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About
Birth
Politics, Power,
and Birth
by
Jackie Tillett, ND, CNM, Milwaukee, WI
Journal of Perinatal and Neonatal Nursing
April/June 2011
Volume 25 Number 2
Pages 108 - 110
Abstract
Politics is the process and method of decision making for
individuals and groups. Politics may define the power relationships
between women and their healthcare providers. Politics may shape the
experience for the woman. Nurses and birthing women can learn to
negotiate the politics and power relationships surrounding the birth
experience.
_____________________________________________
Politics is the process and method of decision making for
individuals or groups. Although the term is usually applied to
governments, politics is observed in all human group interactions.
Politics, as a process, is relevant to the interactions between
women, their care providers, and their families. Politics as a
process is dependent upon the power relationships between groups and
individuals.
During the feminist revolution of the 1960s, the slogan "the
personal is political" became popular. Nowhere is the personal more
dependent upon human interactions and power relationships than in
healthcare and in particular, the birth process.
Power relationships became particularly defined, as birth became
a process that came out of the home and into the hospital.
Where birth had been viewed and accepted as a natural and normal
event in the daily life of a family and a community, birth became
medicalized, perceived as dangerous, and physician care developed
into the gold standard. Sadly, little real change in the
evidence-based care of laboring women has taken place in the 20
years that the Journal of Perinatal and Neonatal Nursing has been
published. The environment has improved, with private rooms
resembling hotel rooms, but women are still continuously monitored
even with normal labor, food and drink may be restricted, movement
is discouraged, and the cesarean section rate hovers near 30%.
Happily, more births are attended by midwives, the episiotomy rate
has declined, and water birth and birth centers have increased.
The political progression continues today. The demand by a few women
for elective cesarean section, the refusal of some physicians to
attend a trial of labor after cesarean, and the condemnation of the
home as a safe birth setting are issues that test the practitioners
and women who would like to weigh the evidence and make informed
decisions regarding labor and birth. The power relationships between
women and their healthcare providers limit the choices that women
may have and may even constrain the discussion of choices. If the
healthcare provider believes that choices should be limited to those
the provider feels comfortable providing, other choices may not
enter into the dialogue.
Ideally, decision making regarding labor and birth will begin
during prenatal care. The antepartum period is a time of
exploration and questioning for many women. Care providers can
facilitate this learning with adequate time during appointments,
concern for a woman's misgivings, and encouragement. Informed
consent may and should initiate a discussion of risks and benefits
of procedures and routines.
However, even though informed consent implies an understanding
and agreement with a plan of care, too often a woman is influenced
by her perception of the healthcare provider as an unbiased expert.
This is true of her perceptions of physicians, midwives, and nurses.
We can compare the discussions relating to elective cesarean on
demand and the home as a setting for birth, and briefly analyze the
politics. Elective cesarean on demand has been defended by
physicians as a women's rights issue. Minkoff explains
that physicians should be reluctant to refuse a woman's request for
an elective cesarean birth if the woman is properly informed about
the risks and benefits of the procedure. He details the
principles of autonomy and beneficence relating to the relationship
a woman shares with her physician. He also reviews the
deliberative model. In this model, the physician attempts to
guide the woman to choose the optimal course (or the physician's
view of the optimal course) and interventions for her pregnancy,
using persuasion rather than imposition of values. However, if
the physician does not offer some interventions, he or she may be
reluctant to discuss these interventions with a woman, such as trial
of labor after a cesarean birth. Conversely, if a physician
thinks that some interventions are absolutely necessary, he or she
may not even offer the woman a choice or an explanation, such as
continuous fetal monitoring during a normal labor. If
interventions are routine, imposition of values is implicit, and
embedded in the care and the discussion.
Few physicians or midwives discuss birth setting with pregnant
women, although midwives may discuss the risks and benefits if the
woman asks about home birth. The press release announcing the
American College of Obstetricians and Gynecologists' Opinion on
Planned Home Births quotes Dr Richard Waldman, "As physicians, we
have an obligation to provide families with information about...the
different maternity care providers." Physicians rarely
exercise this obligation to provide families with information about
midwives. Politically, this "obligation" to discuss the pros
and cons of other healthcare providers attempts to establish the
physician as the expected provider of maternity care. A
woman's request to give birth at home does not seem to be a women's
rights issue for physicians.
POLITICS AND POWER OF
LABOR AND BIRTH
The
politics and power relationships of the labor and birth process may
be seen to revolve around the word "allow." To allow is to
make possible through a specific action or lack of action, or to
consent to or give permission. The concept of allowance
gives the power to the healthcare provider, whether physician,
midwife, or nurse and makes the laboring woman dependent upon this
allowance. Allowance removes some aspects of choice and
consent from the woman and makes her dependent upon the actions and
beliefs of the healthcare provider. To define the services one
offers to pregnant women using the phrases "I allow" or "I don't
allow" transfers all control to the provider. To "allow"
ambulation during labor is to give a tacit approval and to not
"allow" a trial of labor after a previous cesarean birth (TOLAC) is
to imply that TOLAC is dangerous and imprudent. To "allow" an
action implies an authoritarian relationship, similar to a parent
and gives political power to the healthcare provider. The
concept of allowance signifies that the healthcare provider is the
expert, that the provider knows what is best without discussion and
that the provider will always make the best decision for the woman.
This language extends to nursing also; nurses are "allowed" to
perform some procedures in hospitals and not in others. More
respectful language would imply mutual consent between the parties
in the discussion, or political cooperation and compromise.
Compare the statement "midwives are allowed to attend TOLAC and
vaginal birth after cesarean" with the statement "midwives are
qualified to attend TOLAC and vaginal birth after cesarean."
Similarly, compare the statement "laboring women are allowed to
ambulate during labor" with the statement "laboring women are
encouraged to ambulate during labor." The emphasis moves from
permission to active voice.
Nurses experience this concept of allowance in many ways,
limiting the procedures they may perform and the assessments they
make. The Institute of Medicine's recent report encourages the
use of nurses to the full extent of their education and training.
Nurses are not "allowed" to practice but encouraged to use their
skills to the maximum ability. This enhancement of the nursing
role will benefit patients and healthcare systems. As an
example, nurses in some labor and delivery settings are not allowed
to check cervical dilatation because the resident needs the
experience. This limit of practice not only ignores the training and
experience of the nurse, but it objectifies women as learning
experiences, not as participants in the birthing experience.
If birth and the relationships a woman has with her healthcare
providers can be seen as political experiences, can changes be made
using a political approach? The political approach is broad
and encompasses many arenas. Political action can be aimed
at legislative change, local and societal change, organizational
change, and personal change. Legislative actions are not the
ideal approach for changing personal relationships but can help to
redefine power relationships.
Legislation may define the license of the healthcare provider and
set limits on practice. For example, legislation that requires
a midwife to have a signed written agreement with a physician limits
the midwifery practice to those areas with physicians who are
willing and comfortable with signing an agreement. Physicians
do not need signed written agreements between themselves to provide
collaborative services. Collaboration is expected for the
greatest patient benefit. Requiring a profession to seek the
approval of another profession builds a power relationship that is
detrimental to patient care.
Most states have nursing groups who lobby for support within the
state. Physicians are represented by the powerful American
Medical Association, which lobbies at the state and national levels.
Obstetricians and gynecologists are also represented by the American
College of Obstetricians and Gynecologists and nurses who practice
in women's health are represented by the Association of Women's
Health, Obstetric and Neonatal Nurses. Association of Women's
Health, Obstetric and Neonatal Nurses was formerly the Nurses'
Association of the American College of Obstetricians and
Gynecologists. The Association of Women's Health, Obstetric
and Neonatal Nurses left the American College of Obstetricians and
Gynecologists and incorporated as its own organization when it
became clear that sometimes nurses and physicians may have different
political agendas.
The socialization of physicians, nurses, and midwives establishes
a norm in the political power relationships with women and between
professions. Language may play a key role. Physicians
are always referred to as "Doctor," while nurses and midwives are
generally addressed by their first names, both by patients and by
other healthcare providers. The use of the title recognizes
the expertise of the physician and creates a hierarchy within
healthcare. Physician groups may resent the registered nurse
who holds a doctorate and may not wish to recognize him or her with
the title of "Doctor" even though "Doctor" was originally an
academic title. The use of the term "midlevel provider"
may refer to licensing but implies that the provider is not of the
highest level and may signal to patients that a physician is
"better." Political action around this term may take place
organizationally with advanced practice nurses discussing the
implications with the organization's leadership. Discontinuing
these terms may take time but will ultimately be useful and clearer
for patients and organizations.
SUMMARY
In summary, politics as a method of decision making in the birth
process may be overt and recognized or implicit and sanctioned by
existing relationships. Informed consent is affected by power
relationships that impact on the true information given and options
presented. Awareness of the political nature of relationships
can help the healthcare provider begin a dialogue with a woman that
respects the woman's options and choices.
There are many different degrees of political action. Nurses,
midwives, and nurse practitioners can participate at a level at
which they are comfortable and feel effective. Ignoring or
denying the existence of power relationships ignores the need for
change. Basing decisions on evidence can improve the birthing
experience for all women.
References
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3. Tillett J. Understanding and explaining risk. J Perinat Neonatal
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4. Minkoff H. Ethics of permitting or limiting choice of method of
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Link]
5. American College of Obstetricians and Gynecologists. The American
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Home Births [press release]. Washington, DC: American College of
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http://www.acog.org/from_home/publications/press_releases/nr01-20-11.cfm.
Accessed January 24, 2011. [Context Link]
6. Institute of Medicine. The Future of Nursing: Leading Change,
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Aurora Midwifery and Wellness Center
Aurora Health Care, Milwaukee, WI
For 21 years, the Aurora Midwifery and Wellness Center (AMWC), the
largest midwifery group in Wisconsin, has provided access to high
quality, patient-centered obstetrical/gynecological care in
Milwaukee. The 19 AMWC caregivers serve approximately 1000 women
annually and more than 80% of these patients, predominantly African
American women, live in the Milwaukee zip codes with infant
mortality rates that are among the highest in the nation.
Contact:
Jackie Tillett, CNM,
ND, Director, Midwifery and Wellness Center
1020 N. 12th St., 1st Floor
Aurora Sinai Medical Center
Milwaukee, WI 53233
414.219.5861 |
