Friday, January 6, 2012

The Politics of Choice: Autonomy and Ways of Knowing in Pregnancy and Childbirth

I recently read a really wonderful article that asked some thought-provoking questions about medically managed pregnancy and childbirth. Namely, can informed consent in truly exist in an environment where choices are actively – and subversively – shaped by “the system?” What about when “the system” uses fear to motivate and influence choice in a particular direction?

It is such a difficult thing to extract autonomy and personal choice from the context in which they are created - so many things influence our decision-making process, many of which we are not even aware of. When it comes to pregnancy and childbirth, there are a lot of decisions to be made...and yet so few of those who we see as "key players" in pregnancy and childbirth are culturally perceived as capable and competent to make these decisions. The "gut instincts" of mothers and fathers are routinely seen as being unscientific and uninformed and, therefore, not worthy of consideration.

In pregnancy and childbirth, the process of choice is, more often than not, informed by "authoritative knowledge" - that is, the knowledge of someone who is culturally perceived to have sufficient education, experience and general know-how to make them an expert. For women's health, children's health, and health in general in American culture, the holder of this authoritative knowledge is a commonly a doctor or other medical professional. 

There is nothing inherently wrong with authoritative knowledge, but the effect - sometimes intended, sometimes not - of placing great value in this way of knowing is that other ways of knowing inevitably become de-valued. 

Rock-star Reproductive Anthropologists Robbie Davis-Floyd and Carolyn Fishel Sargent edited a book on this topic called Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives. One of the chapters in this book is "Authoritative Knowledge and Its Construction," written by Brigitte Jordan. This chapter, quite simply, blew me away. Jordan sees authoritative knowledge such as that held by medical doctors as part of a larger hierarchical knowledge structure, wherein "non-authoritative" groups (e.g., parents, non-medical birth professionals) are not permitted to engage in the formation of knowledge or the decision-making process. Medical staff act as "gatekeepers" during birth, conveying information about the woman's own body to her, as gathered from the technologies in use; they tell her when she is progressing in labor, when to push, when she and her baby are medically well or not well. Jordan says, "The power of authoritative knowledge is not that it is correct but that it counts." (p. 58). Chilling, no? 
If authoritative knowledge is - as Jordan says - created through a means of social hierarchy, what implications does this have for decisions made in a medical setting during pregnancy and childbirth? How influential is authoritative knowledge in the choices that are made regarding pregnancy and childbirth, such as whether or not to have an elective cesarean, to induce labor, or to have certain diagnostic or other procedures done during pregnancy? What degree of responsibility do doctors and other medical professionals have to be aware of the value that's placed on the knowledge they hold - and how their presentation of this knowledge could potentially affect the choices of those in their care?

Let me be quite clear: I am not saying that medical professionals are inherently malicious or that they intentionally try to influence their parents' choices by withholding information. I can appreciate what a complex medical system these individuals work in, and I am aware that doctors and nurses undertake years of specialized education and are under a great deal of pressure to perform as experts at all times, with little to no room for error. Even still, their opinions guide the choices of pregnant and birthing women every day - for better or for worse - because of the perception that they hold specialized, authoritative knowledge that no layperson can access or attain. 

Your Thoughts? 
What do you think? Do you think Jordan's assessment of an hierarchical system of knowledge is accurate? How much influence do you feel doctors and other medical professionals have had in your own decision-making process, particularly when pregnant or during childbirth? Would you make the same choices again?


  1. have you read "Birth as an American Right of Passage?" the article critiques the established norm of hospitalized birth, but also explains that for the majority of women a hospitalized birth is just that , the norm, it's what's expected, it's culturally appropriate. I think some anthros forget that Americans have culture too so it's good to see this discussion that explains why so many Am women accept authoritative knowledge without much questioning.

    1. I have not read that article but I have heard of it - I will definitely have to check that out. Thanks for reading and commenting!