March 1999 Vol. 26.1
Sheila Kitzinger's Letter from Europe
Obstetric Metaphors and Marketing
Obstetricians use a language about pregnancy and birth that is very different from the language women speak. When doctors talk about being high risk, a labour being prolonged, an inadequate pelvis or diagnose an incompetent cervix or failure to progress but especially when they make off-the-cuff comments about a lazy uterus, a sloppy cervix or a boggy fundus, they present a view of the world, and the place of women in it, that imposes a certain set of values and that assumes that they, as scientists, can step back and make judgements separate from the objects and systems they study.
Obstetric language is mechanistic; women's is experiential. The obstetric script presents a pregnant woman as an ambulant pelvis. If she is having her first baby she is an untried pelvis. In childbirth she is a contracting uterus and a dilating cervix.
Cartoon by Jo Nesbitt
adopt the language of architecture, as if the woman's body were a construction site ... 1.
There is the pubic arch, the pelvis floor, the abdominal
wall and the birth canal. Metaphors are taken from industry, too. The
process of birth is treated as the automatic movement of a bulky object as if it were a
manufactured product along a conveyor belt that is constantly at risk of breaking down.
Management of labor consists in keeping the conveyor belt running. In Sweden antenatal
care is called pre-natal control, implying the management of female patients
in much the same way as managers control factory products rolling off the assembly line.
Sometimes obstetric writing suggests a DIY hobby. For example, when induction fails:
The cervix gives way reluctantly with the impression that it is being forced open,
like a door with hinges rusted.2
Or, perhaps, model airplane enthusiasm: Lift-off never occurs.
Much obstetric language is about conflict. The baby struggles with the maternal body for survival and her pelvis is seen as an arena in which these battles are fought. Certainly there are unhappy women hating pregnancy, who think of the baby inside them as a tumour feeding on their strength, swelling, growing, until they feel they have become monsters. We acknowledge that this is emotionally pathological. But when obstetricians use similar concepts, we accept this as their normal way of thinking. The fetus is competing with the woman for nutrients, threatening her as its head grows ever larger, until finally, during labour, it tears muscles and tissues and as it is propelled down the birth canal, damages the bladder, urethra, anal sphincter and perineum in the process of forcing its way out.
Such sado-masochistic language is well established in obstetrics. Joseph DeLee was a master of it: Labor has been called, and is still believed by many to be, a normal function. It always strikes physicians as well as laymen as bizarre, to call labor an abnormal function, a disease, and yet it is a decidedly pathologic process. Everything, of course, depends on what we define as normal. If a woman falls on a pitchfork, and drives it through her perineum, we call that pathologic-abnormal, but if a large baby is driven through the pelvic floor, we say that it is natural, and therefore normal. If a baby were to have its head caught in a door very lightly, but enough to cause cerebral hemorrhage, we would say that it is decidedly pathologic, but when a baby's head is crushed against a tight pelvic floor, and a hemorrhage in the brain kills it, we call this normal .... In both cases, the cause of the damage, the fall on the pitchfork, and the crushing of the door, is pathogenic ... He then moves from farm to fisheries: ...... I have often wondered whether Nature did not deliberately intend women should be used up in the process of reproduction, in a manner analogous to that of the salmon, which dies after spawning?3
Today audio-visual aids may be used by obstetricians to emphasise that birth is dangerous and that a pregnant woman who spurns obstetric intervention does so at her peril. One German obstetrician actually sits patients down in front of a video of a simulated car crash, the head of a small child hitting the windscreen, to demonstrate what will happen at delivery if he does not perform an episiotomy.
Obstetric language employs metaphors of conflict, war and aggression: the aggressive management of ruptured membranes, the oxytocin challenge test, trial of labor, and the trigger factor for labour. In the Swedish language to perform artificial rupture of the membranes is to explode them, and in Swedish and Dutch the crowning of the baby's head is cutting through.
|In medical textbooks
women are represented as headless, often cut up in little bits a cervix here, a
perineum there, an excised uterus over the page, and depicted as if they were simply a
collection of bone, muscle and nerve fibres. Occasionally humour intervenes and you get a
complete woman in cartoon form. But she is ignorant, gross, a lump of meat with a pinhead
at the far end. A British anaesthetist, Felicity Reynolds, advocates that hospital staff
introduce themselves to their patients. So far, so good. This is how she makes her point.
It is her own drawing. 4
She also believes that women should not be burdened with information about possible risks. Labour is like being on an airplane. From the flightdeck the Captain the obstetrician makes an announcement: Wouldn't it be better, she implies, just to trust that he knows his job and let him get on with it? 5
In a recent paper a British obstetrician, Philip Steer, uses the language of neo-Darwinism and biological determinism to describe the battle between the baby and the mother: The scene is set for a competition between the fetus and the mother. It is inappropriate to see human labour as a harmonious process ... labour should instead be seen as an imperfect solution to a complex problem. Steer believes that rather than indulging in reflex pleas to `return to the simplicity of nature' (which is often `red in tooth and claw'), we should be concentrating on making caesarean section even safer, researching ways to predict labours that will have an adverse outcome, and listening to what (properly informed) women want. Steer sees birth entirely in terms of the size of the female pelvis in relation to the size of the baby's head; because human beings have evolved big brains they often cannot get through the female pelvis without catastrophe. This ultra-Darwinism ignores social and environmental aspects of birth. It reduces the whole process of labor and delivery to a contest between the mother and the fetus.
With a little lateral thinking we might come to very different conclusions. We might ask, for example, What is there about obstetric methods of managing labor and about the birth environment that tends to make birth difficult and might contribute to the present high rates of Caesarean section?
In the late 1920s Solly Zuckerman studied baboons in London Zoo and reported that they lived in a perpetual state of violence. On this foundation he created a theory of social behaviour which became very influential. Every baboon seemed to live in perpetual fear lest another animal stronger than itself would inhibit its activities. The social order frequently collapsed into an anarchic mob, capable of orgies of wholesale carnage6. Other researchers were unable to replicate his findings when working with baboons in the wild. It turned out that baboons in the zoo behaved like this because they were kept in captivity in a restricted space. In his ground-breaking book `Lifelines: Biology, Freedom, Determinism', the biologist, Steven Rose criticises the prevailing fashion for giving genetic explanations to account for many if not all aspects of the human social condition from the social inequalities of race, gender and class to individual propensities such as sexual orientation, use of drugs or alcohol, or the failures of the homeless or psychologically distressed to survive effectively in modern society.7 This is the ideology of biological determinism, typified by the extrapolations of evolutionary theory that comprise much of what has become known as sociobiology. It is this kind of theory that Steer has incorporated into his plea for more Cesarean sections.
||Steer then ties this argument up with the concept of choice and retailing. The concept of choice was basic to the British government document `Changing Childbirth', published in 1993. It set the scene for a new policy of maternity care in England and Wales8. Women should receive clear, unbiased advice and be able to choose where they would like their baby to be born. Their right to make that choice should be respected and every practical effort made to achieve the outcome that the woman believes is best for her baby and herself. Steer picks up on this, says that an increasing proportion of women are requesting Cesarean section, affirms that taking heed of women's views is fundamental to achieving a satisfied customer, and incorporates language drawn from marketing to justify elective Cesarean section. The customer is always right, or at least, one who is `properly informed'. The language of choice has been appropriated by obstetrics9.|
|1||Martin E. The Woman in the Body: A Cultural Analysis of Reproduction. Beacon Press, Boston 1987.|
|2||O'Driscoll K, Meagher D. Active Management of Labour. Department of Obstetrics and Gynaecology, University College, Dublin, 1980, W B Saunders, London, II;27;158.|
|3||DeLee J B.(1920a) `The Prophylactic Forceps Operation'. Paper read before the 45th Annual Meeting of the American Gynecological Society, 24-26 May 1920. American Journal of Obstetrics and Gynecology; 1; 24-44; Discussion 77-80.|
|4||Russell R, Scrutton M, Porter J, ed Reynolds F. Pain Relief in Labour, BMJ Publishing Group, London 1997;12: 237.|
|5||Russell R, Scrutton M, Porter J, ed Reynolds F. Pain Relief in Labour, BMJ Publishing Group, London 1997;12: 180.|
|6||Russell C, Russell W M S, Violence, Monkeys and Man, Macmillan 1968;41.|
|7||Rose S, Lifelines: Biology, Freedom, Determinism, Penguin 1998;1:7.|
|8||Department of Health, Changing Childbirth Part 1: Report of the Expert Maternity Group, HMSO London 1993; 2:25.|
|9||Steer P, Caesarean section: an evolving procedure? British Journal of Obstetrics and Gynaecology, October 1998, 105:1052-1055.|