I think that anyone who came of age in the Schoolhouse Rock era has heard the phrase “knowledge is power.”
However, what is not oft heard is a discussion of which kinds of knowledge are granted power, versus which kinds of knowledge are subordinated or de-legitimized.
One such example of this is midwifery.
One of my most favorite things about the above TED talk, given by esteemed midwifery pioneer Ina May Gaskin, is her reference to effective birthing methods found outside the U.S., in countries such as Mexico and Guatemala. As she says, “Here we have some wisdom that comes from Mexico, and these are unlettered midwives… This is centuries old.” I know many would hear such a statement and immediately look down upon any such so-called “wisdom,” but it is valuable knowledge indeed…
When childbirth shifted from home to hospital, the knowledge carried by midwives— the very practice of midwifery itself— was cast as “backwards” and anachronistic by the all powerful medical institution (think: ACOG and the AMA).
However, as many of us know, midwives possess very important (very *legitimately* important) knowledge about pregnancy and the labor process. After all, they are trained to know all about the natural processes of childbirth, whereas physicians are trained in pathology— they are trained to look for, and spot, complications.
My point is that while institutions of consolidated power take the forefront as bastions of knowledge in our day-to-day society, there are a multitude of knowledges out there, and often one is not “better” than the other, but rather, one just ends up carrying with it more “power.”
The following is an excerpt from my thesis, which I wrote on the shift of childbirth from home to hospital in the early 20th century. I spent over a year researching over 100 sources, including microfilms of early 20th century women’s magazines, scholarly articles, legal analyses of midwifery litigation & legislation, historical nonfiction, documentaries, and more. Enjoy…
Physicians had control over their profession and its formation from the very start. As midwife Adrian Feldhusen says, “ The medical profession helped shape the medical system so that its structure supported professional sovereignty instead of undermining it” (“The History of…”). However, gaining the trust and support of the public towards increasing hospital births meant the inception and propagation of their medical authority and legitimacy throughout society. The fact that they built up their own legitimacy amongst themselves within their own professional community was a boon towards amassing the picture of legitimated power among the public, but they also needed women wanting their services by their own volition. According to scholar Sara K. Hayden,
“To distinguish themselves from midwives and legitimize their profession, physicians realized that pregnant women would have to voluntarily choose to pay higher fees for their services. While it is true that physicians provided medical technology that benefited women with difficult births, they did not restrict their practice to high-risk births. Rather, physicians began to represent every birth as a “potential disaster.” “In order to triumph over [female] modesty, medicine had to convince the public that childbirth was inherently pathological and unsafe, a dangerous condition that required the attention of the more highly valued male birth attendants.” Yet evidence did not support the perceived safety benefits of obstetrics over midwifery.”
Not only did organized medicine propagate a more perilous picture of childbirth, but they portrayed themselves as the “more highly valued” professionals to attend to it as well.
Physicians were instigating a culture of fear around childbirth, something that benefitted no one, except themselves. It drew on already existing fears about the pain involved with childbirth and therefore drew women into the hospital. Naturally, women were more than willing to submit to physicians because they “were afraid to deal with any pain” (Brodsky 7). Moreover, women, who had little access to the study of medicine, wouldn’t dare quarrel with an obstetrician or gynecologist (Corea 96). For the contemporary woman of the late nineteenth and early twentieth century, whatever was deemed best for her health and the health of her baby was accepted without question, and gynecology, “a specialty almost exclusively composed of men”, had the power to define just that (Corea 97). This in itself reveals the gendered power dynamics occurring between women in labor and the male physicians attending them. Citizens for Midwifery President, Susan Hodges, explains, “There’s a huge power disparity… The doctor may think he’s offering you an option, but you hear the expert advising you to do something.” Before physicians, the only women who had extensive knowledge of childbirth were midwives, but with their erasure came the erasure of an entire tradition of knowledge- the midwife model of care.
Unfortunately, the knowledge that midwives have possessed for centuries is not held in as high esteem as the knowledge associated with scientific medicine. As sociology Professor Thomas Gieryn points out, “In credibility contests, the epistemic authority of “science” as a cultural space is chronically reproduced” (14). Succinctly stated, science “often stands metonymically for credibility, for legitimate knowledge, for reliable and useful predictions, for a trustable real” (Gieryn 1). In other words, power is conferred upon those in society who possess institutionalized knowledges, such as that of medicine. Obstetrics is an especially unique case of this legitimized knowledge when viewed through the lens of a knowledge/power perspective, because it is a practice that has dealt exclusively with a historically subordinated class of people: women.
The home to hospital shift in birth practices has been largely facilitated by this exact power structure. The knowledge associated with midwives is still often seen as archaic and ineffective, not quite credible, and perhaps even regressive. What is seen as legitimate and valid according to U.S. cultural norms and standards is science, and only what is backed by science can be officially legitimated, and therefore credible. Donna Haraway says it best when she raises this issue by saying, “Questions about what counts as knowledge need to be examined in terms of practice, institutions, people, funding, and language” (qtd. in Gieryn 342). Indeed, there needs to be a greater degree of respect and value attached to the knowledge that midwives possess. Moreover, there needs to be greater value attached to one’s own physical awareness and the feeling of being in tune with one’s own body. This has been one of the most detrimental effects of the home to hospital shift- the revocation of women’s trust in themselves to give birth. Not to mention the continued privileging of one form of knowledge over another.
While organized medicine in the U.S. may have instigated a vicious campaign to wipeout midwives, and perhaps even natural birth to a certain extent, their power has remained due to a much more complex process. Sociologist Garry Stevens explains that, “power is a product of relations between people, not quality inherent in them…it often lies concealed in the unquestioned ways of seeing and describing the world…the exercise of power does not have to be conscious, or the result of explicit decision-making” (42). As Stevens puts it, power is not always a conscious act of intentional domination by one group over another, but lies in a sort of passive complicity (e.g. not questioning “ways of seeing” or the status quo) and it is in this way that power reproduces itself. The normalization of certain things, such as medicalized childbirth, by way of institutional authority has perpetuated its own legitimacy (and hence, power) through the relations between physicians and women; and it is through these relations, as Stevens suggest, that power is continually reproduced. In the instance of childbirth, the medical model was thrust into society by organized medicine, and subsequently normalized by society, without any questioning. No one bothered to question the so-called knowledge that physicians possessed because it was acquired through institutions of higher learning, and there was no critical analysis of medicalized childbirth because it was seen through a medicine-as-progress perspective. Science and technology would always produce inevitably better results, so the general public thought, and was therefore synonymous with “progress.”
Critiques of midwifery are usually underpinned by this same blind, or perhaps compulsory, faith in “medicine-as-progress” rhetoric. Moreover, they are most likely uninformed about the proven efficacy of this model of care. Even in 2000, the California Legislature stated in an amendment to the Midwifery Practice Act that:
“Numerous studies have associated professional midwifery care with safety, good outcomes, and cost-effectiveness in the United States and other countries. California studies suggest that low-risk women who choose a natural childbirth approach in an out-of-hospital setting will experience as low a perinatal mortality as low-risk women who choose a hospital birth under management of an obstetrician, including unfavorable results for transfer from the home to the hospital.”
In addition to this, it is also important to note that, “Despite the norm of the obstetrical approach to birth, the United States ranks at the bottom in perinatal mortality for the twenty-five industrialized countries”, which demonstrates that a medicalized birth does not mean a better birth- for mother or baby (Hayden 263). The divergence, and consequent suppression of midwifery knowledge and the negative impact this has had on U.S. births is pinpointed by midwife, Ina May Gaskin: “This is the outcome when you are a century or so post-midwives- you lose a lot of knowledge & we’re the one country [where] when birth went into the hospital, the midwives didn’t go there with it” (The Business of…). This, as she illustrates, is the impact of the loss of midwives and the midwifery model of care in the United States.