Response to Karen Lane and Kerreen Reiger

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Response to Karen Lane and Kerreen Reiger

Barbara Katz Rothman
Department of Sociology & Anthropology, Baruch College, The City University of New York, United States of America

Article Text

It is certainly difficult for an American to respond to these two papers. Each presents serious problems that you in Australia are facing in trying to improve maternity care, in trying to create a truly woman-centered approach to childbirth. The problems you are experiencing are difficult. And boy, would I ever love to have those be my problems.

You are working with a system that is not as flexible, as responsive, and as sensitive to the needs of women as you would like it to be. I have no system to work with. You are working with a policy that moves towards support for midwifery care in childbirth. I am working with no recognizable policy at all. You are working with a debate within midwifery about how best to organize itself, educate its students, and meet its responsibilities to birthing women. I am working with hardly any midwives at all, relatively speaking, and those there are with relatively little power to make those decisions.

So I try, really I do, to take your problems seriously. They are important, and do need to be worked out. But I long, simply long to have those problems to work with here.

Karen Lane discusses the issues of consumer representation, and consultation and participation in maternity care, and looks critically at the move from patient, to consumer, seeing that as embedded within the move from welfare state to the market state. This is an interesting and thoughtful analysis, leaving me much to think about. But my own American experience raises some questions. We too wanted to move from a ‘patient’ approach to maternity care to a more ‘consumerist’ model. Yet we did not have a welfare state to start with. It was never the state that controlled pregnancy and maternity care: it was medicine. For the poorest of women in city-run hospitals, to the wealthiest of women in the most elite of institutions, birth was a medical event. There were, of course, variations by socio- economic status. But overwhelmingly, birth for American women was a pseudo-surgical event at best, with all the trappings of surgery even when the birth was, as the doctors like to say, ‘From below’. Our women were knocked out, strapped in, cut into, and had their babies hauled out of them. They paid for it through their insurance, or they paid for it out of pocket, or for some few women the ‘charity’ hospitals provided the care for them. But the dehumanizing, medicalized, ugly American birth was much the same.

The childbirth reform movements of the 1970s were mostly organized by the kinds of women who generally have time to organize reform movements of any sort:women of some privilege. A ‘consumer’ model did put some power back into the hands of these women who were paying to be treated so badly. For us, here in the United States, this was the language of the 1960s and 1970s childbirth movement, as we tried to move out of medical control and into a more woman centered understanding of birth.

The Australian consumerist movement does indeed seem to flow from a later source, from the shift from welfare state to market state. The state, qua state, moves back a step and contracts out functions. Consumers begin to exercise some ‘choice’ in the ‘marketplace’ of medical care, and service providers find themselves reporting to – and maybe, even – courting consumers. ‘Purposeful reporting’ appears to have grown straight out of this, giving consumers the information they need to make rational economic choices about variety of purchasable services in maternity care. And this is where the differences lie between what the clinicians regard as meaningful outcome measures, and what the various consumer advocacy groups might so regard. A live baby, even a healthy baby, out of a live/healthy mother is just not good enough for those who have come to think of birth as a significant rite of passage for mothers, babies and families. Process itself opens up: mothers are talking not about babies as a product, but birth as a process, and they are demanding more of the process than the clinicians do – or are willing to consider.

When I first began to look at childbirth, I was struck by a model of ‘patient-practitioner’ relationships that Szasz and Hollander had developed way back in the 1950’s (Katz Rothman 1982: 177). They distinguished an active-passive relationship in which the doctor makes all the decisions and the patient is ‘worked on’, a ‘guidance-cooperation’ model in which the practitioner guides and directs the patient who, if she is a good patient, takes guidance and direction easily. The third possible relationship – the one that fired me up – was the idea of ‘mutual participation’, in which practitioner and patient worked together toward a common goal. That, I thought, took us right past the ‘patient’ role altogether, and to the kind of mutually respectful, all-in-this-together relationship I saw between home birth midwives and their clients.

Karen Lane talks about an ‘equal partnership’ model, in which women are equal ‘knowers’ about their bodies and their babies, and sovereign in their knowledge of their own values and priorities for childbirth. The consumer model, she says, can go past this, even to a description of the practitioner in a ‘servicing’ role. But as is often, oddly, the case in life, if you go out there far enough, you start coming back round again.

American doctors often huffily respond, when presented with consumer demands for specific treatments or non-treatments, like, say, not doing episiotomies, ‘You wouldn’t tell your mechanic how to fix the car! Why are you telling me how to do my job? You just lie there and let me do my work, and we’ll get you a healthy baby!’

The consumerist approach does not, in and of itself, guarantee the kind of care we – of the various childbirth movements – want to see. That kind of care is, as Kerreen Reiger describes it, practice that emphasizes holist care, that values intuitive as well as technical knowledge, and that involves a collaborative partnership with women. This new kind of caring will, of necessity, demand new ways of working, a new form of work organization for the midwives in Australia, and this is the piece of the problem that Reiger addresses. There are, to put it in a nutshell, simply too many different ideas of what it is a midwife is to begin to talk seriously about how to best organize midwives. That is a problem that I, as an American, can have some sympathy with – we too have a variety of practitioners that are midwives of one sort or another.

The journey Reiger describes for midwives is one from medical handmaiden to autonomous primary carer of childbearing women. Yes, we need to look at that journey – but in the United States we are also looking at the journey in reverse, as midwives who began outside of the system find their way into medical settings and learn to work in collaboration with medical protocols.

What makes midwifery so endlessly fascinating to many of us is that the battle for midwifery is not just an issue in professions and occupations, not just one more turf battle. What exactly the turf itself is, what a birth is, is the driving question. It is not just who gets to provide services, but what is happening in the first place. Who is doing what? Is a woman birthing? An attendant attending? Delivering? Providing care and services?

We go round and round again:as we move in and out of different systems and organizations of care, as we renegotiate the role of women in society, the place of the state in our lives, the value of the market, we still continue to pull at this one thread:what is a birth? What is happening there? If we can understand that, maybe we can understand who is or should be doing what to whom!

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