Caesarean section: The ultimate by-product of the One Two Punch Theory
Article Outline
- Punch One: take a highly successful natural process…
- Punch Two: fix the created problem with technology…
- Punch Three: reframe the technology as a ‘natural’ solution…
- Conclusion
- References
- Copyright
Recently our team has been writing up the analysis of data collected from a small number of Australian women who requested a caesarean section in their first pregnancy in the absence of a medical indication. In an attempt to offer some explanations for what we were seeing in the data our literature search reacquainted us with the early nineties work of Robbie Davis-Floyd. A well-known and published anthropologist, Davis-Floyd has a passion for understanding contemporary rituals around childbirth. It was in her paper, “The technocratic body: American childbirth as a cultural expression”1 that first introduced me to the concept of the ‘One Two Punch Theory’. The insights I gained from applying this theory to the issue of women requesting a non-medically indicted caesarean promoted me to write this editorial.
In her paper Davis-Floyd highlighted how the treatment of the human body reflects a society's core value system (currently technology, science, economic profit2). She argued that this is especially true for the process of childbirth where society has a stake in ensuring the survival of new social members. Davis-Floyd's intention in this paper was to explore the paradigm of birth she labelled the ‘technocratic model’. Her argument being that such a model serves as a “powerful agent of social control; shaping and channelling individual values, beliefs and behaviours”.1(p1125) To show how the technocratic model works Davis-Floyd draws on the work of Peter. C. Reynolds and the concept of the ‘One Two Punch Theory’. Reynolds states that ‘technological progress’ is in fact the ritualistic replacement of natural processes, most often conceptualised as female, primitive, earthly, uncertain and polluting (and therefore dangerous) with man-made processes conceptualised as advanced, scientific, purified, celestial, controllable (and therefore safe) and ‘male’.1(p1125) Reynolds labelled this process the “One-Two Punch”.
The basic premise is that the first punch destroys the natural processes and then the second punch seeks to replace it with a culturally fabricated process. The new, supposedly improved process becomes a representation of a technocratic societies ‘supervaluation’1(p1125) of science and technology over nature. Davis-Floyd argues that modern societies, such as ours, have transformed themselves into technocratic cultures using this dominant value. In her paper the analogy of Salmon farming is used to walk the reader though this concept. I have used this same analogy placing some aspects of childbirth alongside. In addition I have included what I’ve called ‘punch three’: the reframing of technology as the natural solution.
Punch One: take a highly successful natural process…
Salmon swimming upstream to spawn. Render it dysfunctional with technology – dam the water and prevent salmon reaching spawning grounds.
[Take a highly successful natural process – a woman's labour and birth – render it dysfunctional with technology. Apply rules to the length of pregnancy. Promote hospital birth as the only safe environment. Divide labour into stages; standardise it through routines and timelines (VE's and action lines), limit movement and fluids and disallow food. Take away privacy by forcing women to birth in public spaces filled with equipment and unfamiliar people. Make the bed and clock the centre piece of care. Restrict the support of loved ones. Tell women that pain is the enemy. Promote the use of drugs as the only acceptable way to manage a normal labour. Apply protocols and guidelines without individuality. Develop pathways that punish women for variance and consent them for whatever intervention they undoubtedly will need. And when they become so anxious and fearful that their labours slow, stall or fail to start…]
Punch Two: fix the created problem with technology…
Take the Salmon out of the water with a machine, make them spawn artificially, feed them, grow eggs in trays, release downstream near the ocean.
[In childbearing use synthetic hormones to induce and/or augment labour. Artificially break the waters to ‘see’ the colour. Use intravenous fluids to prevent dehydration, epidurals to remedy pain, catheters to empty bladders and electronic monitors to track and label the heart beat. Use fetal scalp electrodes to ensure we record the pattern, fetal scalp PH's to ensure we know how the baby is and antibiotics just in case. Episiotomies to hasten delivery. Vacuum and forceps if too slow, and caesarean section to ‘fix’ the non reassuring fetal heat rate pattern. In the labour and birth scenario, however, the use of surgically delivery, in the form of caesarean section, becomes the ultimate technological advancement to bypass the ‘complete’ female (and thus inherently dangerous) process of birth and ‘guarantee’ a healthy baby].
Punch Three: reframe the technology as a ‘natural’ solution…
Now if the culture ‘recognises’ the mutilated process, as in the building of salmon hatcheries, then Punch Three (my addition) happens – society dismisses it as “an accidental by-product of industrialization” or alternatively embraces it as “a compromised solution to unfortunately competing demands”.1(p1126)
[The rising caesarean rate in resource rich countries, such as Australia becomes recognised by some as a problem. However, the growing voice of concern has been countered by an increasing medical discourse that dismisses such concerns as illogical and ill-founded. This, of course, is based on a cultural worldview that reinforces that the health of the baby is paramount and that the process of birth, itself, is of little or no consequence; or indeed ‘dangerous’. Under these circumstances caesarean becomes embraced as a safe and ordered alternative to vaginal birth; some discomfort to the woman is seen as a reasonable price to pay to ‘ensure’ the process of childbirth results in a healthy baby. Simultaneously we start to see an unfounded argument in the literature suggesting that women themselves are to blame for the rise because they are ‘choosing’ caesarean section. Western society's economic imperative perpetuating the view that Obstetricians are thus only responsible for acting as providers of a service!2 In this way, the arguments over the mutilation of the childbirth process become confused and veiled].
The justification and repackaging of birth technology, however, has not stopped there. Take for example the publication by Smith and associates (2008) titled, ‘The natural caesarean: a woman centred technique’.3 In this article the authors acknowledge that women having caesareans are less satisfied, at increased risk of postpartum depression, experience bounding difficulties and are less likely to successfully breastfeed (interestingly there is no mention of the adverse clinical outcomes of having a surgical birth). Rather than advocating vaginal birth and careful limited use of caesarean the authors introduce the reader to a set of obstetric initiated techniques that they argue ‘replicate’ a natural vaginal birth and thus overcome these difficulties.
Although initially I was not particularly surprised at the direction of the article once I realised one of the authors was Fisk (a long time advocate of the caesarean section), I soon became stunned by the use of language. Words, phrases and sentences such as; “walking the baby out”; “as the fetal head enters the abdominal incision” “hands off approach” “baby autoresuscitates breathing air… while attached to placental circulation”; “this delay of a few minutes … allows maternal soft tissues to expel lung liquid…”; “mimic what's happening at vaginal delivery”; “Shoulder eased out”; “passive expulsion… by contracting uterus and active assistance… the baby wriggles out… head and torso supported” and “baby born”3(pp1038–1039); are woven together and ‘sold’ as new obstetric led techniques that mimic and/or ‘emulate’ a natural vaginal birth. While none of us would deny that there is a real need to make the experience of birth better for women having a caesarean what is so confronting is that the language and images used to describe vaginal birth (which has been consistently labelled as dangerous and an insignificant event in a woman's life) are being so unashamedly ‘spun’ together to ‘sell’ caesarean section. These medical men, who have regularly denigrated natural birth whilst portraying caesarean as the only safe option, have manipulated the powerful positive images of the female birthing body to serve their own agendas. What is perhaps more abhorrent is that they lay claim to these and make them their own. There is little doubt that these authors and clinicians are indeed reframing surgical birth as the natural solution.
Conclusion
At the time of her article Davis-Floyd argued that the cultural management of American birth was a perfect example of the One-Two Punch. Some 15 years later the argument still stands with Australia's increasingly ‘routine’ use of caesarean section. It would seem to me, however, that we are currently well and truly in the throes of the Punch Three deabte! The issue for us is how to swing the pendulum back; how do we help women and their daughters (and ourselves) regain cultural knowledge around birth and trust their pregnant, birthing and lactating bodies? How do we show the midwives of the future (and our medical colleagues) the way forward? How do we as midwives retain resilience in the face of such a pervasive cultural belief in techno-science? How do we work with women to help them believe in their own ability to keep birth normal? Working towards a community-based, social model of maternity care where every woman has access to her own midwife/s is an essential foundation. Our remit today is to not only walk beside childbearing women but to hold tight to our belief that childbirth is a normal significant event in a woman's life. We need to remember the long term ramifications for the physical and mental health of women, babies, families, communities and society as a whole.
References
- . The technocratic body; American childbirth as cultural expression. Social Science and Medicine. 1994;38:1125–1140
- . Caesarean birth: consumption, safety, ordering and good mothering. Social Science and Medicine. 2007;65:1192–1201
- . The natural caesarean: a woman centred technique. BJOG. 2008;115:1037–1042
PII: S1871-5192(09)00067-5
doi:10.1016/j.wombi.2009.08.002
© 2009 Australian College of Midwives. Published by Elsevier Inc. All rights reserved.
