the goal of the class, to make us aware of everything. During one of the childbirth classes, Laura passed around an IV needle, an amniotic hook, an external monitor, an internal monitor, a vacuum extractor, and forceps. She discussed the uses of each instrument, and explained the circumstances under which each might be used. Laura acknowledged that the couples might not want to think about the possibilities of doctors using the equipment on laboring women: "I know what this equipment makes you feel like. However, I don't want anything to come as a surprise to you." Laura took care to explain to the couples in the class that even though some of the equipment looked scary, doctors would use it only if the situation warranted it. When Laura passed around the internal monitor, which

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138 consists of a cord attached to a twisted metal wire that doctors may attach in a baby's head during labor, a husband exclaimed, "They hook that in him?" Laura responded, "Yeah, just a little." The class laughed. Laura continued, "They only use it if necessary." The obstetrician also worked to prepare his clients for the possibility of medical interventions. Dr. Smith told Kelly that because a possible discrepancy between the size of her baby and the size of her pelvis, she would probably need a c-section. Kelly's husband, Mitchell, explained that the obstetrician's staff also warned them of the possible need to induce labor. Mitchell: Today they said they might induce labor a week early. . . . Janet: Why would they induce labor a week early? Mitchell: The nurse said because of how much she's swelling. But the doctor said that we'd just wait and see, as of right now. Medical Personnel are the "Experts" and Have Specialized Roles Obstetrici an/medical team is in charg e. In the obstetrical paradigm of pregnancy and childbirth, the obstetrician carries expert knowledge and controls pregnancies and deliveries. Obstetricians' language use reflects this view. While telling me a story about a woman who had a particularly difficult labor. Dr. Smith claimed responsibility for the birth by referring to the woman as "the nurse I delivered." During the women's pregnancies, the obstetrician made the decisions concerning which medical tests and procedures would be performed. Chris explained that even though he and Jane wanted another ultrasound administered, they could not get one because the doctor decided that it was unnecessary. We would like maybe just one more ultrasound, but I understand thaf s maybe asking too much because the insurance won't pay for it. But the doctor didn't say, "Hey, the insurance won't accept it, but we'll

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139 do it if you pay the $70." We would be more than happy to pay the $70. [Janet: Did you ask him if you could have another ultrasound?] He said it wasn't necessary. During labor, obstetricians decide if a women's labor is progressing "normally." They also decide what actions to take if labors do not progress on a standard course. Laura explained. Every hour during your labor . . . we'll strap on the external monitor for a while so that we can monitor your contractions and the baby's heartbeat. If the baby's heartbeat slows down or you don't progress [with cervical dilation], the nurses will contact your doctor, and he'll decide what needs to be done. Each woman's obstetrician makes decisions about the particulars of her specific pregnancy and delivery. General guidelines for labor and delivery, however, are formulated by each hospital. The obstetrical paradigm is apparent in these policies. For example, the view that those with specialized medical knowledge should control the birth process is reflected in policies concerning (a) what women can eat during labor: Woman: What should we eat at the start of labor? Laura: Eat something light, but do eat. They won't let you eat anything once you get here but ice chips. (b) what women can wear during labor: Laura: In the triage room, you'll take off everything but your bra and your socks. They'll give you a gown to put on. (c) what position the women will be in when she delivers the baby: Laura: You will be leaning back on the bed. You will have one person on each leg. and, (d) how the women will push: Laura: The nurses will tell you how to push. . . . You v^U get three good breaths for each contraction. . . . You may make a grunting noise. The partner needs to count to 10 [during each push]. You will put your hands behind your legs to hold them back. Pretend a contraction is starting, you take a

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140 big, cleansing breath, let it out, take a big breath, hold it, put your chin on your chest, count to 10. Then blow out, take another breath and hold for 10, blow out, one more breath, hold for 10. Thaf s the way if s going to go per contraction. Roles are narrowly defined. Obstetricians acknowledge that understanding the processes involved in childbirth can make the experience easier for women. When I asked Dr. Smith what factors contributed to making childbirth a positive experience, he replied: If she knows what she's getting into ahead of time and \mderstands the process her body's going to go through. . . . Even the nurse I delivered, [a] labor and delivery nurse . . . had . . . 24-hours of hellish labor, she pushed forever, and we finally had to vacuum it out and it was just a really hard delivery. And that was probably a negative experience, but she views it all very positively, because the end result was very positive. But if you asked about her labor, she never complains about it, but she'll tell you it was hard. Nevertheless, Dr. Smith and his office staff did not offer much on-site education to their patients. Dr. Smith explained: I don't do that much true childbirth education in my office. I encourage them all to go to childbirth classes. We talk to them about whaf s going to happen during their pregnancy and what they can expect with each trimester, but we really don't talk to them too much about whaf s going to happen in labor and delivery. . . . There's tapes you can rent [from a video store], we give them all [the book] "What to Expect When You're Expecting," and we . . . encourage them to go childbirth classes, but we don't talk to them about labor, "If s going to be like this, and this is going to happen." We don't do a lot of childbirth education here. Dr. Smith believed that psychological factors play a significant role in determining how women experience their pregnancies. Some people [find pregnancy] overwhelming . . . and they don't seem [to be] preparing to deal with it and whaf s going on. Then other women are thrilled by whaf s happening and anticipate it very much and are very motivated, and it brightens their lives. [For] others it seems to be a real burden.

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141 Nevertheless, in the obstetrical paradigm, obstetricians' roles are limited to concern with the physical aspects of pregnancy and childbirth. The following prenatal visit is typical of the visits I observed at the obstetrician's office. The nurse calls Amy's name from the door of the waiting room. Amy and Ronald follow the nurse into the hallway. The nurse tells Amy to give her a urine sample. Amy goes into the bathroom and Ronald stands in the hallway and waits. Amy comes out of the bathroom and she and Chris go into the nurses' station, which contains a stool, a scale, and various medical equipment. After a few minutes, the nurse comes in and asks Amy to stand on the scale. She asks Amy, "How are you doing?" Amy replies, "Pretty good." The nurse announces, "You're going down." Amy asks, "I lost weight?" The nurse doesn't respond. The nurse takes Amy's blood pressure. The nurse asks, "How's the baby moving?" Amy replies, "A lot, I feel like if s about to burst out." The nurse writes something on Amy's chart, looks up on a pregnancy calculator how many weel^ pregnant Amy is, and writes without comment. She then asks Amy, "Any swelling?" Amy responds, "In the past, but not now." The nurse looks down at Amy's ankles. She then dips a test strip into Amy's urine, and writes down the results, without comment. The nurse then asks Amy, "Did you pre-register [at the hospital]?" Amy replies, "Yes," and the nurse says, "Good." The nurse then leads everyone into the examination room. Amy sits on the bed, and Ronald sits on a chair in the corner. The nurse leaves, and Ronald and Amy chat quietly for five minutes. Amy says to Ronald, "I can't believe I lost a pound. Maybe it's because of the last two months of rapid growth-maybe she's taking more." Dr. Smith walks in and says "Hello." Amy lies down on the bed, and Dr. Smith measures her stomach. Dr. Smith asks, "Is everything going well?" Amy replies, "Yes, but I've lost weight." Dr. Smith says, "Thaf s OK, I wouldn't worry. The scale may be broken. Is the baby moving well, have you had any bleeding, did your water break?" Amy answers, "No." Dr. Smith finds the heartbeat with the Doptone, and announces, "There he is. 135-136 beats a minute." Dr. Smith walks away from Amy and starts writing on her chart. While writing, he asks, "Any questions or concerns?" Amy replies, "I've had some nosebleeds, I thought it might be because of the weather." Dr. Smith says, "It could be caused by the dry weather, if s

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142 also common during pregnancy." Amy says, "I've also had a strong craving for ice." Dr. Smith states, "You need to not eat too much, especially with your anemia. If s a common craving. Limit your ice intake." Dr. Smith turns to Ronald and explains, "If s not just her, a lot of other women get weird cravings during pregnancy too." Ronald asks, "There's no chance that the baby will get too big for her stomach, is there?" Dr. Smith replies, "Small women have small babies on average. However, this feels like a big baby, seven or eight pounds." Ronald asks, "Do we still come every two weeks?" Dr. Smith replies, "For the next two visits. Make sure the baby keeps moving well. Let us know if there are any problems." Dr. Smith walks out of the room. The prenatal visit took 15 minutes, and the couple was with the doctor for just over 5 of those minutes. The obstetrician and his nurse asked questions only about Amy's physical well-being. They provided the couple with information about the pregnancy only in response to direct questions. When Dr. Smith told the couple that their baby might be too large for Amy's small stature, he did not offer any information concerning what this signified. In another situation when a woman encountered disturbing information about her pregnancy. Dr. Smith did not provide educational information or suggest where such information might be found. When Kelly explained that Dr. Smith told her that she was at high risk for a c-section, I asked her, "Did [Dr. Smith] give you any information about c-sections?" Kelly replied, "No. He didn't." Adherents of the obstetrical paradigm acknowledge that there is more to pregnancy and childbirth than physical factors. They do not believe, however, that the obstetrician should deal with these other factors. Obstetricians define themselves as medical experts and leave it to others to play the educative role. The hospital that Dr. Smith used offered childbirth classes to pregnant women and their partners. The classes met once a week for 6 weeks, with the

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143 last class devoted to infant CPR and safety. Two sets of classes were offered at a time, one set meeting on Tuesdays, and the other meeting on Thursdays. The first five classes in each series were taught by a labor and delivery nurse, and the CPR and child safety class was taught by the hospital's "Safety Expert." The childbirth classes at the hospital were not well attended. The average class size at the classes that I observed was seven couples. This means that, on average, only 14 couples attend each series of classes. The hospital charged couples $150 for the classes and a tour of the hospital maternity rooms. This cost usually is not covered by insurance, and this is possibly one reason why so few couples took the classes. Also, although Dr. Smith did give his clients information about the childbirth classes during their first prenatal visit, neither he nor his nurse subsequently asked if patients were attending the classes. Dr. Smith mentioned that there are videos on childbirth that the women could watch, but the women have to go to a local video store to rent them. Jane was the only obstetrician-assisted woman in my study who took childbirth classes. She liked them and found them moderately helpful: I liked them. However, I thought that they weren't very technical. They were good, and I'm glad that I had them. . . . But the book that they gave us is a little bit earthy. If s not very nineties. The book is ten years old, and it could have been updated. . . . They don't go over any of the book in class. I thought I would have been better served if it was kind of like a college class where you have a textbook in front of you that you could reference. . . . She goes over the same exact thing every time, and we watch videos. I don't have a lot of time to do extra reading. . . . I'm learning some, but I could be learning a lot more. I definitely know more now than before. The obstetrician's role is also restricted after the birth. Once a baby is bom, the obstetrician continues to attend to the mother, but a pediatrician takes over neonatal care. Laura explained during a childbirth class that.

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144 Once the baby comes out, it is given to the pediatrician, and he will examine it and assess the APGAR score. Sometimes the baby just needs extra suctioning or maybe a little oxygen. They can give that in the room. If if s anytFdng more serious, they will bring the baby up to NICU. Effects of the Obstetrical Paradigm on Pregnancy and Childbirth The obstetrical paradigm uncovered in this study consists of four components. These components were evident during prenatal visits and childbirth classes. In the following section I discuss how the paradigm effected women's experiences of pregnancy and childbirth. Effects During Pregnancy Amount of information given. The clients differed in their reactions to the obstetrical paradigm during their pregnancies. Two of the couples wanted their obstetrician to play a larger role during pregnancy. These people wished that their obstetrician had been more of an educator. Kelly's husband, Mitchell, explained that I guess [I'd like the doctor] just to be more straightforward with things. . . . There were a couple of times when I asked him a question and he never answered it. I'd sit in the room in that comer, and he'd just leave and that was it. I had a question to ask him, and he was gone. Mitchell was concerned that nobody had given him any information about the labor and birth process. I guess I'd like to know everything thaf s going to happen, how if s going to happen, what we need to do, when do we need to go to the hospital. All of those things. I mean, the only thing I know about her and giving birth right now is that she's 3 centimeters dilated. Thaf s all I know, and I really don't even know 100% what that means. Jane also wished that her doctor would have been more eager to share information. I require a lot of communication, and he hasn't communicated beyond the first visit. The other visits have been kind of fast. . . . I've held a lot of my questions because I felt that I would have bothered him He

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145 should take the initiative and check and see if I'm eating right and that kind of thing. He only monitors the baby's heartbeat. Jane was frustrated that the doctor did not adequately answer her questions. For example, she was concerned that her baby was going to be too large for a vaginal birth. When she shared her concern with Dr. Smith, he did not let her know whether her fears were valid or not. [When I tell him that I'm worried], he really doesn't say anything to that. ... He just kind of looks at me like there's nothing that he could do about it, anyway. In that, if s just going to be the size if s going to be. ... I mention it every time I'm there, so I'm assuming that he realizes the concern [it holds] for me, but last time he kind of made fun of me and said— he kind of guessed a funny weight, like not a real number, like he said, "Oh, I think if 11 be 793.25 or something." I kind of took offense to that, because I could tell he was making fun of me. . . . The nurse interjected and said that "Well, I think he's trying to make you feel better," but said that he didn't have a crystal ball, and that he wasn't going to. . . . In my book that I'm reading, it says that they can measure and determine the relative size just so they don't put you through 12 hours of labor if they already know you're not going to be able to deliver. And that was what my concern was, but obviously he doesn't share that concern. Jane's husband, Chris, also wished that Dr. Smith would explain things more clearly: Jane's always concerned about the blood. I'm A positive, she's O negative, and she just wanted to know how the actions would work, and [Dr. Smith] said, "Well, you're going to get your shot at 28 weeks, and a shot after the delivery if if s needed, after the blood type of the baby's determined." But he would never really go into much detail. We just wanted a couple of minutes just [for him] to explain some things [such as] what could happen if things conflicted with the blood. Amy and her husband, Ronald, held different perceptions. They thought that Dr. Smith did a good job answering their questions. Amy: [Our relationship] is basically on a friendly basis, he has that open door policy. If you have any questions you can go ahead and talk to him, and he's pretty down-to-earth. There's no, you know, "He's the doctor," and you have that weird feeling, that wall in between you or anything. If s really open and relaxed.

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Janet: Have you taken advantage of that policy, have you ever called outside of regular visits? Amy: Yes. There was one occasion when I got a really bad rash, and I have no idea up to this day~we don't really know where it came from. I had to call him about that. Janet: Did he call you back quickly? Amy: Yes. Janet: Are there any matters you don't feel comfortable talking to him about? Amy: None at all. Ronald also thought that Dr. Smith did a good job answering questions. Janet: Do you feel comfortable asking [Dr. Smith] questions? Ronald: Definitely. Janet: Are there any matters you don't feel comfortable talking to him about? Ronald: Ifs pretty comfortable. Relationship with doctor. The doctor's seeming lack of emotional concern disturbed two of the couples, Kelly and Mitchell, and Jane and Chris. They wanted the obstetrician to include more personal and empathetic treatment. Kelly explained that, although she was comfortable with Dr. Smith's technical abilities, she wished that she felt more comfortable with him on a personal level. I like him, but I think that I would want somebody that was a little more talkative. [I wish he] made you feel a little more comfortable going in each time. I mean, he's a great guy, and he's a great doctor, but I'd like to have somebody that was real talkative with me. Jane in particular was upset at the doctor's impersonal and matter-offact manner.

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147 I got really sick early this week I called [Dr. Smith] at 5:00, when the office had closed, and left a message It was one hour before he called me back. When he did call back I explained everything, and he said I could do what I wanted, which wasn't the answer I was looking for. I thought that if I wasn't feeling 10 baby movements a hour, I should go to the hospital, no questions asked. He didn't offer anything for my fever or coughing or anything. I was worried, especially since I'd been having diarrhea, but he didn't say anything. We went to the childbirth class since we had paid for it, and after an hour and a half I asked the nurse to take my temperature, and she did, and then she told me to call the doctor. ... I told him my temperature, and he said, "So what?" I was in tears, I was really getting upset I said, "What should I do?" and he said to do whatever I wanted to do. Go to the ER, or come in the next day to see him in his office. ... It was a 15 second conversation. . . . The whole experience was disappointing, especially the response from the doctor. . . . He's just somebody that doesn't provide good enough communication at all, and if s kind of a shame for women to have to go through that. The more pregnant I get, the more irritated I get. If s appalling that I'm paying him. ... I don't think that the doctor is incompetent, he just doesn't know how to communicate. But Amy and Ronald thought that their relationship with the doctor was good. They described a different relationship with Dr. Smith than did the other couples. My relationship with [Dr. Smith] is on a friendly level. We joke around and if s easy to speak with him. I ask a lot of questions, and he's good at answering them. I'm a pretty open person, I don't have problems speaking with people. (Amy) We're on a friendly basis. I haven't myself had to contact him after hours or anything. He's told us everything we needed to know. He's a good guy, he walks in [the examination room] and he talks to us a little while before getting down to business. . . . [Do you think he includes you enough in the visits?] Yeah, I do. (Ronald) Effects During Childbirth Reactions of women to their births. Dr. Smith attended Kelly and Amy's births, and his on-call partner. Dr. Jones, attended Jane's birth. The

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148 women had different reactions to their labors and births. Amy thought that her early labor was easy. It wasn't bothersome at all, to be honest. ... It just felt as if I was contracting every five minutes and then they hooked me up to the machine, the fetal monitor and everything, [and] they realized that I was contracting basically every minute, which was strange. I'm like, "I'm not feeling that but hey, okay." After being given pitocin to speed up her labor. Amy's contractions became more painful, but by then. Amy explained, "Most of it I don't remember, because I was so drugged up at the time." Problems in Amy's labor resulted in an emergency cesarean section, and Amy ended up with bad feelings about her birth. [I was] disappointed because it wasn't the natural way, so to speak, because I wasn't aware of her actually being bom and I wasn't there for it. I didn't see her immediately, because I was under at the time. And because it was a c-section and that was heavy surgery, I wasn't able to get around and be able to participate and take good care of her and all that immediately. I was not happy with that at all." Kelly described her birth as difficult: "It was pretty hard-she almost didn't come out. He almost had to do a c-section." Kelly developed a mild case of pre-eclampsia during her third trimester, and Dr. Smith decided to induce her labor with pitocin. Kelly's contractions were therefore strong from the beginning of her labor, but an early epidural relieved her pain. It wasn't as bad as I thought it was going to be, but I guess thaf s just because I had the epidural so early. I was in a lot of pain before I had it, and then once I had it I couldn't even feel the contractions or anything. Although the epidural alleviated Kelly's pain, the combination of the epidural and the pitocin lengthened the labor to what Kelly believed was an almost unbearably long time. When he started the pitocin, my blood pressure went way down, and her heart rate went way down, from like 150, 160 it dropped down to 60-something. ... So they had to slow down the pitocin, which drew

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149 [labor] out even longer and then once I had the epidural . . . that made [labor] even longer. ... I was in labor for 12 1/2 hours. Jane had mixed feelings about her labor and delivery. She stated that she had back labor, and this made her early labor difficult. Once the epidural removed the pain, however, Jane began to enjoy her labor. It was better than I thought it would be. Labor was pretty intense. I didn't imagine I would have such strong back labor pains. It was really painful. . . . Once they . . . brought me into the labor and delivery room I got some pain medicine, which helped a lot. It took the edge off the pain, and I was able to sleep for two hours. ... I think that the [labor] itself was hard, but once I got the epidural, then I felt that I could enjoy [labor] more. ... It went really quickly after the epidural. ... I thought labor was easy and not as frightening as I thought it would be. Making births more comfortable. The medical staff worked within the obstetrical paradigm during the births. For example, the way that the staff readily gave the laboring women pain killers and epidurals made evident the obstetrical view that "medical personnel can make women comfortable during childbirth." The women appreciated the relief that the medicine gave them. Kelly explained. People were telling me [before labor] that with the epidural your back would hurt for years . . . and I thought twice about it But I'm glad I did [have the epidural] because if I would had to go through all that for 12 1/2 hours without [pain relief], that would have been horrible. I couldn't have handled it, I don't think. The women appreciated the epidural's ability to make labor and birth more bearable. Nevertheless, they did not like the way that the medicine's after-effects made the immediate post-partum period uncomfortable. Jane complained that. After the birth, I was pretty much out of it, because of the drugs and because of being tired It bothered me because I had no feeling in my lower half, my legs were swollen, and I couldn't move them. They took the catheter out right away, but then I couldn't [walk] to the bathroom. It took a long time for the epidural to wear off. I delivered at 8:15, and it was not until late that afternoon [that] I could get up and

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150 walk. I was glad to have feeling back in my legs, and I could finally take a shower. The obstetrician also intervened in the births to make the women more psychologically comfortable. For example, even though Amy was still two days away from her due date. Dr. Smith explained that he could induce labor if she wanted to speed things up. We called the office and said, "I'm having contractions, and they are regular," and they basically said, "Well if they become five minutes apart, then come on down." . . . About 2:00 PM we went ahead and went to the doctor's office, because they had become closer enough, and we were checked out there and the doctor said, "Well, I can't really say if you're going into real labor, or if it's false labor. We really have to wait and see. Or, you can wait and come back to the hospital later on and we can just go ahead and induce, and get it over with." I [said], "Okay, thaf s fine." Making births safer. The many medical interventions that the staff performed on the women reflected the obstetrical view that pregnancy and childbirth are potentially dangerous but doctors can make them relatively safe. Two of the women, Jane and Kelly, had vaginal births, assisted with epidurals, episiotomies, and vacuum extractors. Amy had an emergency Csection. The obstetricians ordered pitocin to be given to all the women to induce or speed up their labors. The obstetricians used technological measurements to decide when to perform certain interventions. Kelly explained that during her labor the staff spent a good deal of time gathering medical measurements. When they couldn't find her heartbeat [using an external monitor], then they had to do it internally, and monitor it that way. Then they couldn't see my contractions on the monitor, and then it just went on and on and on. The obstetricians ordered and performed interventions for various reasons. The obstetricians sometimes turned to medical interventions to keep the labors progressing at a "normal" pace. Amy explained that even

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151 though she was dilating, the obstetrician determined that the pace was too slow, and wanted to speed it up: "The most [dilation] that we had gotten was maybe 4 [centimeters] all together, and that was after some hours." Similarly, even though Jane had just begun pushing. Dr. Jones decided to use the vacuum extractor to get her baby out quicker. There were two sets of three pushes, and that was it. [Dr. Jones] asked after the first set of pushes ... if he could do an episiotomy and use [vacuum] suction and I said, "Yes," so I did a few more pushes, and he was out. Another reason that the obstetricians performed some of the relatively mild medical interventions, such as episiotomies and vacuum extraction, was to avoid having to perform a more drastic intervention, such as a cesarean. Kelly explained that she was wary of the vacuum extractor, but saw it as the only option to a cesarean section. He cut [episiotomies] twice, and still used the vacuum. . . . We had seen [the vacuum extractor] on 20/20 a couple of weeks before, and I was so scared when he said that was what they were going to have to do, because [20/20] had this thing about how it causes brain damage, and all this other stuff. And I [thought], "I can't do this by myself, but I don't want to hurt her." But he was pulling with all of his might and he pulled twice before she even came out. I mean, he was pulling and I was pushing. Jane stated that the medical team used pitocin to speed up her labor to make it easier on the baby. They put me on pitocin. I didn't ask for it, but after the pain killer wore off, the heartbeat of the baby had slowed down They wanted to speed up the labor because I was only 2-3 centimeters dilated, and it had been a long night. Obstetricians also used medical interventions if they determined that the mother was in danger. For example, Kelly explained that Dr. Smith decided to induce her labor "because of all the swelling [that I had], and my blood pressure was really high. I had a mild case of pre-eclampsia."

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1 152 Dr. Smith performed a cesarean section on Amy when the heart rate of her baby slowed to a dangerously low level. Amy explained that after they gave her pitodn to speed up her labor. My uterus started contracting and it wouldn't let up, and [the contraction] went for about 17 minutes straight. And so, thafs when the doctor decided to do an emergency c-section. ... It ended up being that her heart rate slowed down to about 60 beats [per minute]. Control over labor. The obstetrical view that "medical personnel are the 'experts' and have specialized roles" was manifest during the labor and births. It was clear to the women that as soon as they entered the hospital, the medical team was in charge of their experiences. When Jane first checked into the hospital, for example, she had to wait in the triage room for hours before the medical staff decided that she was in serious enough labor to be admitted to the hospital. It was hard for [the nurses] to determine whether or not my water had actually broken. I really thought that it had, but they tested [the fluid] with a stick, and said that it hadn't. They were pretty busy that day, they had a full house, and they were debating whether to send me home. The staff finally decided to admit Jane to the labor/ delivery room. Once Jane was admitted, however, she found that she had less control over her labor than she wanted. She explained that after the medical staff gave her some pain medicine. The nurses wouldn't let me walk around. They were afraid that I would fall down because of the pain killer. But really, I was fine enough to walk. Every once in a while I got up and snuck into the rocking chair, which was really helpful. Jane found her labor to be extremely painful, especially because she could not move freely to find more comfortable positions. She wanted an epidural early in her labor, but the medical personnel denied her request.

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153 I had told them I wanted an epidural then, that I didn't think I could handle the contractions getting more intense. [The nurse] laughed at that because she thought that I really wasn't giving it a chance because I didn't even have the pitocin yet. She laughed because I was not much dilated, and I just had the pain killer in my system for two hours. She thought that I was asking for too much medication. Reflecting on her experiences, Jane explained that, "I would have liked to have been given my epidural sooner. I also felt like they should have let me walk around. That bothered me, not having control over how I could have my labor." Amy, who had originally planned on having a natural childbirth, had little control over her labor, and could not remember much of her childbirth experience. When I asked Amy what medications the medical staff gave her during her labor, she stated, I have no idea. I have no idea— the pitocin is the only thing I know of. I'm not sure, because I asked for the epidural, but I never received that. They whisked me off to the emergency room before then, I believe. But they did give me something else, I'm not sure what it was, to make me drowsy. . . . The drugs were taking effect, so I wasn't really aware, and I'm still not sure as to what really happened. I have to hear from other people that were able to understand at the time. In labor, as during pregnancy, the obstetricians played a limited role, and had little direct contact with the women. Kelly's experience was typical. [Dr. Smith] came in once to [place] the internal monitor, and to break my water, and then he left. He was gone for hours and hours. I guess he came back once to check [my dilation] and then at the very end he just came in, delivered her, and left. I didn't really talk to him much, or anything. Kelly explained that the nurses were the ones who were with her during most of her labor, and they provided the support that she needed. The [nurses] that I had all through the whole day-from 7 in the morning until 7 in the evening-they were great. I loved them. They even came up after she was born ... to check on us and see how we were doing. And they were great. They let me know what was going on and everything. . . . They were just real talkative, letting me know

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I 154 j what was going on and showing me different things. They were just really nice people. Effects on the Newborns The medical interventions had noticeable effects on the newborns. All the babies' heartbeats slowed to borderline or dangerous levels during labor. After birth, the drugs' residual effects on the babies were manifest to varying degrees. Jane's baby had the least amount of neonatal problems. She explained that immediately after birth, [My baby] was wide-eyed, and he spent a lot of time looking at me. He was pretty alert but then he did sleep all that day and all the next day. I had to wake him up to breastfeed. Hospital staff brought Kelly's baby and Amy's baby to the neonatal intensive care unit immediately after birth, but released the babies after a few hours. Kelly described her baby's problems: She didn't cry at first, and she was totally blue. . . . They worked real fast to get her breathing, and then she started crying. I didn't get to see her until two hours afterwards. They put her in the little incubator, they rolled her over to me but she had a oxygen mask on so I couldn't see her face, I could just see her body. Then they took her to NICU, but they didn't admit her, they just looked at her. And one of her arms wasn't moving at first, but once they got her upstairs she was fine. And she hasn't had any problems. Summary In my study, adherents of the obstetrical paradigm believed that childbirth is not a pleasant experience, but it can be made safer and more comfortable through technological interventions. The obstetrician in my study viewed himself as an expert technidan—there to monitor and control the birth process and keep it running within acceptable standards. In the obstetrical paradigm, the obstetrician's role is limited to the pregnancy's physical aspects. Nevertheless, pregnancy and birth is a highly personal and emotional process, and two of the couples wanted their

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155 obstetrician to be more concerned about non-physical pregnancy aspects. These couples also wanted the obstetrician to play a larger educative role and provide them with more information about their pregnancies. Another couple was satisfied with their obstetrician, and stated that they enjoyed a good relationship with him. During the childbirths, the medical personnel working in the obstetrical paradigm relied on medical technology to control many labor and delivery aspects, such as length of labor, strength of contractions, women's positions during labor, pain relief during labor, and type of delivery. Adherents of the obstetrical paradigm claim that this control is necessary to ensure safe, enjoyable, and efficient births. The obstetrician-assisted couples in my study believed that the technology and interventions that medical staff used during their births was necessary and important. Nevertheless, these women and their babies experienced several negative effects as a result of their technologically enhanced births.

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CHAPTER 7 CONCLUSIONS In this study I set out to discover how the beliefs and actions of health care professionals can help make pregnancy and childbirth a positive experience for women. My results suggest that using Kuhn's paradigm construct is beneficial in understanding reasons for differences between midwife-assisted and obstetrician-assisted births. The health care professionals' paradigms of pregnancy and childbirth affected their interactions with their clients. In turn, this difference in care produced different childbirth experiences. The results of this study also suggest that pregnancy and childbirth can have significant psychological effects on women. The midwives in my study talked about childbirth in terms of rites of passage and transformations, and this made me consider the mythic characteristics of midwife-assisted childbirth. I found Robbie Davis-Floyd's "childbirth as rite of passage" theory and Joseph Campbell's writings on mythological quests to be particularly helpful in understanding the individual and societal ramifications of the different birth paradigms. In this chapter, I present Davis-Floyd's and Campbell's theories, and explain how they provide a useful framework for interpreting my data. I then discuss how the midwives' actions reflect the feminist principles discussed in Chapter 2, and describe how midwives help make the childbirth experience empowering. Lastly, I discuss implications of the research and make suggestions for future research. 156

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157 Birth as a Rite of Passage Robbie Davis-Floyd (1992) and Joseph Campbell (1984; 1988) discuss how childbirths, especially first ones, are rites of passage. The rites' results differ depending on the childbirth paradigm under which they are conducted. Joseph Campbell, in an interview with Bill Moyers, explains how becoming a mother is a rite of passage, akin to a heroic deed. Campbell: Giving birth is definitely a heroic deed, in that it is the giving over of oneself to the life of the other. . . . Moyers: Its a journey— you have to move out of the known, conventional safety of your life to undertake this. Campbell: You have to be transformed from a maiden to a mother. Thaf s a big change, involving many dangers. Moyers: And when you come back from your journey, with the child, you've brought something for the world. Campbell: Not only that, you've got a life job ahead of you. (1988, p. 125-126) Davis-Floyd (1992) agrees that birth is a rite of passage, although she does not consider all births transformative. She explains that becoming a mother is a transformative process, and pregnancy and childbirth aid in this transformation. Nevertheless, according to Davis-Floyd, birth does not always consist of a mother moving "out of the known, conventional safety" of her life, as Moyers states in the above dialog. Rather, she claims that many births, those that follow the technocratic paradigm, reinforce conventional societal values. A woman who gives birth under the technocratic paradigm becomes more firmly entrenched in that paradigm. According to Arthur van Gennep (1966), all rites of passage consist of three stages: (1) separation from the previous state; (2) transition; and (3) reintegration to a new state. Davis-Floyd (1992) explains that during pregnancy, the separation stage begins when women find out that they are

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158 pregnant and lasts until they fully accept their pregnancies; a process that can last days or months. Once women come to terms with their pregnancies, they enter the transition stage, which lasts until after the immediate postpartum period, usually three to six weeks after their babies' births. Reintegration occurs after the babies' first few months of life, as mothers adjust to their new status and responsibilities. Davis-Floyd explains that women are in a state of flux during the transition stage of pregnancy. During this stage, women are changing, and preparing for future change. Psychologically, women are exceptionally open to learning and changing at this time: "The near-constant inner and outer flux of pregnancy keeps the category systems of pregnant women in a continuous state of upheaval as old ways of thinking change to include new life" (1992, p. 24). Confirming and adding to women's sense of difference is the reaction they receive from others. Once a woman begins to "show" her pregnancy, even strangers may reach out and pat her timimy, regale her with stories, or become solicitous (Davis-Floyd, 1992). The emotional turmoil and uncertainty that occurs during the transition state makes women susceptible to guidance and suggestions. It is at this stage, Davis-Floyd contends, that rituals instill societal paradigms in the women. Role of Rituals Davis-Floyd describes social occurrences that surround birth as rituals, "patterned, repetitive, and symbolic [enactments] of a cultural belief or value . . . [whose] primary purpose is transformation" (1992, p. 8). Davis-Floyd explains that pregnancy and childbirth have ritual characteristics, including: symbolizing the ritual's messages; being based in a belief system; offering cognitive stabilization for individuals under stress; providing order.

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159 i i formality, and a sense of inevitability; intensifying toward a climax; and enabling cognitive transformation. Summarizing the work of several authors, Davis-Floyd says that the role of ritual is to (a) make it appear that natural transformations, such as birth, are controlled by and serve society, (b) control the uncertainty present during transition periods, (c) convey core societal values to the initiate, and (d) reaffirm the values for those conducting and witnessing the ceremony. Role of Myths Cultural and individual importance. Joseph Campbell (1984; 1988) claims that myths help people understand their cultures' implicit themes and contain underlying societal values. They are embedded in folktales, legends, and hero stories but, as Schorer (1960) explains, myths are not just fanciful tales. Instead, they are the instruments by which we continually struggle to make our experience intelligible to ourselves. A myth is a large, controlling image that gives philosophical meaning to the facts of ordinary life; that is, which has organizing value for experience. A mythology is a more or less articulated body of such images, a pantheon. Without such images, experience is chaotic, fragmentary and merely phenomenal, (p. 355) Myths inculcate members of a society in the societal paradigm, helping societal members interpret the world around them. Furthermore, myths help individuals form personal identities. Jerome Bruner explains the importance of myths in guiding identity development: It is not simply society that patterns itself on the idealizing myths, but unconsciously it is the individual man as well who is able to structure his internal clamor if identified in terms of prevailing myth. Life then produces myth and finally imitates it. (1960, p. 285) Campbell emphasizes the value of myths in guiding people through life stages: "One of the main functions of myth . . . [is] what I call the pedagogical: to carry a person through the inevitable stages of a lifetime"

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160 (Maher & Briggs, 1988, p. 32-33). Campbell asserts that people are biologically driven to do many things, such as procreate, separate from parents, and give birth, and "certain things can happen that make it repulsive or difficult or frightening or sinful to do some of the things that one is impelled to do and that is when we begin to have our most troublesome psychological problems" (1988, p. 143). Transformative possibilities of mvth . Myths function at a consciousor shallow-level, and at a deeper, intuitive level. When individuals read or hear myths, and understand the "moral" in the story, they may create only an intellectual understanding of the myths, which does not instigate personal growth. Maher explains: "Myths don't count if they're just hitting your rational faculties-they have to hit the heart. You have to absorb them and adjust to them and make them your life" (1988, p. 35). Once absorbed, myths give people the tools to create firm identities and deep understandings of events around them. According to Campbell, myths provide "not only a physical instrument but a psychological commitment and a psychological center. The commitment goes past your mere intention system. You are one with the event" (1988, p. 146). Based on the above descriptions, one might conclude that myths lock people into their societies' specific world views. Campbell, however, emphasizes that myths not only guide people in understanding their society's paradigms better, they also help people control their own identities in the paradigms. Myths help people learn how to relate to their societal systems so that they are "not compulsively serving [them]" (1988, p. 144 ). Individuals usually can do very little about changing the systems, but they can learn how to function within them while holding on to their own ideals. Myths can

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1 161 free people to consciously construct their actions so that they can do what they believe is best, while staying within their societal boundaries. Campbell calls this expansion of one's world view "creative mythology" and states that it can occur through personal journeys (Sartore, 1994). As children grow up, they are initiated into their society's dominant mythology. Once past childhood, they may venture on personal journeys, or "quests." The journeys are initiated when trauma, force, circumstances, or volition lead people to leave their society or culture. The journey itself leads to the person making important discoveries. Once people return from their journeys, they are in one of the three possible return states: (a) They have suffered and learned from their journey and conclude that their old society/ culture is best; (b) They are happy to return to their society/ culture but believe that it needs some changes; and (3) They reject their old society/ culture.^ If people emerge from their journeys in either of the second two return states, they will change their societal view, rejecting the dominant mythology in favor of a new, creative mythology (Campbell, 1984; Sartore, 1994). Personal journeys do not necessarily cover physical distances, nor do they require the travelers to be physically separate from their societies. Journeys can be psychological or "spiritual," although many spiritual journeys have physical dimensions. Nevertheless, the emphasis of these journeys is psychological. Campbell explains that a spiritual quest is "the quest to find the inward thing that you basically are" (1988, p. 139). ^Fictional characters who went on journeys and ended with return states that illustrate the three possible outcomes are, respectively, (a) Dorothy in the Wizard of Oz. (b) Andre, in My Dinner with Andre, and (c) Huckleberry Finn.

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162 For first-time mothers, childbirth and pregnancy constitute a rite of passage.2 The results of this rite, however, vary depending upon the paradigm under which the rite occurs. Under the obstetrical paradigm, the event marks the change in a woman's status from childless to mother. The rituals conducted during childbirth in this paradigm serve to reinforce society's dominant mythology. Midwifery paradigm proponents, however, emphasize the transformative elements of pregnancy and childbirth, and childbirth under this paradigm does not reinforce dominant mythology. Instead, midwifery pregnancy and childbirth rituals aid the women in completing spiritual quests, and as a result the women may emerge empowered by a creative mythology. The Obstetrical Paradigm: Wonders of Technology /Patriarchy In the obstetrical point of view, birth is a potentially dangerous situation that must be carefully and expertly managed to insure a positive outcome. Obstetricians attend to technology, and in so doing minimize the participation of the individual women. Obstetricians therefore are likely to recommend medical interventions as soon as a woman's labor deviates from the statistical "norm." A Technocratic World View During the childbirths, the medical personnel working in the obstetrical paradigm relied on medical technology to control many labor and delivery aspects. This faith in technology, and the obstetrical paradigm in general, is a product of society's dominant mythology (Davis-Floyd, 1992). The model of reality that has dominated American society since the ^Women become mothers through avenues other than childbirth, such as adoption. Undoubtedly, these women also go through transformation processes in becoming mothers. It is beyond the scope of this work, unfortunately, to examine the changes that these women go through.

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163 seventeenth century, according to Carolyn Merchant (1983), is that of a mechanistic universe. The laws of this universe can be discovered through science and manipulated by technology. This view, combined with the JudeoChristian belief that people should dominate nature, transformed the body of the world . . . into a mechanical system of dead corpuscles, set in motion by the creator Because nature [is] now viewed as a system of dead, inert particles moved by external, rather than inherent forces, the mechanical framework itself could legitimate the manipulation of nature. (Merchant, 1983, p. 45) Davis-Floyd explains that as technological improvements have grown exponentially, the mechanistic world view has evolved into a technological world view. Our technological artifacts are both embedded in and formative of our worldview, and their primary uses will reflect and perpetuate the paradigm underlying that worldview. . . . These technologies have developed in a hierarchical social context that supervalues them and the individuals who control them. (1992, p. 47) The medical personnel in my study demonstrated their adherence to this technocratic world view with their actions during pregnancy and childbirth. The obstetrician's actions suggested that he viewed himself as a technician-someone who would "fix" whatever was wrong during the birth process. During the women's pregnancies, the obstetrician relied more heavily on medical measurements than on the women's subjective reports of their own feelings. Instead of letting each woman's labor progress naturally, in every case the hospital staff used drugs to speed up labor and obstetrical interventions to extract the babies. Research shows and my study confirms that obstetricians like it when pregnancies and labors progress in a machine-like fashion, "according to schedule," and they do not easily make allowances for individual variations. Obstetricians view any deviance from the norm as potentially problematic

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164 and in need of being "fixed." For example. Dr. Smith was concerned about Jane's weight gain, although Jane and her husband did not think that it was excessive. Davis-Floyd (1992) takes care to point out that valuing technology is not necessary negative, and many mothers-to-be benefit from technological interventions. Nevertheless, she explains that technocracy as the basis for a societal paradigm may be problematic, especially when combined with the societal view of people's supremacy over nature. This combination makes it unlikely that doctors will hesitate to use technological interventions. For example, when Amy was in early labor. Dr. Smith told Amy and Ronald that they could "wait and see" what would happen, or they could "come back to the hospital later on and we can just go ahead and induce, and get it over with." Obstetricians may also be quick to recommend technological interventions because they enjoy performing the interventions. As the obstetrician in my study explained, the obstetrical field is attractive partly because obstetricians have the chance to perform surgeries and other medical procedures. Obstetrical Paradigm's Service to Society Effects of rituals on individuals. The obstetrical paradigm does not merely reflect the larger societal paradigm. Davis-Floyd (1992) explains how standard medical procedures, or rituals, reinforce the women's beliefs in society's dominant paradigm. These rituals are based on medicine's prevailing paradigm. By participating in these rituals, the women's initial socialization into the dominant paradigm is confirmed and strengthened. In my study, the obstetrician-assisted women accepted the obstetrical paradigm without question. They were living in the dominant paradigm, and they did not mention considering alternatives ways of having birth.

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Their pregnancy and childbirth experiences validated their beliefs. All the couples ended up with healthy babies and they credited the technological interventions that they experienced for these positive outcomes. Had nature run its course, they believed, birth would have been unbearable and their babies might have been hurt. Two of the couples were not happy with their experiences. They blamed their specific obstetrician for the problems, however, and did not challenge the obstetrical paradigm under which he worked. Even Amy, who originally wanted to have natural childbirth and ended up with a cesarean section, was happy with her treatment at the hospital and grateful to her doctor for successfully getting her and her baby through a difficult experience. Effects of rituals on patriarchy. Several theorists maintain that the obstetrical paradigm affirms the patriarchal structure of our society by taking the credit for childbirth away from the women and giving it to the medical personnel (Bortin, Alzugaray, Dowd, & Kalman, 1994; Cassidy-Brinn, Hornstein, & Downer, 1984; Davis-Floyd, 1992; Jordan, 1980; Leavitt, 1986; McLoughlin, 1997; Mitford, 1992; Rothman, 1982; Spitzer, 1995; Turkel, 1995). In our society the dominant view of women is that they are the "weaker sex," who need protection and help from men. Davis-Floyd (1992) explains why childbirth threatens this view: The majority of human cultures are strongly patriarchal, ours included. Yet birth, upon which men must totally depend for their own and their children's existence, is a purely female phenomenon. As such, birth poses a major conceptual threat to male dominance, as male dependence upon females for birth would seem to demand that women be honored and worshipped as the goddesses of their society's perpetuation. The dilemma here: how to make birth, a powerfully female phenomenon, appear to sanction patriarchy? (p. 61) The obstetrical paradigm comes to the aid of patriarchy by portraying childbirth as dangerous and making women believe that they are not capable

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'1 166 of taking charge of their childbirths.3 xhe medical personnel are there to take care of the women. The attitude of hospital staffs toward laboring women is: "Don't worry, we'll handle it." Practitioners in the obstetrical paradigm tell women that they do not need to be strong-in fact, it may be preferable for the women to be numbed and distant from the entire experience. The results of my study support the claim that obstetrical paradigm practitioners diminish the importance of the women's role in childbirth. They accomplished this in a couple of ways. First, the medical personnel did not give the women much information about their individual conditions, or birth in general. The childbirth classes that they offered the women were available at extra expense, and were ill-attended. Even if the women had attended the classes, however, they would have received little empowering information. The childbirth educator spent much more time teaching women about hospital procedures and medical interventions than she did teaching them how to direct their labors. The second way that the medical personnel minimized the women's role in childbearing was by controlling all medical information obtained during pregnancy. The nurses at the obstetrician's office weighed the women and tested their urine at each visit, tasks that could have easily been accomplished by the women themselves. The medical personnel recorded the results of these measures, as well as results of laboratory tests, on the women's charts. They did not offer to let the women see their charts. The 3This view is humorously illustrated in the Monty Python movie. The Meaning of Life . In the opening scene of the movie, a women is laboring in a hospital room. A host of medical personnel rush about looking busy, rolling in different machines (including one machine that does nothing but goes "beep"). The expectant mother asks the doctor in charge what she should do, and the doctor (played by John Cleese) replies with an irritated expression, "Nothing! You're not qualified."

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obstetrician only sometimes gave the women information, such as their babies' position or size. Medical personnel guide pregnant women toward the technocratic society's patriarchal norms. Obstetricians could help the women understand the transformation process and encourage the women to take charge. The obstetrical paradigm, however, prevents doctors from considering this role definition. For example, the obstetrician in my study acknowledged that many psychological changes occurred in women during pregnancy and childbirth, but he did not perceive it to be his job to educate women about or guide them through these changes. They were out of his control and not relevant to his work. Davis-Floyd (1992) explains that doctors are themselves enculturated to maintain the status quo and are in an ideal position to do so: It is no cultural accident that doctors themselves must undergo an eight-year-long initiatory rite of passage, a process of socialization so lengthy and thorough that at its end they will become not only physicians but the representatives of American society. . . . For our medical system encapsulates the core value system our society has based on its technocratic model of life and thus is well-qualified to pass this system on. (p. 63) The Midwifery Paradigm: Wonders of Nature Midwives listen first and foremost to the individual women, and work with the women to maximize the experience of their particular births. By paying attention to the individual, midwives are able to help more women avoid needless medical interventions and have natural births. These practices result in healthier mothers and babies. The paradigm underlying modem midwifery is different than the paradigm used by midwives 200 years ago. In early US history, midwives practiced their art because it was the natural thing for them to do. Birth was a

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168 social event, and those women with the most experience in witnessing childbirths aided women in labor. Beginning in the 1960s, midwives began to advertise their childbirth paradigm as an alternative to the medical model. They expanded the midwifery paradigm to more explicitly embrace the transformative, empowering aspects of birth. The reasons given by Barbara, Liza, and Judy for entering midwifery reflect these differences. They came to midwifery because they were unhappy with what they took to be the dehumanizing and impersonal obstetrical paradigm. These women knew that there was potentially more to childbirth than the obstetrical paradigm acknowledged. Like obstetricians, midwives' definitions of a successful birth include a healthy baby and a healthy mother. The midwifery definition requires more, however. For midwives, the process of childbirth is as important as the product. Ideally, the process will result in a healthy baby and a healthy, transformed, and empowered mother. A Holistic World View The midwifery paradigm that I identified in this study corresponds to what Davis-Floyd calls a "wholistic [sic] model of birth" (1992, p. 155). She explains that in this model science and technology are used to serve rather than control women. The holistic paradigm includes the concepts that birth is a normal event, the body is an organism rather than a machine, social support is important, and the body is integrated with mind and its surroundings: The human body is a living organism with its ovm innate wisdom, an energy field constantly responding to all other energy fields. Health or illness is the reflection, the mirror, the manifestation of the health or illness of one's self, one's daily life, one's family, one's past, one's society-one's whole world. (Davis-Floyd, 1992, p. 156)

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169 As we have seen, the obstetrical paradigm is a reflection of the prevalent societal paradigm. The midwifery paradigm offers an alternative paradigm that is both mythic and holistic. In this paradigm there is no clear distinction between people and nature, rational processes and intuition. Joseph Campbell explains, "Consciousness thinks it's running the shop. But if s a secondary organ of a total human being, and it must not put itself in control. It must submit and serve the humanity of the body" (1988, p. 146). In the holistic world view, technology cannot protect people against nature. Instead, nature is acknowledged as an inescapable part of life. Maher and Briggs explain, "Nature becomes feared if it has been suppressed long enough and if you are out of accord with it, it is always going to break up the quadrangular mode of planning that you've had for your life" (1988, p. 106). Technology is a part of rather than a master of nature: "Science really comes from paying attention to nature. It takes the possibilities of nature and recombines them; its basis is nature, too" (Maher & Briggs, 1988, p. 106). Childbirth in the technocratic paradigm reinforces society's technologyover-nature paradigm. Childbirth under the holistic paradigm is a mythic journey of test, courage, and transformation. Transformative Possibilities The midwives in my study treated pregnancy and childbirth as a significant transformation ritual that when properly understood empowers mothers. To help women achieve this transformation, the midwives told birth stories and encouraged women who already had babies to share their stories with expectant moms. They described birth as a rite of passage, akin to a spiritual quest. Pregnancy, they explained, is the preparation for the birth journey.

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170 Campbell's description of a heroic journey closely resembles the childbirth process: The usual pattern is, first, of a break away or departure from the local social order and context; next, a long, deep retreat inward and backward, as it were, in time, and inward, deep into the psyche; a chaotic series of encounters there, darkly terrifying experiences, and presently (if the victim is fortunate) encounters of a certain kind, fulfilling, harmonizing, giving new courage; and then finally, in such fortunate cases, a return journey of rebirth to life. And that is the universal formula also of the mythological hero journey ... 1) separation, 2) initiation, and 3) return. (1984, p. 208-209) Childbirth can be a spiritual journey inward. Women, midwives explain, must find the inner strength necessary to accomplish the birth. Campbell explains that during a spiritual journey, "the place to find is within yourself. . . . There's a center of quietness within, which has to be known and held. If you lose that center, you are in tension and begin to fall apart" (1988, p. 161-162). The midwives explained that mothers-to-be had everything necessary for the successful completion of their quest inside themselves. The midwives assured women that if they relaxed and trusted their bodies, their bodies would "know what to do" when the time came. According to Campbell, myth helps people make the conscious/ unconscious connection: "The whole function of myth is to unite these two orders of our nature: mental nature~the waking consciousnessand that thing which takes over in sleep" (Maher & Briggs, 1988, p. 106). The pain of childbirth plays an important role in the spiritual quest. It is pain that provides the quest's challenge. Myths give meaning to the pain and give guidance for overcoming suffering: Myths tell us how to confront and bear and interpret suffering, but they do not say that in life there can or should be no suffering. When the Buddha declares there is escape from sorrow, the escape is Nirvana, which is not a place, like heaven, but a psychological state of mind in which you are released from desire and fear. (Campbell, 1988, p. 160)

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171 Midwives teach women that to endure labor pain, women first have to accept it and not fight against it. Women then need to work with the pain, letting it help them focus inward, where they can find their "centers" and strengths. All quests have temptations that may divert heroes from their goals (Campbell, 1988). The main temptations present in the childbirth journey are painkillers. In the midwifery view, using drugs to numb the feelings of labor and childbirth removes the women from the birth experience. Drugs also affect the baby in some degree. The midwives in my study prepared women to resist painkillers in two ways. The childbirth instructor warned women of the negative effects of drugs. In addition, they let women know that it is common for women to reach a time in their labors where they feel that they cannot continue. Usually this feeling signals the transition stage of labor, which is short in duration and occurs right before the pushing stage. Suzy stated that she was greatly tempted to abandon her quest and have her baby in the hospital after she had labored for seven days. With a little encouragement and guidance from Barbara, the midwife, Suzy resisted the temptation and gave birth eight hours later. Midwives as spiritual guides . Throughout women's pregnancies and childbirths, midwives function as spiritual guides. Spiritual guides are not essential for quests, but they are helpful. Campbell explains that, "if you don't have someone to [guide] you, you've got to work [the journey] all out from scratch-like reinventing the wheel" (1988, p. 143). The role of spiritual guide includes the functions of teacher, supporter, and encourager. As teachers, the midwives in my study related childbirth mythology to the women and prepared the women for their childbirth journeys. This preparation consisted of two components: physical and psychological. For the physical aspect, the midwives educated the women about proper diet and

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172 exerdse, and encouraged the women to get in shape for the birth. For the psychological component, the midwives made sure that the women were psychologically stable and referred them to places where they could receive help if needed. The midwives also educated the fathers-to-be of the importance of providing emotional and psychological support to the mothers. Throughout the pregnancies, the midwives made suggestions, not demands of the women. This practice reflects Campbell's assertion that "a good teacher is there to watch the [questing] person and recognize what the possibilities are—then to give advice, not commands" (1988, p. 143). The midwives in my study gave the women support during both pregnancy and childbirth. The midwives supported the women's rights to plan their own births, even letting Amanda keep open the option of having a water birth. During labors, the midwives continued to support the women's decisions. At this time they also gave further support by giving the women suggestions for making their labors more bearable and productive. At all times, the midwives functioned as encouragers, assuring the women that they could accomplish their childbirths. They encouraged the women to look deep within themselves for power and strength. The midwives let the women know that a childbirth could only be accomplished by the woman herself. This view corresponds to Campbell's statement, "Ultimately, the last deed has to be done by oneself" (1988, p. 149). Empowerment possibility. The midwives in my study emphasized that childbirth, when done the "right" way, would be an empowering experience. They worked hard to educate their clients about the pregnancy and childbirth process, and they gave the women a good deal of responsibility for monitoring and planning their pregnancies and childbirths.

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173 The midwife-assisted women in my study felt well prepared for childbirth and were confident in their abilities to have unmedicated childbirths. All the women were successful in their quests for natural, meaningful births. The women found their births to be "wonderful," "beautiful," "incredible," and "exhilarating" experiences that they would gladly repeat. Five months after their births, the positive effects remained. The mothers felt empowered—stronger, more confident, and more competent because of their childbirth experiences. The mothers did not view only their individual selves as stronger, they stated that they viewed women in general, especially mothers, as stronger people than before. Not only did the midwife-assisted mothers feel more empowered, but they also returned from their journeys in Campbell's second or third "return state." The women believed that there were problems with the dominant patriarchal social view of woman as delicate and in constant need of male assistance. In accepting the midwifery paradigm, the women accepted the tenets of a creative mythology. Although none of the midwives in my study explicitly mentioned feminism, their paradigm reflects feminist principles. The midwives viewed women as strong and capable, and helped women maximize their strengths. The holistic world view that the midwifery paradigm supports is not patriarchal. The holistic model does not recognize differences among people on the basis of sex. Instead, it recognizes differences based on actions and achievements. Role of education. The results of my research suggest that education plays a large role in empowerment. One of the primary functions of present day midwives is that of educator. An important tenet of the midwifery paradigm is that "women give birth," and the midwives worked to ensure

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that their clients make informed choices. Midwives view pregnancy as a time for women to prepare, physically and emotionally, for the childbirth experience. The midwives believed that education is the vehicle through which women can become empowered. The midwives provided more education than the obstetrician and they strongly encouraged the women to take advantage of educational opportunities. The nature of the educational offerings was as important as the amount. The instructor of the hospital childbirth classes taught the women the mechanics of labor and birth and prepared the women for medical interventions. In the classes at The Midwife Center the women also learned about the mechanics of labor and birth, but in addition the instructor helped them develop the ability to take charge of their pregnancies and births. The midwives also encouraged their clients to take nutrition and exercise classes where the instructor gave them a clear understanding of what was happening to their bodies and suggestions for what they could do to make their pregnancies and labors as healthy and easy as possible. Childbirth is certainly an achievement, and so women who successfully negotiate the mind /nature relationship to give natural birth are successful in the holistic paradigm's terms.'* And their achievements are not insignificant. The heroic quests that pregnant women undertake are full of uncertainties, pain, and temptations, illustrated most dramatically in Suzy's seven-day ordeal, but present in the other women's births as well. The women explained that although they had the expert guidance of midwives, ^It is unclear what the effects are on women who have complications that prevent them from having natural childbirth. The effects may differ depending on several variables: Did the women not have natural childbirth because they did not believe that they could do it or because of medical need? How long of a labor did the women experience? For example, if a woman labored for a long time and then needed a medical intervention during delivery, she may still feel that she completed a quest, with assistance. If the woman had little or no labor time, her resulting evaluation of her experience would probably be different.

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175 the midwives "stayed in the background" during labor, letting each woman find her own way to accomplish her quest. And in accomplishing this quest, a woman may find that she has gained more than a healthy baby. She may have begun to internalize an alternate way of looking at the world, a way in which she does not feel limited by her sex, and in which she has a better accord with the world's mysteries. Initial Differences Between Groups of Women It is possible that differences between the groups of women in my study accounted for some of the differences in experiences and outcomes. Previous research has partially supported the view that women who choose midwife caregivers may be psychologically and behaviorally different from women who choose physician caregivers. Women who choose to have midwives as caregivers may do so because they intend to play a more active role in their pregnancies and births. My research lends some support to this view. The two groups of women were similar in many aspects, but there were also areas of definite differences. The women who chose midwives were more likely to base their decisions on their own research. They actively sought the birth situation that they believed had the best safety record. They also were more active in ensuring that their childbirth attendant would be a person with whom they felt comfortable and who respected their wants. These women also may have entered their pregnancies less accepting of the dominant patriarchal societal paradigm. They mentioned similarities among women and men and focused less on differences, were more concerned with the sacrifices of motherhood, and were likelier to perceive woman as strong.

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176 The photographic self-narratives of the women who chose obstetricians reflected more socially prevalent ideas about women. These women were more concerned with manipulating their appearances, stated that they did not mind having little control over their labors, and wanted the medical personnel to take charge of the process. Research Implications Selection of Pregnancy and Childbirth Caregivers The results of this study can help pregnant women make informed decisions concerning their choice of health care professionals. Most likely, a woman in our society will go through pregnancy and childbirth only two or three times. This makes it imperative that each birth is as meaningful as possible. By understanding the midwifery paradigm's safety and individual growth potential, women can choose to maximize their chances of a successful birth experience by picking a midwife caregiver. Improving Obstetrical Care Technological advances in obstetrics have greatly improved the chances of a mother and her baby emerging from childbirth alive and healthy. Nevertheless, when these doctors do not allow for normal individual variations among people, technology can create more problems than it solves (Cassidy-Brinn, et al, 1984; Mitford, 1992; Rowland-Serdar & Schwartz-Shea, 1991). The results of this study suggest that more women could experience safer and meaningful childbirths if the obstetrical paradigm incorporated a more holistic view of childbirth. The holistic paradigm does not preclude the appropriate use of medical technology. It merely points out the dangers inherent in over-reliance of this technology.

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1 177 This study also indicates that it is not a matter of who helps the pregnant women, but how the pregnant woman is being helped. Hospitals are increasingly using nurse-midwives to provide prenatal care and to assist women during labor. The primary motivation for this increase in midwives, however, is to save money^. These hospital birth centers are not changing obstetrical views of the meaning of the pregnancy and childbirth experience. Instead, hospitals are producing "midwives" who view childbirth through the obstetrical paradigm, and these midwives function mainly as labor and delivery nurses. Su ggestions for Further Research Nature of Empowerment All the midwife-assisted women in my study said that they felt more empowered as a result of their pregnancy and childbirth experiences. It is unclear, however, exactly what is meant by the term "empowerment," or what precisely the women are empowered to do. Future research could flesh out this conception of empowerment by examining its manifestations. For example, do midwife-assisted women have a larger sense of efficacy in specific situations? Are midwife-assisted women more confident and/ or involved parents? What are other ways that this increased sense of empowerment changes or better their lives? Research of this nature might be particularly valuable in the area of teenage motherhood. If midwife-assisted births are empowering in significant, long-term ways, we may want to encourage teenage mothers to experience birth in this way. ^Therefore, there has been a recent slew of reports on the relative costs of in-hospital birth centers versus "traditional" obstetrical births.

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178 Effects on Multiparous Women The results of my study suggest that childbirth is a rite of passage for first-time mothers and can be an empowering experience for them. The effects of subsequent pregnancies and childbirths on multiparous women is unknown. There are several questions in this area that researchers can address: (a) What are the psychological effects of pregnancy and childbirth on multiparous women? (b) If women have previously had unsatisfactory childbirths, can subsequent births be empowering? (c) What role do health care professionals play in defining pregnancy and childbirth for multiparous women? Effects on Fathers Childbirth is undoubtedly a rite of passage for men as well as for women. The men in my study discussed how they were beginning to feel different now that they were fathers. It is possible that the midwifery paradigm is as empowering for fathers as well as mothers. In the holistic view of birth, family involvement in birth is very important. The midwives in my study ensured that the fathers felt welcome and involved during all prenatal visits and classes. During the births, it was the fathers who took the lead role in helping the mothers, while the midwives stayed "in the background." The fathers were the main support people for the mothers, giving them massages, preparing food for them, and holding glasses for the mothers to drink from. After the baby's birth, the father was put in charge of the baby whenever the mother was bathing or otherwise occupied. It would be interesting to study the midwifery paradigm's short and long-term effects on fathers. In the short term, do midwife-assisted fathers bond quicker and better with their babies? Are they more willing to be involved in newborn care? How does the experience affect their

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179 relationships with their wives? Are there any long-term effects on the fathers? Studies that address the above questions could yield useful information for potential mothers and fathers as well as health care professionals. In addition, the studies may lend support for Joseph Campbell's claim that in order to live a full life, one should pay attention to mythological concepts. Campbell: It has been well said that mythology is the penultimate truth—penultimate because the ultimate cannot be put into words. ... If s important to live life with the experience, and therefore the knowledge, of its mystery and of your own mystery. This gives life a new radiance, a new harmony, a new splendor. Thinking in mythological terms helps to put you in accord with the inevitables of this vale of tears. You learn to recognize the positive values in what appear to be the negative moments and aspects of your life. The big question is whether you are going to be able to say a hearty yes to your adventure. Moyers: The adventure of the hero? Campbell: Yes, the adventure of the hero— the adventure of being alive. (Campbell, 1988, p. 163)

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1 GLOSSARY Back labor Occurs when unborn babies are positioned with their backs rather than their fronts against their mothers' spine. This position often causes a particularly painful labor, characterized by bad backaches. Braxton-Hicks contractions Uterine contractions that occur before labor actually begins. They are weaker than real contractions, irregular in rhythm, and brief in duration. When they persist over several hours they create a "false" labor. They may begin many weeks before the onset of true labor. Certified Nurse-Midwives Midwives educated in both nursing and midwifery. They can be licensed in the individual states in which they practice. They most often practice in hospitals and birth centers. Cesarean section Also known as a c-section. This is a surgical procedure where the physician cuts through the uterine wall in order to remove a baby. Certified Professional Midwives These midwives may gain their midwifery education through a variety of routes. They are direct-entry midwives who are nationally credentialled, having been evaluated by a national certification agency and passing an exam. Their legal status varies from state-to-state. Dilation Refers to the opening of the cervix during labor. The cervix is considered to be fully dilated, and labor has reached the "pushing" stage, at 10 centimeters. 180

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181 Direct-Entry Midwives These midwives, licensed in some states, are not required to become nurses before training to be midwives. Their legal status varies according to state, and they practice most often in birth centers and in homes. Epidural A drug inserted into the spinal cord of women in labor. The drug blocks all sensation from the waist down. Episiotomy A surgical procedure where the health care professional makes an incision in the opening of the vagina in order to permit easier passage of a baby's head or the introduction of medical implements, such as a vacuum or forceps, into the vagina. Free-standing birth center A place physically unconnected to a hospital or clinic where women may receive prenatal care and deliver their babies. Free-standing birth centers usually are owned and operated by midwives, sometimes in connection with physicians. Natural childbirth Occurs when a woman goes through labor and delivery without the use of painkillers. Non-stress test This test is done to assess the fetus' health during pregnancy. The pregnant woman lies down for twenty minutes while the baby's heartbeat is monitored by a device attached to a belt strapped around the woman. The baby's heartbeat rises sharply when it moves, so this test can help determine whether the baby is as active as it needs to be. Prenatal The period of time occurring between conception and birth. In this study, participants often used the word "prenatal" to mean a routine prenatal visit with the health care professionals. Postpartum The period of time beginning after birth.

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I 182 Water Birth Occurs when a women births her baby immersed in water. The baby is bom underwater, which theoretically lessens the trauma of birth.

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REFERENCES Alcoff, L. (1988). Cultural feminism versus post-structuralism: The identity crisis in feminist theory. Signs, 13(3), 405-436. Bell, R. R. (1981). Worlds of friendship . Beverly Hills: Sage. Berg, M., Lundgren, I., Hermansson, E., & Wahlberg, V. (1996). Women's experience of the encounter with the midwife during childbirth. Midwifery. 12(1), 11-5. Blanton, W. B. (1931). Medicine in Virginia in the eighteenth century . Richmond, VA: Garrett & Massie. Bortin, S., Alzugaray, M., Dowd, J., & Kalman, J. (1994). A feminist perspective on the study of home birth: Application of a midwifery care framework. Journal of Nurse-Midwifery, 39(3), 142-149. Browne, C. V. (1995). Empowerment in social work practice with older women. Social Work. 40(3). Browne, H. E., & Isaacs, G. (1976). The Frontier Nursing Service: The primary care nurse in the community hospital. American journal of Obstetrics and Gynecology. 124 . Bruner, J. S. (1960). Myth and identity. In H. A. Murray (Ed.), Myth and mythmaking (pp. 276-287). NY: George Braziller. Callister, L. C. (1995). Beliefs and perceptions of childbearing women choosing different primary health care providers. Clinical Nurse Researcher. 4(2), 168-80. Campbell, J. (1984). Myths to live by . NY: Bantam Books. 183

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184 Campbell, J. (1988). The power of myth: With Bill Movers . NY: Doubleday. Cassidy-Brimi, G., Hornstein, F., & Downer, C. (1984). Women-centered pre gnancy and birth . Pittsburgh: Cleis Press. Center for Disease Control (1995). US Birth Cohort of 1990. Table 43 . Available: http:/ / www.cdc.com [1999, July 9]. Churchill, H. (1995a). The conflict between lay and professional views of labour. Nursing Times, 91(42), 32-3. Churchill, H. (1995b). Perceptions of childbirth: Are women properly informed? Nursing Times, 91(45), 32-3. Clarke, S. C. (1997). Trends of midwife births. Stat Bulletin. Z8(ll), 9-18. Danzinger, S. K. (1986). Male doctor-female patient. In P. S. Eakins (Ed.), The American way of birth (pp. 104-118). Philadelphia: Temple University Press. Davis-Floyd, R. E. (1992). Birth as an American rite of passag e. Berkeley: University of California Press. Donnison, J. (1977). Midwives and medical men . NY: Schocken Books. Dye, N. S. (1986). The medicalization of birth. In P. S. Eakins (Ed.), The American way of birth (pp. 39-51). Philadelphia: Temple University Press. Eakins, P. S. (1986). Out-of-hospital births. In P. S. Eakins (Ed.), The American way of birth (pp. 224-236). Philadelphia: Temple University Press. Fischler, N. R., & Harvey, S. M. (1995). Setting and provider of prenatal care: Association with pregnancy outcomes among low-income women. Health Care for Women International. 16, 309-321. Fox, R. C. (1989). The sociology of medicine: A participant observer's view. Englewood Cliffs, NJ: Prentice Hall.

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185 Gilbert, T. (1995). Nursing: Empowerment and the problem of power. Journal of Advanced nursing , 21, 865-871. Gregory, S. (1848). Man-Midwifery Exposed and Corrected . Boston: George Gregory. Hafner-Eaton, C., & Pearce, L. K. (1994). Birth choices, the law, and medicine: Balancing individual freedoms and protection of the public's health. Journal of Health. Political Policy and Law. 19(4), 813-835. Hall, C. M. (1992). Women and empowerment: Strategies for increasing autonomy . Washington, DC: Hemisphere. Hallsdorsdottir, S., & Karlsdottir, S. I. (1996). Journeying through labour and delivery: Perceptions of women who have given birth. Midwifery. 12(2), 48-61. Harvey, S., Jarrell, J., Brant, R., Stainton, C, & Rach, D. (1996). A randomized, controlled trial of nurse-midwifery care. Birth, 23(3), 128-135. Jordan, B. (1980). Birth in four cultures (4th ed.). Prospect Heights, IL: Waveland Press. Kennedy, H. P. (1995). The essence of nurse-midwifery care: The woman's story. Journal of Nurse-Midwifery, 40(5), 410-417. Kuhn, T. (1970). The structure of scientific revolutions (2nd ed.). Chicago: University of Chicago Press. Leavitt, J. W. (1986). Brought to bed: Childbearing in America. 17501950. New York: Oxford University Press. Leavitt, J. W., & Walton, W. (1984). Down to death's door: Women's perceptions of childbirth in America. In J. W. Leavitt (Ed.), Women and health in America (pp. 5-19). Madison, WI: University of Wisconsin Press. Litoff, J. B. (1978). American midwives: 1860 to the present . Westport, CT: Greenwood Press.

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186 Maher, J. M., & Briggs, D. (Eds.). (1988). An open life: Joseph Campbell in conversation with Michael Toms . NY: Paul Brunton Philosophic Foundation. Martin, E. (1987). The woman in the body . Boston: Beacon Press. May, K. A. (1980). A typology of detachment/ involvement styles adopted during pregnancy by first-time fathers. Western Journal of Nursing Research. 2(445-453). McLoughlin, A. (1997). The 'F' factor: Feminism forsaken? Nurse Education Today. 1Z(2), 111-114. Mendelsohn, R. (1979). Confessions of a medical heretic . NY: Warner Books. Merchant, C. (1983). The death of nature: Women, ecology, and the scientific revolution . San Francisco: Harper and Row. Midwife Alliance of North America (1999). Available: http/ / www.mana.org [1999, July 24]. Miller, L. G. (1979). Pain, parturition, and the profession: Twilight sleep in America. In S. Reverby & D. Rosner (Eds.), Health care in America (pp. 231-248). Philadelphia: Temple University Press. Mitford, J. (1992). The American way of birth . NY: Dutton. National Center for Health Statistics (1998). Monthly vital statistics report. June 30, 1998. On-line journal: http / / www.cdc.gov/nchswww. 46(11)North American Registry of Midwives (1999). Midwifery model of care. Available: http/ / www.mana.org/narm [1999, July 9]. Oakley, A. (1984). The captured womb: A history of the medical care of pre gnant women . NY: Basil Blackwell, Inc.

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187 Ozer, E. M., & Bandura, A. (1990). Mechanisms governing empowerment effects: A self-efficacy analysis. Journal of Personality and Social Psycholog y. 58(472-486). Riger, S. (1993). Whaf s wrong with empowerment? American Journal of Community Psycholog y. 21(3), 279-292. Rothman, B. K. (1982). In labor: Women and power in the birthplace . New York: W. W. Norton. Rothman, B. K. (1986). The social construction of birth. In P. S. Eakins (Ed.). The American way of birth (pp. 104-118). Philadelphia: Temple University Press. Rowland-Serdar, B., & Schwartz-Shea, P. (1991). Empowering women: Self, autonomy, and responsibility. Western Political Quarterly. 44(3), 605-624. Sartore, R. L. (Ed.). (1994). Joseph Campbell on myth and mythology . NY: University Press of America. Schorer, M. (1960). The necessity of myth. In H. A. Murray (Ed.), Myth and mythmaking (pp. 354-358). NY: George Braziller. Scully, D. (1980). Men who control women's health: The miseducation of obstetrician-gynecologists . Boston: Houghton-Mifflin. Shorter, E. (1982). A history of women's bodies . NY: Basic Books. Speert, H. (1980). Obstetrics and gynecology in America: A history . Chicago: The American College of Obstetricians and Gynecologists. Spitzer, M. C. (1995). Birth centers: Economy, safety, and empowerment. Journal of Nurse Midwifery. 40(4), 371-5. Spradley, J. (1979). The ethnographic interview . New York: Holt, Rinehart and Winston. Spradley, J. (1980). Participant observation . New York: Holt, Rinehart and Winston.

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188 Starr, P. (1982). The social transformation of American medicine . NY: Basic Books. Troutt, B. (1996). Changing childbirth: The best-kept secret ever. Midwives. 109(1303), 235. Turkel, K. D. (1995). Women, power, and childbirth: A case study of a free-standing birth center . Westport, CN: Bergin & Garvey. van Gennep, A. (1966). The rites of passag e. Chicago: University of Chicago Press. Walker, J. M., Hall, S., & Thomas, M. (1995). The experience of labour: A perspective from those receiving care in a midwife-led unit. Midwifery, 11(3), 120-9. Webster, C. (1993). Caring for health : History and diversity . Philadelphia: Milton Keynes. Ziller, R. C. (1990). Photographing the self: Methods for observing personal orientations . Newbury Park: CA: Sage.

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BIOGRAPHICAL SKETCH The author received her bachelor's degree and master's degree, both in Elementary Education, from the University of Florida. The author is now living in Troy, Alabama, where she is employed as an Assistant Professor of Foundations of Education at Troy State University. She has three children, all of whom were bom through natural birth, with midwife caretakers. 189

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1 certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. M^U-&JMi. Rodman B. Webb Professor of Educational Psychology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Bnaget Ai Franks Associate Professor of Educational Psychology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. William Marsiglio Associate Professor/of Sociology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Robert R. Sherman Professor of Educational Psychology

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. RoBert C. Ziller Professor of Psychology This dissertation was submitted to the Graduate Faculty of the College of Education and to the Graduate School and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. December, 1999 ^'^man. Educational Leadership, Policy, and Foundations Dean, College of Education Dean, Graduate School