In Consideration of the Book

I was reading a bit of Birth as an American Rite of Passage by Robbie Davis-Floyd tonight, and found myself wishing repeatedly that the book, a 2003 second edition, had been updated with newer and more statistics. The focus of the book is the “technocratic” model of birth in America, in which intervention reigns supreme over women’s desires and the natural processes of labor. It describes the messages women receive, over and over, in traditional (in the modern obstetric sense) hospital births, including how women internalize the message that they are a broken machine not equipped to birth without serious medical attendance. The author also takes on the official (medical establishment) rationales, physiological effects, and ritual purposes of, and women’s responses to, many activities that occur when a women presents in labor, such as wheeling her in via wheelchair, the old shave and enema routine, fetal monitoring, pitocin, fasting, being placed in bed, episiotomy, and other “routine” procedures.

As an example, regarding the wheelchair that transports many women to their laboring destinations, Davis-Floyd writes:

“The wheelchair is an interesting first step in this process. To place a healthy woman in a wheelchair instead of allowing her to walk on her own is to tell her that at the very least the hospital thinks of her as disabled and weak… Moreover, the first impression she makes on her hospital attendants will include the images of fragility, passivity, and disability, images on which their further assessments of her will be based. Her lowered position has the effect of making hospital personnel talk to the partner standing, while talking down to the laboring woman in the wheelchair. The image of disability will most especially include the image of inability to walk; from the moment of her entry into the labor and delivery unit, the laboring woman is marked as someone who should not or cannot walk (a significant message, since walking is one of the most beneficial things a woman in labor can do)… As in any initiatory rite of passage, this estranging or “strange-making” device is employed at the very beginning; the effect is to start the breakdown of the initate’s category system necessary to ensure her openness to new learning.”

The author makes some interesting points, and the chapter on Birth Messages is certainly worth a read, but I constantly wished for more updated medical research. Likewise, I am a big supporter of birth free of unnecessary interventions, but I like my discussion of medical practice with a little less Plato, Sartre, and tales of Narcissus, and more than one citation per sweeping statement. The figures on c-section rates I know to be out of date; a 2003 update would have painted a more compelling picture of the abnormality of c-section rates in this country. In reviewing the book’s references, I didn’t find any newer than 1995, and only a handful were published after the first edition of the book, leading me to wonder whether the book’s original assumptions were reexamined for the purposes of the new edition. Meanwhile, a simple search of PubMed reveals that tens of thousands of articles on the topic of childbirth have been published between the original publication and the book’s second edition release in 2003. Surely some of these would have been relevant to the second edition.

This is the problem I have with relying on books to guide your medical decision-making – although they may give you a good introduction to an issue or topic, they can never represent the most recent medical evidence. I experienced the same doubts when reading Born in the USA, and books like it that take a strong stance on healthcare issues, regardless of how much I may agree with their premise. Is it up to date enough? Have these findings been contradicted since the book was published? How good was the searcher who sought out the evidence? Did the author truly do a thorough review of the literature and present findings regardless of whether they agreed with his or her agenda? Did the author understand whether the methodology and findings of the cited studies was valid? Vetting all of the references and checking for changes in the knowledge base is a nearly impossible task for the casual reader. While Born in the USA seems to describe a system in a way that I intuitively feel is accurate, feelings are no substitute for understanding the research they’re based upon.

What’s the point? Medicine is a constantly changing field, and what is known is being continually reevaluated. Although childbirth is nothing new, the knowledge base available to the people who attend most of the births, whether they read and consider it or not, is ever evolving. Perhaps nothing substantial has changed since a book was published, but it takes a tremendous effort to verify that a study actually means what the author insists it does, and that what is known about a topic has been completely and fairly represented. Which is a long way of saying, I love books that take a social or political approach to healthcare, but you must take everything with a grain of salt and refuse to put your trust solely in one author’s representation of the facts.

That said, check out Birth as an American Rite of Passage; the chapter on Birth Messages is an excellent primer for getting all riled up about the treatment of women during childbirth in America.