All posts by Allison T Silverman

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?