Unrealistic expectations

Dot writes: more reading from the midwifery section (some part of my poor squeezed brain still works, just not the doing-my-actual-job part): Birth in Four Cultures: A Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden, and the United States, by Brigitte Jordan, 4th edn rev. by Robbie Davis-Floyd (Long Grove, IL: Waveland Press, 1993) and The Midwife and Society: Perspectives, Policies and Practice, by Anthea Symonds and Sheila C. Hunt (Basingstoke: Macmillan, 1996). I read the first voraciously – its data is old (first edition 1978, based on fieldwork carried out in 1972-4) but the practices it describes are fascinating and the issues raised still vital; plus it is beautifully written. The second I’ve only dipped into, but it’s an extract from this book that I’m thinking about now.

[part of a hypothetical case study followed by discussion points. The chapter is about ‘Social divisions and patterns of inequality’]
Vicky…has read widely on the subject of birth and has already written an extensive Birth Plan. She does not want any pharmacological pain relief in labour, she does not want Syntometrine, she does not want continuous fetal monitoring. The list is extensive and clear. It is obvious to Helen [the midwife] that Vicky has many unrealistic expectations… (p. 57)

The unspoken attitudes encapsulated in that phrase ‘unrealistic expectations’ were a real slap in the face when I read this, especially as they seem genuinely unconscious in the context. Vicky’s very efforts to educate herself seem to be held against her: she needs to be gently helped down off her high-horse and taught to accept whatever is going to happen to her. All that research on cascades of intervention and the benefits of waterbirth and whatnot is all very well, but the hospital has its protocols.

Brigitte Jordan has some relevant things to say (in the more recent editions of her book) about how the rise of birth education and the ideal of informed consent has been assimilated by the medical establishment in the US, with hospitals taking ante-natal classes in-house and using them to ‘socialize’ women in preparation for their technologized practice of birth (Birthing in Four Cultures, p. 143). As Jordan notes, this is a big improvement on the old model (which she documents) in which the labouring woman figured as little more than a body to be monitored and acted upon, with her mind ignored almost entirely. It’s still a model in which the woman must learn to subordinate herself to medical authority and know only what she’s allowed to know. In fact, the rhetoric of ‘unrealistic expectations’ is a way of blaming the victim: it blames women for the fact that the system doesn’t deliver what they can quite easily learn, from a plethora of perfectly respectable books, would be the ideal.

(Aside: OK, ideals are rarely encountered in this world, and not too many first-time mums get through a hospital labour without any pharmacological pain relief. But there are ways to think about this that would be less patronizing.)

So far so depressing. However, Jordan sheds more light on systems and how we can work in them. Compared to the US in the early seventies, Yucateca birthing practices sound marvellously humane (and not as unsafe as one might expect, though Jordan does have some worries about hygiene): the woman is supported emotionally and physically by her husband and a group of female helpers as well as by the midwife; she gives birth in her home, using her hammock to adopt good positions for labour and giving birth in an upright position, often with the aid of a stool. On the other hand, the system is still pretty rigid (and parents are not expected to know anything about it until they first have a child themselves). It takes account of the personal but it is not personalised. This low-tech system, like the high-tech systems available in most modern hospitals, doesn’t really allow a woman much space to choose beyond the course laid down for her by the culture. As Jordan puts it, what counts for women’s psychological well-being is that the system minimizes ‘the dissonance between the woman’s conception of herself and the treatment she is accorded’ (p. 141). Thus, it might in fact be fair to say that Vicky has ‘unrealistic expectations’, but it is vital that Helen fully recognise Vicky’s genuine knowledge and intelligence as she addresses them. And, from Vicky’s point of view – and mine – the route to a good birth may well be to focus, not on constructing a blueprint for the perfect labour, but on learning to be active and strong within the situations that the local system might produce. And then joining

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