Technology vs. Tradition: The Role of Midwives in Modern Births

Following the commonly accepted epidemiological narrative – that medical discoveries decreased deaths from infectious diseases and increased lifespans – lower levels of mortality in childbirth are likewise frequently attributed to innovations in technology. Yet, as shown first by Thomas McKeown and later by John and Sonja McKinlay, much of the decrease in general mortality rates occurred far before vaccines or antibiotics became prevalent. More likely, people started living longer because of broader social changes such as improved sanitation and superior nutrition. Could this same misconception be true about the relationship between medical technology and childbirth? And if so, what normative positions might we have to question as a result, e.g. the superiority of doctors over midwives, hospitals over homes, and technology-heavy births over natural births?

Lately, two opposing narratives have dominated discussions of the birthing process in the news: the disappearance of midwives from developing countries as they are outclassed by doctors, and the reemergence of midwives in developed countries like the U.S where “non-traditional” i.e. non-medicalized births are rapidly increasing. Yet through these stories, the news often makes clear causal assumptions about the life-giving benefits of technology. “[Chiapas, Mexico] is poor,” Denise Grady of the New York Times writes, but describes the impact of this fact as that these women “live without cars along rough roads far from hospitals” and “often give birth at home,” at high risk for death during birth because of their lack of access to technology and reliance on midwives. Throughout history doctors have drawn similar conclusions about their relative superiority, dismissing midwives as unclean, under-educated, and reliant on primitive techniques (see Megan Vaughan).

Yet while basic technology can be extremely beneficial in the birthing process, especially when looking at the results of individual, medically-complicated pregnancies, can it single-handedly improve mother and infant health in developing countries? What about poverty, for example? As in the news article, poverty is cited in relation to lack of access to medicine and hospitals. Yet the effects of poverty on nutrition are also key for a mother’s health from pregnancy to birth to the postnatal period. What too of “physically exhausting” labor in the fields, “abundant infectious disease” and poor sanitation, and many other trappings of living poor in a poor country? All of these are factors that Kris Holloway describes seeing affect maternal health, and mortality, during her years working with a midwife in Mali – factors that IVs or C-sections alone could not necessarily alleviate (89).

In addition to the effects of general inequality on reproductive health, cultural expectations of women place them in an even more disadvantaged position in many countries. Holloway describes women in her town in Mali as lacking significant agency over when they have sex or children. Complications occur because the woman aren’t allowed to rest appropriately or end up pregnant again soon after giving birth. And the cultural phenomena of female circumcision has led to lasting effects, including an increased risk of vaginal ripping during birth – and thus severe hemorrhaging, a major cause of maternal death.

Meanwhile, well-off American women have begun voicing other concerns about hospital births, speaking out against the idea that liberal usage of modern birthing technology creates a reproductive utopia. While clearly having access to technology is preferable to not, many are now arguing that U.S. doctors overuse this technology to the detriment of women’s health – and that midwives, with their more natural approach, are a way to protect women. Holloway cites with astonishment that 25% of American births are C-sections, far above the ideal limit given the maternal/infant health complications that can result from such invasive surgery (89). And Vaughan describes how Americans, “oppressed and alienated by biomedicine,” are actually “env[ious]” of “natural” African births (24). So while we should be careful not to romanticize poverty or lack of agency, there does seem to be an argument – biological but also social – for limiting technology in births. Importantly, however, is that many of these American women utilizing midwives are well fed and far above the poverty line. The point is not that technology is bad, but rather that when the woman is already relatively healthy and economically privileged, technology often isn’t key to, or even necessary for, a successful, healthy birth.

Together, these examples weaken two major assumptions about the relationship between technology and birth: one, that technology alone can solve the problem of maternal mortality in developing countries, and two, that more technology will always be beneficial to maternal health and well-being. While there is no clear-cut answer to solving maternal mortality, my main argument is merely that a more careful definition of the cause of the problem can illuminate potential solutions. To speak broadly and reference Paul Farmer, I think it is clear that this biosocial problem needs a biosocial answer, not just a biomedical one. We should work towards providing medicine and technological help for individuals, but also social change for the population. And midwives for all women.

Articles:

Gaestel, Allyn and Allison Shelley. 2013, July 8. What is Pregnancy Like in Nepal. http://www.theatlantic.com/health/archive/2013/07/what-pregnancy-is-like-in-nepal/277287/

Grady, Denise. 2015, August 31. Training Midwives to Save Expectant Mothers in Chiapas. New York Times. http://www.nytimes.com/2015/09/01/health/midwife-mexico-chiapas.html

Santa Cruz, Jamie. 2015, June 12. Call the Midwife. The Atlantic. http://www.theatlantic.com/health/archive/2015/06/midwives-are-making-a-comeback/395456/

Readings:

P. Farmer. 1999. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press.

K. Holloway. 2006. Monique and the Mango Rains: Two Years with a Midwife in Mali. New York: Waveland Press.

Kim, Jim et al 2000 Dying for Growth: Global Inequality and the Health of the Poor. Monroe, Me.: Common Courage Press.

McKinlay, J.B. and S.M. McKinlay. (1977) The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century. Milbank Memorial Fund Quarterly 55(3): 405-428.

Discussion Questions:

What do you think the role of technology should be in birth? Should birth be treated differently than a disease in terms of the application of medicine and medical technology? Further, how much of this decision should be left to the woman? And what if she doesn’t have the autonomy to make choices or decisions? How should “culture” be treated in these situations?

What do you think about the opposing trends described occurring in the U.S. and developing countries? Do you think that a specific subset of American women rejecting medicalization of birth is relevant to the experiences of most other women globally? Why or why not? Further, can this be understood in a way that doesn’t romanticize the experiences of the poor?

Additionally, why is birth often the focus of these conversations about women’s (reproductive) health? What about menstruation, birth control, and the many other aspects of reproductive health that women have to deal with? (See http://kristof.blogs.nytimes.com/2015/09/01/menstruation-innovation-lessons-from-india/?_r=0 and Holloway as well.) Is this focus similar to the misconception of infectious diseases being so much more prevalent and thus important than chronic diseases in developing countries – that women are dying in childbirth and so it is the most important topic?

22 thoughts on “Technology vs. Tradition: The Role of Midwives in Modern Births”

  1. Allison,

    Thank you for the very thought-provoking post! I find your argument that using only biomedicine to address maternal mortality may be analogous to assuming that the introduction of vaccines greatly decreased the rates of infectious diseases in developed countries to be very compelling. Holloway brought up the frequency of infection post-birth and the lack of sanitation available to Monique, and we discussed in class how malnutrition leads women to develop with smaller pelvises, which increases their chances of developing a fistula during birth. Broad social developments including improvements in sanitation and nutrition could significantly lower the maternal mortality rate in Monique’s community and other similar communities.

    In response to your second question, I do not think that the small subset of American women who reject medicalization of birth are relevant to the experiences of women globally. As you point out, most of these American women have not suffered the weakening effects of living in poverty and they have life-saving medical technologies at arm’s reach in case of emergencies, so they have the luxury of being able to choose a non-medicalized, or “natural” birth, without choosing an unsafe birth. This choice is really not comparable to the deprivation of safety during birth experienced by women such as those living in Monique’s community.

    Thanks so much,
    Mira

    1. To ask another related question, too, if the experiences of American women are not relevant to those in other countries, how do you see the parallel media representations of these stories? Do you feel that the coverage is effective in presenting the side of rural women in developing countries? In representing them? Secondly, do you have any thoughts about the potential for medicalization to spread to other countries as well with the spread of technology?

  2. Allison, I like your discussion about midwives becoming more popular in the United States. I also like how you compare the United States and developing countries, pointing out that women in the US are moving more towards undeveloped countries while women in these undeveloped countries move more towards westernizing child birth. I believe that there is a fine line to walk here.

    While women in the United States want to do natural child-births, there is a difference between natural in United States and natural in developing countries like Mali. While Holloway describes the “woman’s birthing house” in Nampossela, where she worked with a midwife during her time in the Peace Corps, it is still far from what women in the United States would view as a natural child birth. This building is a small building made out of mud bricks, with a tin roof torn apart by a storm, mud floors, and a large stone slab used as the birthing table. As Monique explained in Holloway’s book, women could not give birth here during the rainy months because of the torn apart roof, so they had to give birth in their small huts.

    To women in developing countries, these are the natural child-births, and Monique, along with many of her patients so greatly wish they could have some of the modern comforts and technology available in Western countries. In the United States, the idea of a natural child-birth for many women is simply a birth without any pain relieving drugs, often with the assistance of only a midwife. Many women even still consider it a natural birth if they used electronic monitoring, IV fluid, and sometimes even labor inducing drugs. Many natural births still occur in hospitals, where they have hospital beds for mom to lay in, nurseries for babies to be brought to afterward and doctors and equipment should medical intervention be needed.

    Women in places like Mali could only dream of such luxuries, while they are giving birth in mud huts on a stone slab, with no where for the baby to go but in their arms after it is born. Even for home births in the US, there is still always the chance of receiving emergency medical care if need be. As we learned from Monique, when explaining what happened when Bintou, a village woman, died after giving birth, had emergency medical care been available, she may have been able to keep Bintou alive. I think it is important that women, in the United States especially, realize the difference between the natural child birth in a Western society versus that in developing countries, and understand the luxuries they are still being afforded, ensuring they and their babies stay alive.

    1. Hey, Kelly. Thanks for your response! I think your point about the different definitions of “natural childbirth” is a very good one. Having the technology available in case something goes wrong creates a very different atmosphere of natural than the births you talk about Holloway describing. And to add on to your point, what I think is perhaps the most striking difference the ability to choose – the agency on the part of the women. In the U.S., because the technology is available, women are able to choose to not use it and decide which type of birth they would prefer. In Mali and other developing countries, women only have access to the “natural” births, leaving a birth without technology their only option.

  3. Allison,

    I’d like respond to your second discussion question first by noting that this topic is one that I find both immensely intriguing and one of which is also deeply personal. Despite our society’s general trend of giving birth in a hospital attended by an OBGYN, both my twin sister and I were born at home in the presence of a midwife. My mother had no labor-inducing drugs nor pain medications, and despite the fact that by today’s standards the pregnancy would most certainly have been considered high-risk (twin babies, the second of which was born breach), there were fortunately no complications and my mom was able to vaginally deliver to healthy baby twin girls.

    To begin, I’d like to note that I was born at home partly because my mother had the luxury of having a home birth that was just as safe as a hospital birth—a reality that does not apply to women globally. I don’t think my mother’s birthing experience is relevant (nor, I believe, would she) to the experiences of women worldwide. Nor do I believe her—or any other woman who has purposefully chosen a non-hospital birth—to be romanticizing the experiences of poor women who do not have access to modern biomedical technology. As we have discussed in class and section: context matters. Choosing to deliver at home in the care of an experienced midwife is not romanticizing the struggles faced by women without access to care, but rather making what you feel to be the best-informed decision about your health within your own sociocultural context. For many women in the U.S., giving birth outside of a hospital context can be just as safe—some may say arguably safer—than giving birth at a hospital. While medical technology can be life saving in high-risk situations, certain interventions can actually be detrimental when applied unnecessarily. Furthermore, choosing a non-hospital birth for yourself does not mean that you believe no births require medical intervention, nor that women in developing countries should not have access to life-saving technology. As Allison pointed out, certain women in North America have the privilege to be able to give birth at home because it can be the safer option given their sociocultural context, whereas women in parts of the developing world give birth at home and without advanced medical technology not because it is the better option, but because they have no other option at all.

    Also as a last aside, today in section Sara mentioned the documentary The Business of Being Born. If you are interested to know more about why women in the U.S. choose to have a non-hospital birth, I really recommended it!

    1. Sabrina, thanks for sharing your story! I also appreciate the distinction you make between home births that are just safe and chosen, and those that are unsafe and simply a result of a lack of options. Given the differences, I agree that more privileged women can take advantage of the options available to them while not romanticizing the experiences of the poor – simply because there are so many clear differences in safety and agency. As you write, context matters!

  4. Allison,
    I really liked this post because it provides a lot to be considered. Both sides of the problem have important arguments to back them up, so it’s difficult to answer the question of the extent to which technology should be involved in the birthing process.

    In my opinion, since the decision of whether or not to use technology is so complex, it should be the choice of the mother. Just like when it comes to abortion, I think really personal decisions should not be regulated by the government or other policy making institutions. That being said, if mothers do not have access to the technology, then they can not make that choice.

    However, I definitely would agree with you that technology is not the only solution to fixing deaths in pregnancies, both of the mother and the infant. As you said, sanitation, nutrition, and many other factors contribute to the success of pregnancies. I would also like to point out that this argument can be applied to many different public health problems around the world. Technology cannot be the only solution to illness. Many times, medical technology can fix the illness at hand but does nothing to address the underlying problems causing the illness in the first place.

    1. To ask further questions, based on your response, I was wondering how you would propose furthering the choices of the mother beyond just offering access to the technology? Do you think we would need to, for example, combat gender inequalities that allow husbands to make decisions for their wives? Or the educational inequalities that allow doctors to act as gatekeepers to resources? Even just on the social level, before practical implementation involving buildings roads and buying equipment, I think there are potentially significant barriers to maternal agency. In recognizing the complexities of your simple statement – that it should be the choice of the mothers – do you have any thoughts about the process (or consequences) of actual implementation?

  5. My thoughts on technology and birth have pretty much been covered by everyone else, so I’d like to talk about your last question. Why is the act of giving birth the focus of reproductive health efforts globally?

    I think you’re right, and that the obvious answer is that women are regularly dying from childbirth, something we often see as easily preventable. I think also women’s social value around the world is largely based on their ability to have children, which adds to the sense of urgency and importance.

    But saving women’s lives isn’t the same as saving their livelihoods. I would argue that we should also be focusing on getting girls ways to handle menstruation that allows them to stay in school, increasing availability and decreasing stigma of contraception, improving our responses to sexual violence, and just in general educating women and girls about their bodies and the processes of reproduction. Childbirth doesn’t just happen, and all of these things are likely to influence it. And obviously, women are more than just their reproductive capabilities! The inaccessibility of menstrual hygiene products worldwide may not seem like as urgent an issue as maternal mortality, but I think tackling both (all) of them is extremely important to improving women’s health and livelihoods around the world.

    1. Elena, I agree with you – I think that the clear connection of childbirth to life and death is a main reason those in a position to help focus on it, as is the importance of live children to men as well as women. However, I think that menstruation and cervical and other women’s health problems have perhaps less direct but still clear connections to morbidity and even mortality of women, and further affect their lives in more quotidian and ordinary ways. Perhaps if these connections were made more explicit, would people consider these reproductive health concerns as important? Or is it also that helping with childbirth, a discrete event, seems more manageable and feasible? I’m not sure, but thank you for responding!

  6. Allison,
    I really enjoyed your post, particularly your emphasis on poverty as an important factor in maternal death and the comparison you made with the natural birthing movement that has gained prominence in the United States.

    One may argue that the imposition of “Western” high-technology stems from a desire to impose Western practices on the developing world and may therefore be utilized as a form of cultural imperialism to assert Western superiority. For example, as we learned in class, many Indian women reaffirm their support for natural death due to widespread cultural belief that female power is gained through pain, particularly the pain of childbirth. The introduction of technology that would eliminate natural births and the use of midwives could therefore be seen as a challenge to fundamental cultural practices, one that may be unwelcome even by the women experiencing the pain themselves. On the other hand, technology may be essential for the survival of these women and for a significant reduction in maternal death. In addition, even if women claim to want natural births, to what extent is this really an exercise of their free will and not an automatic response due to the cultural prominence of these practices, which have been established as fundamental norms within these societies? I believe that the will of these women must definitely be considered as a major factor; the implementation of technology must be as much of a choice in the developing world as it is in the West, yet how can we distinguish what is choice and what is the pressure of society?

    In response to your second discussion question, I believe that a large emphasis is placed on childbirth because it is essential to the continuation of these societies and for the advancement and development of communities, particularly those that are severely lacking in economic and political resources and must depend on the continuation of generations and steady births for their survival. Childbirth is the most essential process of human life; heavy emphasis is therefore, in my opinion, justified. In addition, we may pay particular attention to childbirth in developing countries because it is no longer considered a very dangerous or life-threatening practice in the West.

    I completely agree that the question regarding natural birth is very different for healthy women in the West, who have the luxury of choice that poorer women in developing countries do not. However, we cannot ignore cultural practice, nor can we force a society of women to do something they are fundamentally opposed to. We must therefore find a way to acquire these women’s true wishes and implement them accordingly.

    1. Alexandra, thanks for your response! I agree that distinguishing between individual agency on the part of the woman and societal pressures can be very complicated. I do think there can be health benefits to technology that go beyond assertions of Western superiority; in other words, there are clear biological benefits as well as social boasts. But as you said, it is hard to separate the neutral uses of technology from the imperialism and paternalism the access situation creates. Our best bet is to push for choice – but I agree, I don’t have a good answer for quite how to make sure that is happening. Lastly, to address your second point, do you think though that there might be other reasons too that childbirth is emphasized over other female reproductive issues that we’ve learned can also effect maternal mortality and birthrates? Do clearer male interests play a role, or clearer solutions? Thanks again for responding!

  7. In rereading my post with the rest of the semester’s material in mind, I want to first clarify the nuances of my original argument and then turn my attention from complicating the problem of maternal health to considering potential solutions to high maternal mortality.

    First, revisiting my views on technology, I want to clearly articulate that I am not dismissing it as important but rather arguing that it cannot be a complete solution. As I wrote, “the point is not that technology is bad, but rather that when the woman is already relatively health and economically privileged, technology often isn’t key to, or even necessary for, a successful, healthy birth.” However, I want to take this even further and add that I do think, regardless, that technology should be available for all women. Following Farmer, I don’t subscribe to the idea of “appropriate technology” because I think it sets up a dangerous double standard that tries to justify inequalities between different populations. Thus, withholding such technology based on cost or concerns of noncompliance seems ethically suspect. And again, just as Farmer argues repeatedly, I think we need to both treat or save individuals as well as try to create social change on a population level. My goal in bringing up the potential problems of technology was more to raise questions about something we take for granted – and to ponder that if our elites no longer want to use it, then perhaps we should be wary of foisting it onto other populations. In sum: equal access to technology is a necessary component of increasing healthy births, but is not a sufficient answer to maternal mortality.

    Secondly, I want to raise some new discussion questions concerning the implementation of these ideas, based on our readings from the second half of the class. In a situation like maternal and child mortality, do you think that cost-effectiveness analysis should apply? What about cost-benefit analysis? Or should there be a right to health in this context? If so, should it be supported by external NGOs or by the government? How would you secure funding? What tactics would you use?

    I also want to recognize the generality of a lot of the claims that I, and I think perhaps we, have been making, and ask whether you think you could create a program that would be able to be scaled-up and generalized, or whether you would want to focus on a specific population you have studied intensively. In other words, what is the role of local context here? How would you do research on the population to figure out how to help, and how much? What kinds of local variations could you imagine being relevant? What kinds of consequences? And would you focus somewhat vertically, or try to create a horizontal approach? Is there a crisis-like atmosphere you think you could stir up to raise money for this issue, or if so do you think that would be ethical, or imperative? These are a lot of questions, but just more food for thought!

    1. Thanks for the update, Allison! Your post was already powerful for me and definitely got my gears turning and the questions you bring up in both your post and update are super thoughtful. SO many questions…so many thoughts…

      I definitely had overlooked the fact that technology does not make for a healthy birth/eliminate the issue of maternal mortality entirely, which now creates a conflict between putting money into creating the emergency health resources/hospitals/technology or towards interventions like food supplementation, breastfeeding, and making sure that women are healthy which would lead to healthier births.

      I think cost benefit analysis would work as far as evaluating how much money should go towards maternal/women’s health infrastructure and how much should go towards the food supplementation, literacy, non-infrastructure aspects of an intervention.

      The positive of creating health infrastructure with women’s health (esp. birth) as a starting point is that it can be made more diagonal and lead to more emergency health services and infrastructure for other health issues, not just birth.

      We read about the institutional partnerships in Rwanda, and I think that a similar approach (the in-service trainings) can be taken for the birth process. Maybe midwifery can be added to a health worker’s set of skills.

      Your questions about the effect of local variations and how we would “scale up” to fit a more general, larger group make me wonder if birth is affected by local biologies the way that disease is. And to answer your question, I think that there are different approaches,”rituals”, and practices that lead up to birth which can vary locally and there’s something to be said for the tradition of storytelling and sharing experiences around the birth process that it’s important to be conscious of. People romanticize this, so it would be hard to get them behind introducing a more technocratic “birth ritual” so to speak.

      I don’t think creating the infrastructure itself would be as dependent on local culture as considering the process of birth, who the midwives are, how to create an atmosphere that can allow some of the culture to continue, while making the process safer.

      I think we could definitely get people on board about things that are easy to fix and are icky–like fistulas.

      1. Hey Sylvie, thanks for your response! I agree, the realization that most health problems are biosocial leads us directly to the question of how to solve such complicated problems – by targeting the biological part, through hospitals for example, or the social part, through food supplements as you bring up. However, I think that the real answer to this, like Farmer describes, is to do both, at the same time. I don’t think there’s a dichotomy between the two types of interventions, and in fact there is probably (definitely) a positive synergy between them. Technologies often save individuals; broader economic reforms will help the population. The former is mainly biological, but the latter is more social, together providing a more comprehensive method of approaching the problem. As I think Farmer accurately points out, we should be saving lives, but also not letting this distract us from the true underlying causes of death, disease, and inequality. What do you think? Do you agree?

        In terms of using cost-benefit analysis here, I worry that the result would be to provide only relatively cheap biological interventions, and again I think that we should try to push both bio and social solutions. I like your idea about a diagonal approach, though, and think that maternal and child health could be a good way to get this type of process started. It was, I believe, one of the four pillars of PiH’s plan to raise funding. I was interested to see it there, however, because I’m not sure that it has the same level of “emergency” or scariness or magic bullet solution associated with it as AIDS or TB, and feel like in its nebulousness and ambiguity it might garner less funding. What do you think? Do you see this type of global health problem as on the same plane as AIDS or SARS? It certainly doesn’t have the same biosecurity threats or fear attached to it as many infectious diseases, sparking less of a crisis in this sense. Let me know your thoughts!

        1. Well, I didn’t think about the idea of food supplementation as a more “social” intervention–only that is was lower tech and not infrastructure related. I was leaning towards putting in a hospital as casting more social ripples than something like supplementation or ORT’s. Creating health infrastructure like hospitals creates new sorts of relationships (doctor-patient), changes the job market, leads to different practices when people get ill (going to the hospital and consulting a doctor, rather than a local person or having to “tough it out” and the burden of care is placed on the family–social suffering) and there is *definitely* a strong social component to creating infrastructure like housing, schools, wells, etc. And

          I agree that there is not a dichotomy between the “bio” and “the social”; the dichotomy that I’m sensing is “build stuff or nah” (for lack of better phrase here) . I definitely agree that there’s a positive synergy to taking a biosocial approach, that both approaches are needing, and that doing both together will lead to the best result. I wonder how it would go/what would happen if the technology component was taken away entirely–but that sort of freaks me out in an “appropriate technology means sh** for the poor” kind of way. And I hadn’t even thought of economic reform as a health measure–but that’s.so.real.

          Well, cute babies are also pretty helpful for garnering funding, haha. But it’s true–there isn’t the same scariness factor, I agree. It may be their way of appealing to a different sort of donor–maternal/child mortality is a major marker of the health of a population and it’s a universal and timeless concern (unlike these big scary diseases). Maybe it is easier to be hopeful about maternal/child mortality since so much is already known about the subject and a lot of the issues related to maternal and child health are very treatable, simple, and/or preventable (i.e. ORT, resources for family planning). Is it icky? Is it fixable? –> funding. (just a thought). There is also less stigma associated with *some* of these issues, unlike the stigma attached to AIDS, for example.

  8. Hey Allison!

    I too was intrigued by the trend in the US towards more natural births and an aversion to the “civilizing” of childbirth that leaves women feeling violated. I think you make an extremely solid point when you say that we shouldn’t romanticize poverty and lack of agency, and I think the cultural trend here to shift towards more “natural” lifestyles requires a reality check at times. One example of this is what you mentioned in your post: cases where women are envious of “natural African births.” That just screams ignorance to me. One can vouch for a natural birth without making it about women in Africa, because I think that perpetuates the colonial mentality of uncivilized people who are close to nature. I think the experiences of these American women are important because other countries are developing and moving into the same over-medicalization that is present in the US – I know that this is the case in India, for example. Perhaps then, as other countries improve their maternal health, they can avoid over-medicalization and hit some kind of “sweet spot” in the use of technology in childbirth.

    I agree with pretty much everything you’re saying, especially two closing points in your conclusion. I don’t think you’re understated the importance of technology, but I just want to bring up the argument against using the McKeown hypothesis when trying to improve health in developing countries: this technology could have a huge impact in countries that haven’t shown “natural” declines in maternal (and other kinds of) mortality. I think providing women in Mali with some basic medical technology would be far from useless even if it’s not the magic bullet.

  9. Hey Ria, thanks for your response! I agree as well. Given the trends that you mention, in India for example and then in the U.S. like I described, are you optimistic about reaching such a “sweet spot”? Do you think it is possible, particularly in today’s over-medicalized America and under-resourced Global South? Further, how do you think we might go about trying to find and then reach it?

    Another interesting, and related, question you made me think of as well is about whether there is a relationship between the resources over consumed here, and the lack of resources elsewhere. We talked in class about not having one global pie but rather a bunch of isolated national pies, or even pies for different populations within nations I would think. In some way, though, it does seem that if we used fewer interventions during births in the U.S. that we could perhaps afford to help more people in other countries… What do you think? I certainly agree that medical technology would be useful and should be provided to these women – my point with the McKeown hypothesis, as I’m sure you understood, was not to raise awareness of the social factors rather than undermine the importance of medical ones. As we talked about with Durkheim and with Farmer as well, helping individuals and saving individual lives is different from and unfortunately does little to change population-level statistics. Medical advances will definitively save lives, but we need to at the same time not lose sight of the higher level social agenda we should be supporting as well.

  10. Thanks again to everyone who commented one my post – you guys brought up some really interesting points I hadn’t thought of, made me think, and spurred a great discussion about the role of technology in childbirth!

  11. Allison, thank you for your post! You brought up so many great points – the misconception that increased life spans and improved infant mortality rates are mainly a product of technology, romanticization of “the experiences of the poor”, and the importance of nutrition to reproductive health. I was particularly drawn to your thoughts on some American women’s “return to” midwives and older birthing methods, and the extent to which this subset of women rejecting medicalization of birth is relevant to the experiences of most other women globally.

    Similar to previous comments on your second discussion question, I would say that the answer is no. These American women have a choice. They decide to distance themselves from the technocratic model of birth in favor of a less biomedicalized birth experience, as they have resources to do so. There is a stark contrast between the “agency” of these women and the reproductive experiences of hundreds of millions of women across the world who live in poverty, do not have access to quality maternal care, and are thus forced to have (largely unsafe) natural births. Another distinction with American women opting for a natural birth – the definition of which is different according to who you ask – is that these women selectively eliminate certain technologies (e.g. pain medications, c-section) but probably opt for others (e.g. first trimester prenatal screening, amniocentesis, ultrasounds, etc.). Unlike women without reproductive choices, the American subset of women can ensure that their pregnancy goes as smoothly as possible prior to the actual “natural birth”. Lastly, as Mira pointed out earlier, many of these American women have “not suffered the weakening effects of living in poverty”, and have consistently had “superior nutrition”. When the women in Monique’s community have neither a strong health infrastructure nor money and thereby limited options, could they really have a natural birth experience on par with American women?

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