by Robbie Davis-Floyd PhD

This article appears in the International Journal of Gynecology and Obstetrics,

Vol 75,Supplement No. 1, pp. S5-S23, November 2001.

Abstract: This article describes three paradigms of health care that heavily influence contemporary childbirth, most particularly in the West, but increasingly around the world: the technocratic, humanistic, and holistic models of medicine. These models differ fundamentally in their definitions of the body and its relationship to the mind, and thus in the health care approaches they charter. The technocratic model stresses mind-body separation and sees the body as a machine; the humanistic model emphasizes mind-body connection and defines the body as an organism; the holistic model insists on the oneness of body, mind, and spirit and defines the body as an energy field in constant interaction with other energy fields. Based on many years of research into contemporary childbirth, most especially through interviews with physicians, midwives, nurses, and mothers, this article seeks to describe the twelve tenets of each paradigm as they apply to contemporary obstetrical and health care, and to point out their futuristic implications. I suggest that practitioners who combine elements of all three paradigms have a unique opportunity to create the most effective obstetrical system ever known.

This article describes three paradigms of health care that heavily influence contemporary childbirth, most particularly in Western, industrialized nations, but now increasingly all over the globe.¹ I call these three paradigms the technocratic, humanistic, and holistic models of medicine (Davis-Floyd 1992; Davis-Floyd and St. John 1998). Of these three paradigms, humanism as a model for change stands the best chance of success in this era of the deepening penetration of technology into birth; thus “Humanizing Childbirth” was a most appropriate theme for the International Congress on Humanizing Childbirth held in Fortaleza Brazil in 2000, which the articles in this volume reflect. But in order to understand humanism in health care and obstetrics, it is essential to understand the other two approaches as well.

THE TECHNOCRATIC MODEL OF MEDICINE

The way a society conceives of and uses technology reflects and perpetuates the value and belief system that underlies it. Despite its pretenses to scientific rigor, the Western medical system is less grounded in science than in its wider cultural context; like all health care systems, it embodies the biases and beliefs of the society that created it. Western society’s core value system is strongly oriented toward science, high technology, economic profit, and patriarchally governed institutions (Davis-Floyd 1992). Our medical system reflects that core value system: its successes are founded in science, effected by technology, and carried out through large institutions governed by patriarchal ideologies in a profit-driven economic context. Among these core values, in both medicine and the wider society, technology reigns supreme. As has been clear for over twenty years, most routine obstetrical procedures have little or no scientific evidence to justify them. They are routinely performed not because they make scientific sense but because they make cultural sense. As we shall see below, they exemplify certain fundamental aspects of technocratic life.

The Twelve Tenets of the Technocratic Model

(1) Mind-body Separation and (2) The Body as Machine.

The main value underlying the technocratic paradigm of medicine is separation. The principle of separation states that things are better understood outside of their context, that is, divorced from related objects or persons. Technomedicine continually separates the individual into component parts, the process of reproduction into constituent elements, and experience of childbirth from the flow of life. But first and foremost, it separates the human body from the human mind.

The body presents a profound conceptual paradox to our society, for it is simultaneously a creation of nature and the focal point of culture. How can we be separate from nature when we are part of it? Descartes, Bacon, and others, neatly resolved this problem in the 1600s, when they established the philosophical separation of mind and body upon which the metaphor of the body-as-machine depends. This idea meant that the superior cultural essence of man, his mind–as well as the superior spiritual essence, his soul–could remain unaffected while the body, as a mere part of mechanical nature, could be taken apart, studied, and repaired.

This metaphor of the body-as-machine could have been inherently egalitarian, but the industrializing nations of the West were male-centered, patriarchal societies. Thus the male body came to be medically viewed as the prototype of the properly functioning body-machine. The female body, as it devi­ated from the male standard, was regarded as inherently defective and dangerously under the influence of nature, which due to its unpredictability, was itself regarded as in need of constant manipulation by man (Merchant 1983; Davis-Floyd 1992). As a result, despite the growing acceptance of birth as mechanical like all other bod­ily processes, it came to be viewed as an inherently imperfect and untrustworthy mechanical process, and the metaphor of the female body as a defective machine eventually formed the philosophical foundation of modern obstetrics. Furthermore, as the factory production of goods became a central organizing metaphor for social life, it also became the dominant metaphor for birth: the hospital became the factory, the mother’s body became the machine, and the baby became the product of an industrial manufacturing process. Obstetrics was thereby enjoined to develop tools and technologies for the manipulation and improvement of the inherently defective process of birth, and to make birth conform to the assembly-line model of factory production.

(3) The patient as object, and (4) Alienation of practitioner from patient. 

Mechanizing the human body and defining the body-machine as the proper object of medical treatment frees technomedical practitioners from any sense of responsibility for the patient’s mind or spirit. Thus, practitioners often see no need to engage with the individual who inhabits that body-machine, preferring instead to think of and talk about a patient as “the C-section in 112.”  Jordan (1993) demonstrates how this tendency to objectify patients can extend to refusal to discuss any details of a case with the person who embodies it. This kind of alienation from their patients is often trained into physicians during medical school and residency, as they are taught to protect themselves by avoiding emotional involvement. It logically follows that there is no reason to deal with the patient’s emotions at all. Thus they are free to protect their own feelings from the pain of caring too much. Technocratic physicians do not value lengthy conversations with their patients, preferring to keep their visits short. Although it is well-known that touch and caring are powerful factors that can positively influence both a woman’s experience of labor and the outcome of the birth (see below), it is rare to see obstetricians touching laboring women, holding their hands, or sheltering them in an embrace.

(5) Diagnosis and treatment from the outside in.

When most machines break down, they do not repair themselves from the inside; they must be repaired from the outside, by someone else. Thus in technomedicine, it follows that one must attempt to diagnose problems, cure disease, and repair dysfunction from the outside. The most valued information is that which comes from the many high-tech diagnostic machines now considered essential to good health care. Such diagnostic technologies are pervasive in pregnancy and childbirth, from ultrasounds in early pregnancy to electronic fetal monitoring during labor. And treatment too is from the outside in—when labor slows, the amniotic sack is pierced with a hook and pitocin is poured into a vein to speed it up; when a baby seems stuck, it is pulled out with forceps or cut out with a knife.

The routine administration of IVs to women in labor is a good example of the massive overuse of this outside-in approach. There is plenty of scientific evidence (Enkin et al. 2000; Goer 1995, 1999; Rooks 1997) to indicate that it’s much healthier for a woman to eat and drink during labor. But the IV makes a powerful symbolic statement: it is the umbilical cord to the hospital. The IV places the woman in the same relationship of dependence on the institution for her life as the baby in the womb is dependent on her for its life (Davis-Floyd 1992). By extension, one can see IVs as a perfect symbolic expression of life in the technocracy: we are all umbilically linked to institutions and through them, to society. As a vein is penetrated with a needle and then with the fluid flowing through the IV line, our homes are penetrated by water, sewer, telephone, and electricity lines. The fullest symbolic extension of the IV lies in its expression and display of our ongoing fusions of ourselves with the technologies we create. A “cyborg” is a cybernetic organism, a fusion of human with machine. In the cultural arena of reproduction, we are escalating the pace of our own cyborgification (see Davis-Floyd and Dumit 1998).

(6) Hierarchical organization and (7) Standardization of care.

Like its industrial predecessor, the technocracy is a hierarchically organized society. The term technocracy implies use of an ideology of technological progress as a source of political power (Reynolds 1991). It thus expresses not only the technological but also the hierarchical, bureaucratic and autocratic dimensions of this culturally dominant reality model. Even as many businesses seek to make a paradigm shift by transforming themselves into “organizational networks” and “flat corporations,” the medical system remains true to its role as society’s microcosm, rigidly hierarchical in terms of the power of physicians as a group, the emphasis on specialty over primary care, and in terms of the subordination of individual needs to standardized institutional practices and routines.

The standardization in hospital birth is dramatically evident in most modern hospitals. Upon entering the hospital, the laboring woman is taken in a wheelchair to a “prep” room. There her clothes are removed, she is asked to put on a hospital gown, and a vaginal exam is performed. Her access to food is limited or prohibited, and an in­travenous needle is inserted in her hand or arm. The external fetal monitor is at­tached to the woman to monitor the strength of her contractions and the baby’s heartbeat. Periodic vaginal exams are performed to check the degree of the baby’s descent. All of these procedures in most modern hospitals are routinely performed without scientific justification  (Enkin et al. 2000; Goer 1995, 1999; Rooks 1997).

As the moment of birth approaches, there is an intensifica­tion of actions performed on the woman, as she is transferred to a delivery room, placed in the lithotomy position, covered with sterile sheets and doused with antiseptic, and an episiotomy is performed. After the birth, she is handed the baby for a certain amount of time, her placenta is extracted if it does not come out quickly on its own, her episiotomy is sewn up, and finally, she is cleaned up and transferred to a hospital bed. Or she may have a cesarean section; in countries like Brazil and Mexico, that operation seems to be rapidly becoming routine (Castro 2001; Potter et al. 2001).

Of course, there are many variations on this theme. Some procedures that used to be standard in US hospitals in the 1940s, 1950s, and 1960s such as handstrapping, the exclusion of fathers, and shaves and enemas are no longer used, although some are still common in developing countries. Other major changes since then have included the father’s presence and women remaining conscious during birth. When possible, many women opt for delivery in a birthing suite or LDR (labor-de­livery-recovery room), where they can wear their own clothes, do with­out the IV, and walk around during labor. Yet in spite of these concessions to consumer demand for more humanistic birth, a basic pattern of high-technological intervention remains: most hospitals now require at least periodic electronic monitoring of all laboring women; analgesics, pitocin, and epidurals are widely administered; and cesarean section rates are increasing. Thus, although some medi­cal procedures drop away, the use of the most powerful signifiers of the woman’s dependence on science and technology intensifies.

(7) Authority and responsibility inherent in practitioner, not patient.

In line with its hierarchical structure, the technocratic model invests authority in physicians and in institutions and their personnel. Obvious cues such as titles and white coats signal the authority of the physician, who can add to his status by withholding information, and using technical jargon the patient cannot understand. When the doctor is the authority, the patient lacks responsibility. Many doctors are able to present an option as the answer quite easily, by simply refusing to discuss non-paradigm alternatives. In this scenario, a patient’s most comfortable role is abdication of personal preference in favor of the doctor’s choice.

In childbirth, one of the most graphic demonstrations of the power of “doctor’s choice” is the lithotomy position so popular with doctors not because it is physiologically sound, but because it enables them to attend births standing up, with a clear field for maneuvering. We know very well that this position complicates childbirth, but the many good physiological reasons to allow women to give birth in upright positions (which include increased blood and oxygen supply to the baby, more effective pushing, and wider pelvic outlets) are far less important to most physicians than their own comfort, convenience, and status. In the West, “up” is good and “down is bad”: the person who is “on top” has the status and the power, and rarely gives it up for the good of the laboring woman and child.

Technomedicine’s investment of both authority and responsibility in physicians and hospitals is a double-edged sword. Although medical personnel do have the power to give orders to patients and establish institutional policies and procedures, they can be and often are held to be accountable for deaths and outcomes that no mortal could prevent. The proliferation of lawsuits against obstetricians  over the past two decades is testimony to the way citizens have turned this tenet of the technocratic model against its proponents.

(8) Supervaluation of science and technology.

The general public tends to assume that doctors are scientists, but most medical students receive little or no training in research methodology and analysis. A 1978 study carried out by the Office of Technology Assessment of the United States Congress reported that “only ten to twenty percent of all procedures currently used in medical practice have been shown to be efficacious in controlled trials”;  in the 1990s, it is still true that over half of the techniques physicians routinely employ have not been proven in rigorous testing. Yet the power of the technomedical paradigm is such that physicians will rapidly accept procedures and technologies in keeping with it, while rejecting those that do not. So, while science is “supervalued” as an ideology in this paradigm, its actual findings are often discounted or ignored.

Likewise, the technologies that predominate in medical treatment are those that support the “evolution through technology” ethos of the technocratic model, in which progress means the development of ever more sophisticated machines. When a doctor uses a “low-tech” tool like a stethoscope, he touches the patient, speaks to her, listens with his own ears to hers or the baby’s heartbeats, interprets the sounds through his own bodily perceptions, and arrives at a diagnosis that depends in large part on his physical senses. When the same doctor uses a computerized axial tomography (CAT) scanner or an electronic fetal monitor (EFM), only the machine touches or interacts with the patient during the procedure. The physician’s role is to interpret the mechanically mediated results, which are regarded as more objective and reliable than his perceptions.

Such new technologies are usually introduced by their marketers, who tend to describe them solely in terms of their best-case use and minimize any detrimental effects. EFM  is a case in point (Kunisch 1989). Its manufacturers regularly paid physicians’s trips to medical conferences; upon arrival, they found themselves walking through elaborate EFM displays to get to the meeting rooms (Wagner 1997). Now pervasive in hospital birth, the EFM has resulted not in better outcomes but in higher costs and higher Cesarean rates. Nevertheless, many hospitals in the US routinely employ these machines in more than 80 percent of labors.

Rapid diffusion and acceptance of a new technology often has more to do with its symbolic value than its actual efficacy. Machines can mesmerize:

The amplified fetal heartbeat sounds like galloping horses . . . both the sound of the gal­loping and the vision of the needle traveling across the pa­per, making a blip with each heartbeat, are hypnotic, often giving one the illusion that the machines are keeping the baby’s heart beating” (Harrison 1982:90).

So powerful is this illusion that nurses Davis-Floyd has interviewed often become reluctant to detach the mother from the monitor because they fear that the baby’s heart will stop. While they know intellectually that this is nonsense, nevertheless they are emotionally swayed by the symbolic power of these machines.

Once machines like the EFM, along with CAT and positron emission tomography (PET)  scanners and hundreds of others, are there, they must be reckoned with, and any decision not to use them begins to look like substandard care–a reality that reflects both the financial and the symbolic supervaluation of technology in the American medical system. Such machines serve the powerful symbolic purpose of “upgrading” medical care in keeping with our notions of evolutionary progress; indeed, our newest cultural value is the flow of massive amounts of information through sophisticated electronic systems—just the kind of option that the EFM provides.

(9) Aggressive intervention with emphasis on short-term results, and (10) Death as defeat

Since the dawn of the Industrial Revolution, Western society has sought to dominate and control nature. And the more we controlled nature, including our natural bodies, the more we feared the aspects of nature we could not control. This led to the emergence of a phenomenon that anthropologist Peter C. Reynolds (1991) has labeled the “One-Two Punch” of technological intervention. Take a natural process that seems to need fixing—say, a river in which salmon annually swim upstream to spawn. Punch One:  “Improve it” with technology–build a dam and a power plant, generating the unfortunate byproduct that the salmon can no longer swim to their spawning grounds. Punch Two: Fix the problem created with technology with more technology–take the salmon out of the water with machines, let them spawn and grow the eggs in trays, feed the babies through an elaborate system of pipes and tubes, then truck them back to the river and release them downstream. Reynolds’ brilliant insight was that, while most people see Punch Two as an accidental byproduct of Punch One, the deeper truth is that Punch Two is the point. We in the West have become convinced that altering natural processes makes them better–more predictable, more controllable, and therefore safer.

It is not hard to see how this One-Two punch of mutilation and prosthesis applies to birth. The birth process seems to us to be chaotic, uncontrollable, and therefore dangerous. So we “improve” it with technology. First we take it apart–deconstruct it–into identifiable segments. Then we control each segment with the obstetrical equivalent of dams and floodgates (EFM, pitocin, drugs.). When the unfortunate byproduct of this technological reconstruction of birth is a baby in distress from a now-dysfunctional labor, we rescue that baby with more technology (episiotomy, forceps, Cesarean section). Then we congratulate ourselves on a job well done, just as the builders of the salmon hatchery congratulate themselves for “saving the salmon.”

Reynolds’ One-Two Punch is a powerful motivating force in American society–I call it the technocratic imperative. This impetus to improve on nature through technology has as its ultimate aim to free us altogether from the limitations of nature. The more able we become to control nature, including our natural bodies, the more fearful we become of the aspects of nature we cannot control. Death becomes the ultimate signifier of defeat, proof that in fact we have not succeeded in transcending nature’s limitations, and thus the ultimate enemy, to be defeated at all costs. Lifesaving procedures for low birth weight infants, often implemented without respect for their eventual quality of life, like high tech intervention for the terminally ill, represent attempts at sustaining the fragile thread of life against all odds. The underlying ethos behind the routine application of so many unnecessary procedures to birth is fear of death. These procedures keep fear at bay by giving both practitioners and birthing women the illusion of safety: they appear to minimize risk while in fact they often generate more problems than they solve.

Technomedical hegemony: (11) A profit-driven system; and (12) Intolerance of other modalities.

The word “hegemony” refers to an ideology espoused by the dominant group in a given society. In a multi-cultural society such as that of the United States in the late 20th century, no one set of ideas about medicine, religion, economics, or anything else is shared by everyone. Nevertheless, there are ideologies that are obviously dominant: in economics, the hegemonic ideology is capitalism, and in health care, it is the technomedical model. When an ideology is hegemonic, all other competing ideologies become “alternative” to it. Thus healing modalities such as midwifery, chiropractic, homeopathy, naturopathy, acupuncture, and so forth have been viewed as alternative to allopathy. While these modalities command increasing respect and usage, allopathic technomedicine still sets the standards for care. Its hegemonic status works to ensure its profitablity: pharmaceutical and medical technology companies constitute by far one of the most profitable industries in the United States. The median after-research profit rate in 1993 for the makers of the top-selling prescription drugs was more than five times higher than the median profit rate for all Fortune 500 companies in the same year (Pollack 1995). Any system–-medical, economic, religious, or otherwise-–that gains sociocultural ascendancy and then rigidifies, shutting out new information and refusing to incorporate contradictory evidence, is in mortal danger both to itself and to the public it serves. Such hegemonic systems can benefit from frontal attacks, which can serve to keep them flexible and responsive to the changing realities of changing times. It is in that spirit that I have presented this analysis.

THE HUMANISTIC MODEL OF MEDICINE

In the United States and elsewhere, the excesses of technomedicine have long been the subject of heated discussion and debate. Humanism arose in reaction to these excesses as an effort driven by nurses and physicians working within the medical system to reform it from the inside. Humanists wish simply to humanize technomedicine–that is, to make it relational, partnership-oriented, individually responsive, and compassionate. This caring, commonsensical approach is garnering wide international appreciation and support. Clearly less radical than holism, clearly more loving than technomedicine, this humanistic paradigm has the most potential to open the technocratic system, from the inside, to the possibility of widespread reform.

The Twelve Tenets of the Humanistic Model

(1)  Mind-Body Connection

The humanistic approach neither demarcates a total separation between mind and body, as does technomedicine, nor claims oneness for mind and body, as does the holistic model. Rather, it recognizes the influence of the mind on the body and advocates forms of healing that address both. Proponents of this paradigm see body and mind as being in constant communication, citing scientific research in the field of psychoneuroimmunology and elsewhere. Thus the humanistic paradigm insists that it is impossible to treat physical symptoms without addressing their psychological components. Psychoneuroimmunologist Candace Pert explains:

Viruses use [the same receptors as the neuropeptides that carry emotions] to enter into a cell, and depending on how much of the natural juice, or the natural peptide for that receptor is around, the virus will have an easier or a harder time getting into the cell. So our emotional state will affect whether we’ll get sick from the same loading dose of a virus.  . . Emotional fluctuations and emotional status directly influence the probability that the organism will get sick or be well. (1993:190)

The implications for childbirth of the notion that the mind affects what happens in the body are obvious and profound. Humanism in childbirth allows for the possibility that the laboring woman’s emotions can affect the progress of her labor, and that problems in labor may be more effectively dealt with through emotional support than through technological intervention.

(2) The Body as an Organism

Although in some ways the human body is like a machine, it is a fact of biological life that the body is not a machine but an organism. Such a conclusion has powerful repercussions for treatment, as the way the body is defined will shape the way it is treated by a culture’s health care system. “Even medical therapies that are the most machine-like would be ineffective without the innate healing powers of the organism,” which has “properties that no machine has: those of growth, regeneration, healing, learning, and self-transcendence” (Tresolini et al., 1994)

Defining the body as an organism charters the development of an array of treatments that may be irrelevant to a machine but matter a great deal to an organism. Unlike machines, mammalian organisms feel pain and respond emotionally to interactions with others and to changes in their environment. Most mammals respond positively to the comfort of a loving touch and shrink from contact that is harsh or punitive. Thus a paradigm of healing based on a definition of the human body as an organism would logically stress the importance of kindness, of touch, and of caring. These dimensions have special significance for the care of laboring women, from the ways they are treated during labor to the need of mother and baby to remain together after birth. The best analog for the term humanism in the medical literature is the term bio-psycho-social, which acknowledges that this model takes in to account biology, psychology and the social environment.

(3) The Patient as Relational Subject

Most humanists are not afraid to establish a real human connection with their patients, to come to know them not just as patients but as individuals, not as “the C-section in 112” but as “the mother with twins whose sister just died.” David Spiegel (et al.1989 ) showed  that women with advanced breast cancer who participated in weekly support groups not only felt better emotionally, but ultimately lived an average of eighteen months longer than did women with comparable breast cancer and medical care who did not attend such groups. This added survival time was, according to Spiegel (1993), “longer than any medication or other known medical treatment could be expected to provide for women with breast cancer so far advanced.” This study has been followed by a number of large-scale studies showing that more and better social support from family and friends is associated with lower odds of dying and better odds of healing at any given age.

Starting in the 1970s, natural childbirth activists in large numbers in the US and other countries began to demand that fathers and significant others should be allowed into delivery rooms, that mother and baby should not be separated after birth, that friends and relatives be allowed to remain with the laboring woman if such was her desire. The effect of the presence of caring others during childbirth does far more than simply work toward a more pleasant labor experience; it can be central to the positive outcome of that experience.

(4) Connection and Caring between Practitioner and Patient

Whereas the technomedical paradigm is based on the principle of separation, and the holistic model on integration, the principle underlying the humanistic approach is connection: the connection of the patient to the multiple aspects of herself, her family, her society, and her health care practitioners. Humanism requires treating the patient in a connected, relational way as any human being would want to be treated–with consideration, kindness, and respect. This paradigm insists on the deep humanity of the individuals involved and stresses the importance of the patient-practitioner relationship to the healing process. The phrase “relationship-centered care” has been suggested “to capture the importance of the interaction among people as the foundation of any therapeutic or healing activity “ (Tresolini et al.1994).

In childbirth the strongest evidence of the power of relationship-centered care comes from the doula research. A doula is a female companion especially trained to give labor support. Sosa, Kennell, Klaus, and their associates, (1980, 1982, 1988) compared the results of normal hospital labors with labors of women attended one-on-one by a doula. They found that doula support dramatically reduced problems of fetal asphyxia and labor dystocia, shortened length of labor, and enhanced mother-infant interaction after delivery (see also Klaus, Kennell, and Klaus 1993).

(5) Diagnosis and Healing from the Outside In and from the Inside Out

Where the technomedical model emphasizes diagnosis and healing from the outside in, and the holistic model from the inside out, the humanistic model calls for a moderate application of both approaches. The physician-patient communication it emphasizes allows physicians to elicit information from deep within the patient and combine it with objective findings. Accordingly, humanists find that how to listen is as important as knowing what to say. Listening skills are crucial for obtaining the correct mix of data required for diagnosis.

Noting that a clinician will perform from 120,000 to 160,000 interviews during a career, Smith (1996) points out that the biomedical model teaches students to elicit symptoms of disease using a “doctor-centered” interviewing process. The physician elicits many bits of nonpersonal data, starting with the patient’s chief complaint, then synthesizes them into a description of the patient’s disease. But humanistic doctors know that the presenting complaint often masks an underlying problem. A woman complaining of fatigue, depression, and body aches may have lupus or may be despondent over a failed marriage. Practitioners must adopt an open-ended learning approach in order to create the space and time necessary to bring forth the underlying dynamic.

This open-ended learning approach forms an important part of what Smith (1996) calls the “patient-centered interview.” Instead of asking a series of closed, rapid-fire questions, the physician simply encourages patients to express what is most important to them, which will usually come out as a combination of personal data and data about symptoms. Allowing patients to lead keeps their ideas and concerns paramount and  enhances their sense of autonomy. The patient-centered interview can form an invaluable part of the humanistic physician’s ability to be both technically competent and humanistically caring.

(6) Balance between the Needs of the Institution and the Individual

Humanism counterbalances technomedicine with a softer approach, which can be anything from a superficial overlay to profoundly alternative methods . It is superficially humanistic to decorate a technocratic labor room so the machines don’t stand out so much; it is deeply humanistic to provide women with flexible spaces in which they have room to move around as much as they like, to be in water if they wish, to labor as they choose.

Most medical institutions are designed to support and implement technocratic principles. These institutions are so highly regulated with respect to infection control, medical/surgical and nursing procedures, security, and liability that it is often not possible for one individual to effect significant change. So sometimes humanistically inclined physicians must content themselves with superficial improvements; but very often, committed individuals find they can do more. In the US, nurse-midwives have gained a reputation as the practitioners who try the hardest to provide deeply humanistic care within hospitals (see Rooks 1997; Davis-Floyd 1998). Thus two humanistic changes often sought by childbirth activists include convincing hospitals to give women the right to choose midwives as their birth attendants, and to have access to one-on-one doula care.

(7) Information, Decision-making, and Responsibility Shared between Patient and Practitioner

The poles between empowerment and dependence form the framework within which doctors and patients make decisions. Most health professionals are trained to bring linear information to bear in their decision-making; in addition, the humanistic paradigm allows non-linear, subjective processing to play a significant role. This is the balanced or empathic style of thinking. “Empathic” refers to the ability of one person to understand another’s reality even if that reality is beyond their direct experience. Even when straightforward evidence of disease is present, doctors still have considerable latitude regarding how mutual they are willing to allow decision making to be. In the technomedical model, each situation seems to dictate a matching action. The humanistic model opens situations to multiple options.

The doctrine of informed consent establishes that patients have a right to understand their diagnosis and prognosis, their proposed treatment and its risks and benefits, and their treatment options. In the technocratic model the discussion of options outside of conventional medicine is generally impossible due to the doctor’s allegiance to technocratic approaches and ignorance of alternatives. Discussing  no treatment as an option is equally unlikely. But in humanism, open discussion of treatment choices leads naturally to an exploration and sharing of values, and doctors are more likely to respond favorably or at least neutrally to a patient’s wish to try alternative methods or to employ no treatments at all.

Arthur Kleinman (1988) expands the notions of the patient’s right to information and the “patient-centered interview” to a more dialogic approach. He suggests that the goal of the practitioner should be to enter into the experience of illness as patients perceive it by listening carefully to their narratives. To more deeply understand a patient’s story, the physician can try to interpret the patient’s symptoms as symbols of deeper life issues and to grasp the influence of the patient’s cultural, personal, and family explanatory models. Like other humanistic and holistic physicians, Kleinman  (1988) stresses the value and importance of the placebo effect, which can be activated purely through the strength of the physician-patient relationship and thus should be tapped in every healing encounter.

Medical sociologist Eliot Freidson (1967) asserts that the need for information is apt to result in conflict simply because a lay culture is encountering a professional culture at a moment of crisis. To balance this, the doctor needs to communicate a trustworthiness to the patient so that the patient can accept or reject recommendations without feeling either bullied or negated. Although some physicians might fear liability with this level of information-sharing, the Consensus Conference on Doctor-Patient Communication held in Toronto in 1992 found that most lawsuits against doctors are the result of communication faults rather than errors in medical judgment.

(8) Science and Technology Counterbalanced with Humanism

Humanistic physicians take science as their standard and use virtually the same tools and techniques as technomedical doctors. The difference lies in timing and selection. Humanists may be more willing to wait, more apt to be conservative, more open to mind/body approaches. Humanists who are primary care doctors (family physicians, internists, pediatricians, gynecologists) may delay referring to a specialist and attempt to resolve a problem using more conservative methods, provided they have the consent of the patient to do so. Humanistic specialists will naturally be inclined to use the technology at their disposal, but will emphasize caring and relationship alongside it, a combination John Naisbitt (1980) captured in the phrase “high tech, high touch.”

A whole new class of birth technologies has been developed that can be considered humanistic, from portable tables that allow babies in distress to be resuscitated at their mother’s sides to sophisticated birthing chairs that allow women to be in upright positions. But for such interventions to be truly humanistic, they should be used at a patient’s request or desire and their use should be soundly evidence-based. For example, epidural anesthesia can be considered a humanistic intervention because it takes away pain while allowing women to be “awake and aware.” But there is nothing humanistic about forcing epidurals on women who don’t want them. On the other side, how humanistic is it to allow women who arrive at the hospital demanding an epidural to have one in very early labor? A great deal of evidence now shows that if given before 5 cm dilation, epidurals can significantly slow labor. But when epidurals are given after five cm dilation, such problems are rare. Humanistic obsetricians and midwives try to evaluate the evidence and to make decisions that reflect the balance between what science shows to work and the needs and desires of the women they attend.

A good example of counterbalancing science and technology with humanistic principles stems from a birth Davis-Floyd once observed, in which a mother laboring in a hospital supported by her husband and a doula rejected the delivery table and asked to be allowed to give birth on the floor. The physician and nurses attending her asked themselves what science truly demanded in that situation. The answer was that there was nothing scientific at all about giving birth flat on one’s back on a delivery table; it was in fact much more evidence-based to give birth upright on the floor. What science did demand was a clean area for the delivery. So the nurses took the sheets off of the table and put them on the floor, and the woman, propped with pillows, cheerfully sat on top of them to give birth. In other words, ideally, humanistic care should be evidence-based care that reflects real science and not medical tradition.

(9) Focus on Disease Prevention

Most proponents of humanism are also strong proponents of science-based public health initiatives that stress prevention and deal sensibly with the public environment. They point out that providing a village or a country with a clean water supply will do far more good for the health of far more people than building high-tech hospitals, as will ensuring clean air, adequate nutrition, and access to primary health care.

Prevention has been limited to the public health arena presumably because it does not turn a profit, unlike the sale of high tech medical equipment and pharmaceuticals. No one benefits in any immediate sense when people stop smoking, but a model in which compassion, not profit, is the driving force, has room for prevention and for social programs that reflect political agendas that protect the disenfranchised. Thus the public health paradigm, which stresses long-term, large-scale disease prevention and health promotion, corresponds closely to the humanistic paradigm, which stresses long-term individual and family (biopsychosocial) disease prevention and health promotion. In fact, humanists often leave private medical practice for work in the wider arena of public health.

The implications of this prevention-based approach in childbirth are enormous. True prevention of complications in childbirth would involve addressing the problems that lead to maternal and fetal deaths at their source. But often public health programs like the Safe Motherhood Initiative are heavily influenced by technomedical perspectives. Technomedicine identifies hemorrhage, toxemia, anemia, and the like as the sources of maternal death. But the underlying causes of these problems are the interrelated factors of poverty, poor nutrition, contaminated food and drinking water, the lower status of women, and overwork. Initiatives that try to solve the problem of maternal mortality by building more hospitals and stocking them with more machines fail to address these core problems; instead, they  perpetrate the agenda of technomedicine.

Both the public health paradigm and the humanistic model are compassion-driven; both focus on disease prevention, health promotion, and public education. The public health paradigm takes a broadscale, population-wide approach, while the humanistic model focuses more specifically on the individual relationships between family, patient, and provider and the effects of these relationships on illness prevention, diagnosis, and treatment.

(10) Death as an Acceptable Outcome

In childbirth, where death usually arrives suddenly, the technocratic approach to the death of a baby is to whisk away the body, leaving the parents with empty arms. The humanistic way is to allow the parents all the time they need with that baby, so that the pain of death is not augmented by the pain of sudden separation. In the wider cultural arena, the humanistic approach to death is one of individual choice about the manner of dying. Individuals can sign living wills in advance, requesting that life-prolonging measures be limited. The hospice movement has brought death back into the home by supporting the dying individual and the family, not with major medical intervention but with the comfort of pain relief. This highly humanistic approach stem from a philosophy that profoundly honors a patient’s individuality and freedom of choice. The process of conscious dying under both the humanistic and holistic paradigms becomes an opportunity to heal one’s relationships with spouses, lovers, children, friends, oneself, and God. Grievances can be forgiven, old wounds mended, unmet needs and wishes fulfilled. In such cases, the death of an individual can provide tremendous opportunities for healing for families and entire communities.

(11) Compassion-Driven Care

Byron and Mary Jo Good (1993, 1995) suggest that the juxtaposed “central symbols” of competence and caring  represent a cultural tension developed throughout medical education that is linked to a dualistic discourse characteristic of contemporary Western medicine.  Competence is closely associated with the natural sciences, caring with the humanities. Competence is a quality of knowledge and skills, caring a quality of persons. They also note that this juxtaposition of competence and caring, present throughout the history of Western medicine, reflects the larger struggle between science and culture, technology and humanism, which in the West are often seen as opposing forces.

It is precisely these contradictions that the humanistic approach to medicine seeks to resolve. Physicians faced with suffering are expected to process information quickly, arrive at, and often implement a course of treatment. In technomedical circles, emotions are thought to interfere with such abilities. In both humanistic and holistic serttings, feelings are accepted as part of the healing response. The driving ethos of the humanist is compassion-–the ability to sense and feel the needs of others even if they are outside of one’s own experience. When they sit down by a laboring woman’s bed and breathe with her through a contraction, humanistic physicians are working to re-create a place in medicine for the human values of partnership, relationship, compassion, and caring. Only after three decades of scientific research documenting the benefits of this humanistic approach are technocratically trained physicians allowing themselves to be human, letting go of the fear that others will think them weak and incompetent if they open themselves to their own feelings and learn skills for processing their patients’ feelings without becoming emotionally overwhelmed.

(12) Open-Mindedness toward Other Modalities

Most humanists have no intention of learning alternative healing techniques, although in general they are open-minded and support patients who chose to use alternatives–as long as the overall treatment program includes conventional care. While many humanists adopt a sort of bemused tolerance to alternative modalities, some do advocate dietary and lifestyle changes that border on the holistic, and take a more proactive stance toward other healing alternatives. Physicians in transition to humanism need not undergo any noticeable change in beliefs about what causes or cures disease. Simply being nicer, more caring, more willing to touch and communicate repositions them in the humanistic model. Most will not undergo the radical shift in values that permits them to go beyond compassion to employ the healing power of that mysterious thing called energy in overcoming disease. This is the realm of the holistic physician.

THE HOLISTIC MODEL OF MEDICINE

If the technocratic model of medicine is the ruling hegemony, the holistic model of medicine is the ultimate heresy. Of the three paradigms I discuss, the holistic model encompasses the richest variety of approaches, ranging from nutritional therapy to traditional healing modalities such as Chinese medicine to various methods of directly affecting personal energy. Some holistic practitioners study a particular modality while others employ an eclectic approach, often of their own design. Holism often calls on individuals to be active, asking them to make major modifications in their lifestyles. It may also ask them to be passive, to simply receive prayer or a transfer of healing energy.

The term holism was adopted by some of the pioneers of this movement to express their inclusion of the mind, body, emotions, spirit, and environment of the patient in the healing process. The principles of connection and integration that underlie the holistic paradigm arise from the fluid, multi-modal, right-brained thinking that, after centuries of devaluation in the West, is finally beginning to regain lost ground (Eisler 1995). While the whole brain is involved in all brain functions, it is possible to say that the right hemisphere is predominantly involved in perceiving the gestalt, the whole. In contrast to the classifying and segmenting unimodal approach of left-brained, linear systems of thought, fluid thinkers use multimodal means of perception to apprehend the whole and to intuit the ever-shifting relationships of its parts. It is thinking of, with, and through the body and the spirit–holistic thinking, fluid thinking that transcends logical reasoning and rigid classifications in favor of what Starhawk (1989), one of its principal spokespersons, calls the “spiral dance.” She means the spiral of the vortex, the tornado, the creative matrix in which all things are tossed around and mixed up beyond any making sense. From the deep integrative chaos of this energy vortex arises the surprise–the unpredictable relationship, the unexpected connection, the revealing intuition–that so often constitutes a prime element of holistic healing.

The Twelve Tenets of the Holistic Model

(1)  Oneness of body-mind-spirit

Mind and body, wrought asunder by Cartesian rationalism, and reconnected in medical humanism, are reunited in holistic medical care. The worst problem here is language: we are so used to speaking in terms of mind/body separation that even holistic healers find themselves still using the words “mind” and “body”; when they are careful, they will refer to the “bodymind” to indicate that it is all one thing. A large part of the initial impetus for the reuniting of mind and body in holistic healing was the dawning realization that the brain, the physical seat of the mind, is not located only in the head but in fact extends throughout the central nervous system. Understanding that the brain is distributed throughout the body makes it much harder to talk or think about body and mind as separate entities.

If the mind is the body, and the body is the mind, then how one responds to the treatment of even so mechanical a thing as a broken arm will have as much to do with how one thinks and feels about that broken arm as about what kind of cast is put on it. In the holistic approach, addressing the psychological states and emotions of the pregnant or laboring woman is not just helpful, it is the essential aspect of care. Like humanists, holistic physicians are finding that they need much more engagement with the patient to get at those intangibles of mind and emotion now seen to be as much a part of the illness as its physical manifestation.

The holistic paradigm also insists on the participation of the spirit in the human whole. In incorporating soul it into the healing process, holistic healers bring medicine back into the world of the spiritual and the metaphysical from which it was separated during the Industrial Revolution. The spirituality of holistic healers tends to be fluid, and to take the form of a loose identification with Eastern or New Age philosophies more often than with Judaism, Christianity, or Islam. Where the technomedical model is rigid and separatist, the holistic model recognizes no sharp divisions or distinct boundaries. This is another reason why holism is so threatening: in many people’s minds, to trifle with boundaries is to invoke chaos. And indeed, chaos theory and systems theory both inform and underpin the holistic paradigm and its insistence on the oneness of body, mind, and spirit.

(2) The Body as an Energy System Interlinked with Other Energy Systems

The holistic paradigm moves far beyond the narrow view of the body-as-machine, past the humanistic view of the body as an organism, all the way to a limitless view of the body as energy. Defining the body as an energy system provides a powerful charter for the development and use of forms of medicine and treatment that work energetically such as acupuncture, homeopathy, intuitive diagnosis, Reiki, hands-on healing, magnetic field therapy, and therapeutic touch. “Energy medicine” acknowledges the possibilities that an individual’s health can be influenced by such subtleties as the vibrations of anger or hostility or the electromagnetic fields created by power plants and microwaves, of these presuppose non-physical reality. Today’s physicists relish documenting the vanishing frontier between matter and energy. Medical research would require complete restructuring if it accepted such conclusions from other disciplines. For example, while medicine hotly refutes the impact of the investigator on research, physics recognizes the Heisenberg Principle, which acknowledges the influence of the observer on the observed. Even the intentionality of the experimenter can profoundly affect the outcome of an experiment (Wiseman and Schlitz 1996). How can an observer separate from the observed phenomenon affect its behavior? Acceptance of this second tenet answers this question: the observer and the observed are not separate, but are energy fields in constant interaction with each other.

Many midwives Davis-Floyd has studied in the US define themselves as holistic and consciously seek to work with what they call “birth energy.” Indeed, they believe that the primary intervention a midwife can make is at the energetic level.  Intervening to “redirect the energies” can ensure that no other type of intervention will be needed. If a labor stalls and a cesarean seems imminent, a midwife who has a feel for the power of energy may  throw open the window, put on some music, and get the mother up to dance. Or she might leave the room to allow the birthing couple some privacy, so that the loving energy of their relationship can infuse the birth experience. The important point is that for the practitioner who works at the level of energy, these sorts of interventions will not be afterthoughts or overlays, but will be basic and primary–the first line of care.

(3) Healing the Whole Person in Whole Life Context

This tenet of the holistic model of medicine, a logical corollary of the first two, acknowledges that no single explanation of a diagnosis, no single drug or therapeutic approach, will sufficiently address an individual’s health problems; rather, such problems must be addressed in terms of the whole persons and the whole environments in which they live. It is no accident that the most commonly asked question in holistic health is “What’s going on in your life?” This question expresses the holistic view that illness is a manifestation of imbalance in the bodymindspirit whole. Here holism accepts to the fullest findings from psychoneuroimmunology and other fields that the immune system, or the process of pregnancy and birth, can be impeded by exhaustion, depression, emotional stress, the loss of a loved one, toxins in the air and the water, the stresses of technocratic life. The corollary of this view, of course, is that a healthy immune system, as well as a healthy pregnancy and birth, can be facilitated by multiple means, from dialogue to dream analysis to dance, from massage to exercise to organic food.

(4) Essential Unity of Practitioner and Client

Many holistic practitioners try to drop the word “patient” in favor of “client,” as this term implies a mutually cooperative, egalitarian relationship.  Where the humanistic model emphasizes the value of a mutually respectful connection between practitioner and client, still essentially separate and distinct beings, the holistic model offers the possibility that they are not separate but are fundamentally one. If the body is an energy field, then as they interact the energy fields of client and practitioner can merge.

(5)  Diagnosis and Healing from the Inside Out

While they may, if appropriate, order “outside-in” diagnostic tests, holistic practitioners will primarily diagnose and treat from the inside out–in other words, they will rely to a significant extent on the knowledge that arises from their own intuition, just as they will trust the inner knowing of their clients. Intuition is defined by the third edition of the American Heritage Dictionary as “the act or faculty of knowing or sensing without the use of rational processes; immediate cognition.” The knowledge on the basis of which decisions are made is defined as “authoritative knowledge “ (Jordan, 1993).  Technomedical practitioners tend to regard textbooks, diagnostic tests, and the advice of experts as authoritative, and to dismiss the still, small voice of intuition. But holistic practitioners (like some humanists) tend to regard intuition as a primary source of authoritative knowledge, along with the books and the machines. Thus, in holistic practice, “diagnosis and healing from the inside out” can refer to the information that arises from deep inside both patient and physician–a phenomenon explained at its core by their essential unity.             Midwives often consider intuition to be a primary source of knowledge about pregnancy and birth, as do all the holistic obstetricians Davis-Floyd has interviewed (Davis-Floyd and Davis, 1997; Davis-Floyd and St. John 1998). Their willingness to rely on intuition comes from their deep understanding of the body as energy and their trust in right-brained, gestaltic kinds of thinking that do not rely on logic but on that sudden flash of insight from which unity and healing can arise.

(6) Individualization of care.

Holistic physicians are trained in technomedicine and have seen the damage standardized hospital policies and hierarchies can do to individuals. In general, they do their best to respond to the individuality and unique needs of each patient within the constraints imposed on them by hospital and legal regulations. For the laboring woman, individualization of care means that standardization does not apply. Her labor is uniquely her own. She eats and drinks and moves about at will. She gives birth in the place of her choice attended by the people and practitioners of her choice. And the practitioner does not respond to the variations in her labor in standardized ways. A midwife dealing with a stalled labor might invite one woman to dance, might ask another if she is afraid to give birth, and might suggest a long walk with a third. Her intuition will guide her to respond to individual circumstances in individual ways. But the focus stays on the birthing woman. It is her unique needs and rhythms that will be paramount in the unfolding of her birth.

The unexpected twists that can result from holism’s high value on both individualization and interconnectedness are suggested in the theory of self-organizing systems (Wheatley 1992), which states that even the smallest event, if it happens in just the right place at just the right time, can dramatically alter the whole system. Holistic healers try not to make assumptions about cause and effect. They tend to expect the unexpected and to be prepared for healing to arise in strange places and mysterious ways. A chance remark can instantly transform a woman’s perception of her condition and become the foundation of a cure. Holistic healers know better than to assume that they are the ones who heal the patient. They know that any one of a myriad of interactions over which they have no control can spark a healing process. Their genius lies in their ability to recognize that tiny flame when it is lit and help it to grow instead of extinguishing it.

(7) Authority and Responsibility Inherent in the Individual

A basic tenet of holistic healing is that ultimately, individuals must take responsibility for their own health and wellbeing.² No one can really heal anyone else; individuals must decide for themselves if they want to be healed, and if so, they must take action to achieve that goal–give up smoking, exercise, eat right, maybe even give up a lucrative job that makes them unhappy or a relationship that is harmful to their health. Holistic practitioners in general tend to see themselves as part of a healing team, of which the patient is a full-fledged, indeed the most significant member. Many of our interviewees repeatedly expressed their frustration with patients who refuse to take responsibility for their own health. They may greet the new client prepared to offer her empowerment, full participation in decision-making, informed choices, and so on, yet the patient may want only to be handed a prescription and told how many pills to take, or to schedule her cesarean between conference calls (Davis-Floyd 1994). Although some of our interviewees refuse to revert to the hierarchical mode and may refer such patients to another MD, most accept and work with the patient’s desire to place the physician in charge, or try  to re-educate patients to take back the authority and responsibility they have surrendered.

 (8) Science and Technology Placed at the Service of the Individual

If the technocratic model of medicine can be snappily characterized as “high tech/low touch,” and the humanistic model as “high tech/high touch,” then it would seem to follow logically that the holistic model of medicine would be “low tech/high touch.” Sometimes this is true, as in the case of hands-on energy, nutritional medicine, herbal therapies—healing modalities for which no technological artifacts are used. But holistic healing can and often does incorporate high technology, from biofeedback machines to lab tests and diagnostic computers. Holistic healers in general do not reject technology; rather, they place it at the service of their clients, instead of allowing the technologies of health care to dominate, intimidate, and lay the ground rules for treatment. Usually these technologies are not invasive, nor do they produce the toxic effects of many of the technologies of conventional medicine. In childbirth, they range from administering oxygen to a laboring woman in need of extra energy, to birth balls that facilitate changes in position, to jacuzzis with overhead ropes to pull on as the woman bears down. Such technologies do not dominate and control; rather, they work with physiology to empower the woman to give birth.

And what of science? As we have seen, physicians are reluctant to change many commonly used procedures even when evidence reveals them to be inappropriate. French physician Michel Odent, a world leader in holistic childbirth, often notes that “science will save us.” He is referring to the emerging trend in Western obstetrics toward evidence-based care. If obstetrical care in most hospitals were to become truly evidence-based, then most standard interventions, including routine IVs, routine use of pitocin, and the lithotomy (flat-on-the-back) position would have to be eliminated; women would eat, drink, and move about freely during labor; and they would give birth in upright sitting or squatting positions (Enkin et al. 2000; Goer 1995, 1999; Rooks 1997).

(9) A Long-Term Focus on Creating and Maintaining Health and Well-Being

Technocratic physicians often express extreme frustration over the patient’s failure to follow doctor’s orders. In contrast, holistic physicians most frequently voice frustration over patients who make no long-term commitment to improving their health but want the doctor to provide them with a quick fix and let them get on with their lives as before. Quick fixes are poor substitutes for long-term lifestyle changes that can maintain good health. Holistic practitioners want their clients to make long-term changes in their diets and lifestyles that will not simply prevent illness but will actively generate good health. Giving up sugar, caffeine, and highly processed foods, taking vitamin supplements, eating nutrient-rich organic vegetables, exercising regularly, and dealing with stress through meditation are examples of the kinds of long-term changes that are often necessary to the creation of wellness. Holistic obstetrical practitioners know that pregnancy is an important time to be making such changes, not only for the health of the baby but also to ensure the long term health of the mother. The problem is of course that many people are resistant to such long-term lifestyle alterations. Holistic practitioners must engage in a great deal of client education, and must maintain a great deal of patience, in order to support people in making this kind of change.

(10) Death as a Step in a Process

Beyond the humanistic view of death as “the final stage of growth” lies the holistic paradigm’s redefinition of death not as any kind of final end but as an essential step in the process of living. This view stems from holists’ definition of the body as an energy field, and from their deep-seated understanding of the transmutable nature of energy. Because of their integrated views on the essential oneness of body, mind, and spirit, it is only at the moment of death that holists grant these a conceptual separation. At death, in this view, the energy of the body decays and returns to earth, while the energy of the spirit or the individual consciousness continues on. Most holists seem to accept some version of Eastern philosophies of reincarnation, a processual view that allows the interpretation of death as an opportunity for continued growth into a new kind of life in spirit and then again in flesh. While this positive view of death does not lead holists to rush to embrace death, it does tend to give them a strong sense of trust in the essential safety of the universe and in the wisdom and worth of its ways.

(11) Healing as the Focus

To say that the holistic model focuses on healing instead of on profit is not to dismiss the role of money and the practitioner’s need to make a livelihood within the system. Holistic practitioners have strong views about money—both for themselves and as part of their professional identity. While they are conscious of the need to earn a living, it follows their personal commitment to work rather than drives it. Few of the holistic physicians I have interviewed practiced within the framework of managed care, for example, where medicine and money are strongly affiliated. Only a few were on staffs of hospitals, where major health expenses are incurred, and virtually none were members of organized medicine (as exemplified by the American Medical Association and its regional counterparts).

Recognizing that healing occurs not in response to their actions but in the support and stimulation of the vital force, in the exchange of energy between individuals, or in the long slow progress toward health that often rewards serious lifestyle changes, holistic doctors are keenly aware of their partnership with patients. Money is part of this exchange. Unlike doctors who practice technomedicine and are apt to live stressful and harried lives wherein they are unable to care for themselves adequately, holistic doctors are tend to find that their own healing often accompanies that of their patients, as it is practically impossible to espouse a holistic philosophy without applying it to oneself. In the mutual appreciation that often arises between holistic doctor and patient, a deep experience of value replaces the focus on money.

(12) Embrace of Multiple Healing Modalities

As we have seen, the holistic paradigm’s definition of the body as an energy field in constant interaction with other energy fields makes possible its embrace of multiple modalities that remain unacceptable to proponents of the technomedical paradigm. The ultimate holistic vision entails a profound revolution in health care. Were this paradigm to gain cultural ascendance, the dominance of the technomedical model would be replaced with the cultural valuation of a multiplicity of approaches. Midwifery, homeopathy, naturopathy, acupuncture, et al. would take their places as respected and legitimate disciplines. Practitioners of each modality would know enough about the others for appropriate referral. Above all, the public would be educated in the techniques of self-care, healthy lifestyle and the appropriate use of a variety of approaches to healing.

Holistic medicine’s embrace of multiple healing modalities is gaining increasing public attention and acceptance. The clearest evidence for this statement comes from a study which determined that one third of Americans sought the services of a non-MD practitioner in a one year time period–and paid out of pocket for three quarters of the cost of these services (Eisenberg at al 1993). Another finding of this survey was that 72 percent of the maverick patients did not tell their doctors about their use of alternative medicine. Perhaps the center stage given to this study reflects the financial impact on medicine it uncovers, as well as the finding that the users of non-conventional therapies were well-educated, middle-income whites, from 25-49 years of age–one of the very best markets for orthodox medicine.

THE TECHNOCRATIC, HUMANISTIC, AND HOLISTIC MODELS OF MEDICINE

The Technocratic Model of Medicine

1. Mind/body separation

2. The body as machine

3. The patient as object

4. Alienation of practitioner from patient

5. Diagnosis and treatment from the outside in (curing disease, repairing dysfunction)

6. Hierarchical organization and standardization of care

7. Authority and responsibility inherent in practitioner, not patient

8. Supervaluation of science and technology

9. Aggressive intervention with emphasis on short?term results

10. Death as defeat

11. A profit?driven system

12. Intolerance of other modalities

Basic underlying principle: separation

Type of thinking: unimodal, left?brained, linear

The Humanistic (Biopychosocial) Model of Medicine:

1. Mind?body connection

2. The body as an organism

3. The patient as relational subject

4. Connection and caring between practitioner and patient

5. Diagnosis and healing from the outside in and from the inside out

6. Balance between the needs of the institution and the individual

7. Information, decision?making, and responsibility shared between patient and

practitioner

8. Science and technology counterbalanced with humanism

9. Focus on disease prevention

10. Death as an acceptable outcome

11. Compassion?driven care

12. Open?mindedness toward other modalities

Basic underlying principles: balance and connection

Type of thinking: bimodal

The Holistic Model of Medicine

1. Oneness of body?mind?spirit

2. The body as an energy system interlinked with other energy systems

3. Healing the whole person in whole?life context

4. Essential unity of practitioner and client

5. Diagnosis and healing from the inside out

6. Networking organizational structure that facilitates individualization of care

7. Authority and responsibility inherent in each individual

8. Science and technology placed at the service of the individual

9. A long?term focus on creating and maintaining health and well?being

10. Death as a step in a process

11 Healing as the focus

12. Embrace of multiple healing modalities

Basic underlying principles: Connection and integration

Type of thinking: Fluid, multimodal, right?brained   

As a society’s medical system mirrors its core values in microcosm, so the evolution of medicine can influence the evolution of the wider culture. We must ask, Who do we want to make ourselves become through the kinds of health care we create? Contemporary obstetrical practitioners have a unique opportunity to weave together elements of each paradigm to create the most effective system of care ever designed on this planet. Information is available about indigenous childbirth practices from many cultures, some of which (such as massage and upright positions for birth) are highly beneficial and should be incorporated.  More information than ever is available from scientific studies that tell us much of what we need to know about the physiology of birth and the kinds of care that truly support women to give birth. And technologies exist to support every kind of labor choice. If we could apply appropriate technologies, in combination with the values of humanism and the spontaneous openness to individuality and energy chartered by holism, we could in fact create the best obstetrical system the world has ever known. This is the challenge we offer to those who attended the Fortaleza conference and to those who wish to continue their work.

Acknowledgements

I wish to express deep appreciation to Dr. Anibal Faundes for his careful, thorough, and sensitive editorial work on this article, and to Gloria St. John, co-author of From Doctor to Healer, for allowing me to adapt some of our mutual work for this article.

Notes

1. Certain portions of this article draw heavily on From Doctor to Healer: The Transformative Journey (Davis-Floyd and St. John 1998) and Birth as an American Rite of Passage (Davis-Floyd 1992). For more information, please see these works; see also Davis-Floyd 1990, 1994; Davis-Floyd and Davis 1997; and <www.davis-floyd.com>.

2. Please note: The notion that authority and responsibility for health inhere in the individual is useful for thinking about the health care of the middle and upper classes. But the poor usually do not have the luxury of choosing their diet, their job, or their lifestyle. Nor can they afford the many options presented by holistic healers, as these are usually not covered by private or government insurance systems. A huge limitation of holistic healing has been its confinement to the wealthier segments of society and its almost total unavailability to the poor. Perhaps the greatest challenge confronting proponents of holism is to make their services available to the poor: it will take a global paradigm shift of epic proportions in order for insurance systems in all countries to reimburse multiple forms of care. But this is the ultimate holistic vision: that allopathic hegemony would be replaced with systems in which all modalities would be equally accessible to all people.

REFERENCES

Castro, Arachu, Angela Heimburger, and Ana Langer, 2001. “Iatrogenic Epidemic: How Health Care Professionals Contribute To The High Proportion Of Cesarean Sections In Mexico.” Unpublished ms.

Davis-Floyd, Robbie E.

1987.   “Obstetric Training as a Rite of Passage.” Medical Anthropology Quarterly 1(3):288-318.

1990. “The Role of American Obstetrics in the Resolution of Cultural  Anomaly.” Social Science and Medicine 31(2):175-189.

1992.  Birth as an American Rite of Passage. Berkeley, Los Angeles, and London: University  of California Press.

1994. “The Technocratic Body: American Childbirth as Cultural Expression.” Social Science and Medicine 38(8):1125-1140. Also available at <www.davis-floyd.com>.

1998. “The Ups, Downs, and Interlinkages of Nurse- and Direct-Entry Midwifery.” In Getting an Education: Paths to Becoming a Midwife, eds. Jan Tritten and Joel Southern, pp. 67-118. Eugene OR: Midwifery Today. Also available at <www.davis-floyd.com>.

Davis-Floyd, Robbie E. and Elizabeth Davis.  1997. “Intuition as Authoritative Knowledge. ” In Childbirth and Authoritative Knowledge: Crosscultural Perspectives, eds. Robbie Davis-Floyd and Carolyn Sargent, pp. 315-349.  Berkeley: University of California Press. Also available at <www.davis-floyd.com>.

Davis-Floyd, Robbie E. and Gloria St. John. 1998. From Doctor to Healer: The Transformative Journey. New Brunswick NJ:Rutgers U. Press.

Davis-Floyd, Robbie E., and Joseph Dumit. 1998. Cyborg Babies: From Techno-Sex to Techno-Tots. New York: Routledge.

Davis-Floyd, Robbie and P. Sven Arvidson. 1997. Intuition–The Inside Story: Interdisciplinary Perspectives. New York: Routledge.

Eisenberg, David M., R.C. Kessler, C. Foster, F.E. Norlock, D.R. Calkins, T.L. Delbanco. 1993. “Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use.” New England Journal of Medicine 328:246-252.

Eisler, Rianne. 1995. Sacred Pleasure: Sex, Myth, and the Politics of the Body.  HarperSanFrancisco.

Enkin, Murray, Marc Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and Justus Hofmeyr. 2000.  A Guide to Effective Care in Pregnancy and Childbirth. 3^rd edition. New York: Oxford University Press.

Friedson, Elliot. 1967. Review Essay:“Health Factories: The New Industrial Sociology,” Social Problems 14(Spring):493-400.

Good, Mary-Jo Delvecchio. 1995. American Medicine: The Quest for Competence. Berkeley: University of California Press.

Good, Byron and Mary-Jo Delvecchio Good. 1993. “’Learning Medicine’: The Construction of Medical Education at Harvard Medical School.” In Knowledge, Power, and Practice: The Anthropology of Medicine and Everyday Life, eds. Shirley Lindenbaum and Margaret Lock, pp. 81-107. Berkeley: U. of California Press.

Goer, Henci.  1995.  Obstetric Myths versus Research Realities.  Westport CT: Bergin and Garvey.

—–1999. The Thinking Woman’s Guide to a Better Birth. New York: Perigree/Penguin.

Harrison, Michelle. 1982. A Woman in Residence. New York: Random House.

Jordan, Brigitte. 1993 [1978])  Birth in Four Cultures: A Cross-Cultural Investigation of Childbirth in Yucatan, Holland, Sweden and the United States, 4th edition, revised and updated by Robbie Davis-Floyd. Prospect Heights, Ill.: Waveland Press.

Kennell, John

1982  “The Physiologic Effects of a Supportive Companion (Doula) During Labor.” In Birth: Interaction and Attachment  ed. Marshall H. Klaus and Martha O. Robertson, pp 92-105. New Jersey: Johnson and Johnson.

Kennell, John, Marshall Klaus, Susan McGrath, Steven Robertson, and Clark Hinckley

1988 “Medical Intervention: The Effect of Social Support During Labor.” Pediatric Research April:211 (Abstract #61).

Klaus, Marshall H., John Kennell, Phyllis Klaus. 1993. Mothering the Mother : How a Doula Can Help You Have a Shorter, Easier, and Healthier Birth. Addison Wesley.

Kleinman, Arthur. 1988. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books.

Kunisch, Judith. 1989. “Electronic Fetal Monitors: Marketing Forces and the Resulting Controversy.” In Healing Technology: Feminist Perspectives, ed. Kathryn Strother Ratcliff, pp. 41-60. Ann Arbor: University of Michigan Press.

Merchant, Carolyn 1983  The Death of Nature: Women, Ecology, and the Scientific Revolution. San Francisco: Harper & Row.

Naisbitt, John. 1980. Megatrends: Ten New Directions Transforming Our lives. New York: Warner Books.

Pert, Candace. 1993. “The Chemical Communicators.” In Healing and the Mind, eds Bill Moyers and Betty Sue Flowers, pp. 177-194. New York: Doubleday.

Pollack, Ron. 1995. “Worthless Promises: Drug Companies Keep Boosting Prices.” Oakland Tribune. July 7.

Potter, Joe C., Elza Berquo, Ignez H. O. Perpetuo MD, Ondina Fachel Leal, Marta Rovery Souza, Maria Celia de Carvalho Formiga, and Kristine L. Hopkins. 2001. “Unwanted Cesarean Sections among Public and Private Patients in Brazil.” Unpublished ms.

Reynolds, Peter C. 1991  Stealing Fire: The Mythology of the Technocracy. Palo Alto, Calif.: Iconic Anthropology Press.

Rooks, Judith. 1997. Midwifery and Childbirth in America. Philadelphia: Temple University Press.

Smith, Robert C. 1996. The Patient’s Story: Integrated Patient-Doctor Interviewing. Boston: Little, Brown and Co.

Sosa, R., J. Kennell, S. Robertson, and J. Urrutia

1980  “The Effect of a Supportive Companion on Perinatal Problems, Length of Labor, and Mother-Infant Interaction.” New EnglandJournal of Medicine 303:597-600.

Spiegel, David.  1993. “Social Support: How Friends, Family, and Groups Can Help.” In Mind-Body Medicine: How To Use Your Mind for Better Health, eds. Daniel Goleman and Joel Gurin, pp. 331-349. Yonkers, New York: Consumer Reports Books.

Spiegel, David, J. R. Bloom, H.C. Kramer, and E. Gottheil, 1989. “Effect of Psychosocial Treatment on Survival of Patients with Metastatic Breast Cancer.” Lancet 2:888-891.

Starhawk. 1989. The Spiral Dance: A Rebirth of the Ancient Religion of the Great Goddess. HarperSanFrancisco.

Tresolini, Carol P. and the Pew-Fetzer Task Force on Advancing Psychosocial Health Education. 1994. Health Professions Education and Relationship-Centered Care. San Francisco CA: Pew Health Professions Commission.

Wagner, Marsden. 1997. “Confessions of a Dissident.” In Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives, eds. Robbie Davis-Floyd and Carolyn Sargent, pp.366-396.  Berkeley: University of California Press.

Wheatley, Margaret. 1992. Leadership and the New Science: Learning about Organization from an Orderly Universe. San Francisco: Berrett-Koehler Publishers.

Wiseman, R. and Marilyn Schlitz. 1996. “Experimenter Effects and the Remote Detection of Staring.” Annual Proceedings of the Parapsychological Convention, San Diego, California.

Zukav, Gary. 2000. Soul Stories. New York: Simon and Shuster.

Author Bio:

Robbie Davis-Floyd, Ph.D, a Research Fellow in the Department of Anthropology, University of Texas (Austin), is an internationally known cultural anthropologist specializing in medical, ritual, and gender studies, and the anthropology of reproduction. She is the author of numerous articles and of Birth as an American Rite of Passage (1992); co-author of From Doctor to Healer: The Transformative Journey and The Power of Ritual (forthcoming), and coeditor of eight collections, including Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives (1997); Cyborg Babies: From Techno-Sex to Techno-Tots (1998); Reconceiving Midwives: The New Canadian Model of Care (forthcoming); and Midwives in Mexico: Continuity, Controversy, and Change (forthcoming). Funded by the Wenner-Gren Foundation for Anthropological Research, she has recently completed a major research project on the development of direct-entry midwifery in the United States, the results of which will appear in Mainstreaming Midwives: The Politics of Change. Her studies of contemporary transformations in Mexican midwifery are ongoing.

Contact information:

Robbie E. Davis-Floyd, Ph.D.

Research Fellow, Dept. of Anthropology, University of Texas at Austin

804 Crystal Creek Drive, Austin, Texas 78746

<davis-floyd@mail.utexas.edu>  <www.davis-floyd.com>

Home and Office: 512-263-2212   Mobile/VoiceMail: 512-426-8969

Robbie Davis-Floyd and Melissa Cheyney

This chapter appears in Childbirth across Cultures: Ideas and Practices of Pregnancy, Childbirth, and the Postpartum , edited by Helaine Selin and Pamela K. Stone, Springer 2009, pp. 1-22.

Once upon a time, there were six little pigs who set out to seek their fortunes in the world (okay, we know that in the original story there were only three, but just bear with us here!). Far away from home they journeyed, until the first little pig spied a peaceful meadow with a stream running through it; there he stopped his hot and weary journey. In two hours he had built himself a house of straw, then he spent another hour building animal traps, after which he set about to laugh and dance and play all day. It was like that every day — he would spend three to five hours hunting wild game, after which he could do as he pleased. The female pigs gathered wild grains, tubers and fruits so that food was available even when the hunt failed. Although the first little pig didn’t always like to admit it, the female pigs brought in 70%-80% of the diet from foraging, and often helped with the hunting and trapping as well. He was feeling very content, for he had wished to find an environment that could sustain him and his small band of kin pigs, and he had. Sure, he and his like-minded friends experienced high infant mortality rates and a resulting life expectancy of around 35 years, as well as high death rates from endemic disease and accidental death. However, as they discussed frequently in their abundant leisure time (in between the long stories they loved to tell), these problems were offset by their varied and nutritious diets and high mobility, which made sanitation and infectious disease transmission non-issues. Life was good and gender relationships egalitarian for the most part

The first little pig and his kith and kin were so successful at their hunting and gathering that after a couple hundred thousand years, they had overpopulated the most fertile areas of the world. Under pressure to feed so many mouths, necessity (the mother of all invention) was combined with the knowledge of plant life cycles developed during the days of gathering to create a new subsistence strategy–horticulture. The second little pig and his matriline began to fell trees and to plant gardens, and for the first time in human history, planted foods to supplement those that were foraged. The work was harder and longer — it took five to six hours a day — but still they had plenty of leisure time for singing, dancing, and storytelling. The females did most of the work anyway, planting, cultivating, harvesting and processing the food they grew, and chopping wood and carrying water, while the males spent their time hunting and performing the rituals that assured them that all was, and would remain, as it should be. They built their houses of sticks because they were still semi-nomadic, moving their villages every five years as garden soil and large game populations were exhausted. This kept life interesting. The diet was highly varied and population densities low enough to keep infectious disease in check, and while the seeds of gender inequality were sown along with the first domesticated plants, for the most part, life was good for the horticultural pigs.

The third little pig was horrified at his brothers’ lack of industriousness. He knew the danger they were in from the big bad wolf, and that silly little houses of straw and sticks stood no chance should the wolf try to huff and puff and blow them down. So he went much farther down the road and through the millennia, away from the wolf’s territory, until he found a nice flat field good for planting, near a large river from which he could divert water for irrigation. He set to work building himself a sturdy house of wood and stone that the wolf could not blow down. It took him weeks of hard labor, working eight to ten hours a day to build the house, and then more weeks to dig the irrigation canals and plant his large field. He knew that his lazy hunter-gatherer and horticulturalist brothers would soon be coming to him for shelter and food, and he, the industrious agriculturalist, planned to be prepared. The third little pig and his friends enjoyed increased population densities as more of them settled down and committed to growing their food. Yes, there was less variability in what they had to eat, and food production was extraordinarily labor intensive, but with the availability of safe weaning foods, female pigs could nurse for shorter periods of time allowing for a return to fertility and shorter interbirth intervals so more little pigs could be born to work the fields and build the communities. Standing water from irrigation ended up being a pesky vector for mosquito-borne diseases like malaria, and sanitation and acute crowd infections became an issue, but agriculturalist pigs could also acquire possessions, own land and rise to the tops of social hierarchies, especially where female pig production and reproduction could be exploited. He was sure that he was much safer from the big bad wolf than his brother pigs who were still living in the forests, the jungles, and the wild fields where danger roamed.[ii] Life was good, although without much leisure, the third little pig didn’t have as much time to enjoy it.

The fourth little pig watched with resentment as intensive agriculture took over the most fertile land, and foraging and small-scale horticulture became marginalized. His desire to roam and explore new lands was the hunting-gathering legacy of wanderlust, and he had no desire to settle down. He gathered up his goat hair tent and began herding animals through agricultural territory, exploiting high hills, low valleys, the wild Northern steppes and the plains of Africa, developing humankind’s fourth subsistence strategy — pastoralism — and enjoying his freedom. Because male pigs tended to own, care for and manage the herds, and because they often had to fight for rights of passage through agricultural lands, pastoral warrior cultures developed that functioned to enhance male pig power. Their domination of herding tended to be reflected in other aspects of social organization – including the near universality of patrilineal decent, patrilocal residence patterns and segregation of the sexes. Life was good for the male chauvinist pigs, but symbolic and social stratification by gender spelled trouble for females, especially where strict honor codes and the exchange of women as chattel challenged girl-pig autonomy.

The fifth little pig, watching the dependence of his brothers and sisters on nature and knowing its dangers, was sure he could improve on matters. Farming could be industrialized, and by moving into cities and building large tenements made of bricks that could sustain huge populations densities, a work force would be available to modify the fruits of agricultural labor into value-added products for sale under a capitalistic economic system. Yes, some exploitation of pig children and recent pig immigrants would be necessary and infectious disease rates would rise, especially where sanitation and food quality was poor, but the fifth little pig could also amass huge stores of material wealth because he owned the means of production. With eventual improvements in sanitation, basic public health interventions and an intentional decrease in family size as children became more expensive to raise,  life expectancy would rise, providing a long lifetime over which to feel the intense need to buy the products produced in factories with innovative technologies and machinery. The fear of the big bad wolf would become a distant memory thanks to habitat destruction and the increasing distance of settlements from unmodified landscapes. Life was good for the fifth little pig and his industrializing friends, especially when they could exploit natural resources and a cheap labor force in the other pigs’ homelands.

The sixth little pig was so far removed from nature that he lost all sense of its value and devoted himself to inventing complex technologies, building gleaming cities of glass and concrete, paving over all things green and putting as many products as possible into elaborate plastic wrappers with widely identifiable logos and branding. He developed a technocratic society[iii] organized around an ideology of progress through the development of high technology and the global flow of information. Beginning just a few decades ago, the forces of globalization, consumerism and neocolonialism transformed even the most remote agriculturalists into dependents in an exploitative, global economy that produces vast inequities between high and low-income nations. The sixth little pig and a few of his elite investor friends benefited, while many others struggled to access even the most basic of resources. Soon environmentalist pigs began to notice that the nature that they had worked so hard to tame through technology was turning on them as industrialization heated the planet, melted the glaciers, and polluted the atmosphere. The sixth little pig started to wonder whether he and his industrialist brother had gone too far. 

And sure enough, as we all know, the big bad wolf (who escaped from a zoo rehabilitation program) did in fact show up, and he huffed, and he puffed, and he blew down the houses of the little pigs, who all came racing over to the house of their technocratic brother, who let them in and slammed the door just in time! In the end, they were safe in the sixth little pig’s McMansion where the big bad wolf could not harm them. But the first five little pigs were unhappy with the eighty-hour work week, lack of medical insurance and rampant consumerism, perceived needs and massive debt that the technocracy had to offer. They were frustrated by the lower status that was culturally assigned to them because of their “uncivilized” pasts. They felt uncomfortable in the air-conditioned home with the zero lot line, and missed the sounds of the wind in the trees. The first five little pigs became medical anthropologists and began to reflect on what had been lost when modernization became the primary goal during the Industrial Era. They realized with regret that the big bad wolf was nothing more than a metaphor for the wild, uncontrollable and chaotic natural world that pigs had been attempting to tame through culture. They didn’t want to give up their cars, computers, and cell phones, but they did wonder…perhaps there was a lesson to be learned from the story of the big bad wolf?

 Folktales often condense millennia of historical events into one short story, and this one is no exception. From the time of our emergence as Homo sapiens, perhaps as long as 195,000 years ago (McDougall, Brown and Fleagle 2005, White et al. 2003), we have lived as hunter-gatherers, picking fruit from trees, foraging wild grains, digging for vegetables, and hunting animals both large and small. The power of our own experiences, “living in the now”, and the effects of socialization that make “normal” simply what we are used to, can obscure the fact that the technocratic society we know and reproduce in today accounts for less than 1% of human history (Table 1). Only 1-2% of our biological make-up has evolved since the ape-human split between five and seven million years ago, meaning that the vast majority of our genes are ancient in origin (Trevathan, Smith and McKenna 2008). There have been a few simple genetic changes since the third little pig and his wife invented agriculture around 10-12,000 years ago,[iv] but the pace of cultural evolution is generally much faster than biological evolution. As a result, humans today occupy 35,000-year-old model bodies that are not particularly well adapted to the technocratic and industrializing cultures many of us live in (Armelagos, Brown, and Turner 2005; Eaton, Eaton III, and Cordain 2002).

Table 1. Human Subsistence Pattern Timeline.

One of the primary contributions of evolutionary approaches in anthropology has been to remind us that Homo sapiens today still live in Paleolithic bodies adapted for the stressors faced by the first little pig. Current diet, lifestyle and reproductive patterns are drastically different from those that produced the selective pressure under which humans and human childbirth evolved. This mismatch in genes and culture promotes, accelerates and fosters certain diseases, especially those associated with changes in diet, reduced exercise levels and excessively interventive and mechanistic approaches to childbirth (Cheyney 2003, 2005; Trevathan, Smith, McKenna 1999, 2008). The notion that discontinuities between the conditions under which humans evolved and the conditions we live in today produce dis-ease is called the “discordance hypothesis”, and it forms the foundation for a relatively new subfield of Medical Anthropology called Evolutionary or Darwinian Medicine. This approach examines health conditions generated by the discordance between evolved biology and current culture and attempts to propose evolutionarily sound solutions or treatments (Stearns, Nesse and Haig 2008; Trevathan, Smith and McKenna 1999, 2008; Williams and Nesse 1991).

In this chapter, we discuss not the diversity in the ways childbirth is treated or culturally elaborated around the world as highlighted in the rest of this volume, but instead, we focus our attentions on the biocultural features that unite Homo sapiens as a species. We review what we see as remarkable similarities in human birth mechanisms and cultural practices over time and argue that, pre-Industrial Revolution, these similarities were an outgrowth of our common evolutionary heritage as bipedal primates. With industrialization, there emerged a fear-based need to control nature that, along with the hegemony of biomedicine, again produced relatively uniform cross-cultural birthing practices, though the latter differ significantly from premodern norms. We examine this shift in the cultural elaboration of birth at the onset of the Industrial Era and discuss three areas where current obstetric approaches can benefit from holistic, cross-cultural and evolutionary perspectives. Our approach is co-evolutionary, meaning that we focus on dual-inheritance, or the identification of relationships between evolutionary biology and culture (Hewlett, De Silvestri, and Guglielmino 2002). We use “biocultural” and “co-evolutionary” throughout to emphasize the interactions between genes, culture, behavior and unequal relationships of power (Goodman and Leatherman 1998) that combine to produce the cross-cultural birthing patterns we see today.

THE BIOCULTURAL EVOLUTION OF MODERN HUMAN CHILDBIRTH

The unique anatomical characteristics of the human pelvis and the complex delivery mechanisms they necessitate have occupied the research agendas of numerous evolutionary biologists (Lovejoy 1988; Rosenberg 1992; Rosenberg and Trevathan 1996; Trevathan 1987, 1988, 1997, 1999; Trevathan and Rosenberg 2000; Washburn 1960) since anthropologist Wilton Krogman (1951) first referred to childbirth as a “scar of human evolution”.  The difficulty of human childbirth relative to other primates (Stoller 1995) is thought to stem primarily from the so-called “obstetrical dilemma” or the conflicting evolutionary pressures on human pelvic shape that necessitate a relatively wide yet flattened pelvis to optimize energetically efficient muscular attachments required for bipedalism (Lovejoy 1988) on the one hand, and an open, rounded and spacious passageway for the birth of relatively large-brained infants on the other.  These competing selective pressures have resulted in an obstetrical compromise that requires the passage of a fetal head that is nearly the same size or larger than the maternal pelvis.  As a consequence, human babies, unlike their primate relatives, must maneuver through a series of complex orientations, called the cardinal movements or mechanisms of labor, as they travel through the changing diameters of the birth canal during delivery (Trevathan 1987, 1988, 1997, 1999; Trevathan and Rosenberg 2000) (Figure 1).  As a result, researchers, with few exceptions (Walrath 2003, 2006), have tended to see human birth as more painful and of longer duration relative to other mammals and to non-human primates, though for healthy mothers and babies, not necessarily more dangerous.

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Figure 1. Mechanisms or cardinal movements of human delivery in occiput anterior presentations (from Trevathan, Smith and Mckenna 1999: 196).  PERMISSION requested from Oxford University Press

The comparatively difficult nature of parturition in our species has led researchers (Rosenberg 1992, 2003; Trevathan 1999) to hypothesize about the effects of our uniquely human obstetrical adaptations on changes in birthing behaviors and cultural norms over time. While non-human primates usually choose to give birth alone and under the cover of night, human mothers almost always seek out assistance from female relatives, friends and/or experienced birth attendants. Biological anthropologist Wenda Trevathan (1997, 1999) reasons that at some point in human history, the benefits of assisted birth would have outweighed the safety of solitary delivery. She finds support for this argument in the cross-cultural observation that very few societies idealize unassisted birth, and in those that do, solitary birth may only be expected of women who have already had one or more babies and/or in mothers with uncomplicated deliveries.[v]

This condition of “obligate midwifery”, or the uniquely human need for an attendant, Trevathan (1997) argues, evolved in response to three important differences between the mechanisms of birth in humans relative to other primates.  First, because human babies almost always emerge facing away from the mother (a position called occiput anterior), it is difficult for the mother to reach down, as non-human primates do, to catch the baby and to clear an airway or remove the umbilical cord from around the infant’s neck (Figure 2). Secondly, modern humans give birth to secondarily altricial[vi]  infants who require extensive care from the time of delivery. The relative helplessness of the human infant may be an additional reason why extra hands at a birth contribute to improved reproductive success, especially where mothers are exhausted by particularly long and difficult labors. Thirdly, Trevathan (1997) notes that powerful maternal emotions around labor and birth, including excitement, anxiety, fear, tension, joy and uncertainty, may have provided the evolutionary impetus for women to seek out support. The emotions of childbirth that encourage us to pursue assistance and companionship may be seen as biocultural adaptations to the physiological complications that result from bipedalism.  Taken together, these three components of human birth may have contributed to the transformation of the process from a solitary to a highly social enterprise, setting humans on a trajectory toward social and cultural interventions in birth (Trevathan 1997).

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Figure 2. Solitary, occiput posterior delivery in nonhuman primates (from Trevathan 1987: 91, Drawings by Bryan McCuller).  Permission requested from Aldine de Gruyter.

THE CULTURAL ELABORATION OF CHILDBIRTH: BIOMEDICAL HEGEMONY AND THE TECHNOCRATIC MODEL

Enter culture… At some point in human history, perhaps around a million years ago with the appearance of large-brained Homo erectus, as Karen Rosenberg (1992, 2003) has proposed, human ancestors began to seek assistance, and in so doing, initiated the transformation of birth from a solitary, biological process to a biocultural and social one. As the chapters in this volume demonstrate, the nuances of each culturally constructed birthing system — the dietary taboos, the ideal direction to face during delivery, the rituals considered necessary for a successful birth, the first words whispered into the ears of newborn babes — are limitless in their variety. However, a broad, historical view makes far more visible what the birthing systems of hunter-gatherers, horticulturalists, pastoralists, and agriculturalists have in common. Up until the Industrial Age just 250 years ago, the essential cultural practices associated with childbirth were relatively uniform. Women all around the world moved freely during labor, changing positions frequently as a method for managing the pain associated with labor contractions and cervical dilation. They ate and drank as they pleased within the cultural confines of what was considered acceptable, nourishing and safe for the mother and baby. They were attended by other women whom they knew well, in a place that was familiar to them — usually in their home or in the home of a female relative. They labored and birthed in upright positions using instinctive knowledge to expand the size of the pelvis, capitalize on gravity, and to maximize the efficiency of the abdominal muscles needed for pushing (Figure 3). They developed artifacts like birthing stools and chairs, threw ropes over beams to pull against, birthed in flexible hammocks, and used poles for support in order to facilitate upright birth. Midwives knelt down in front of the upright mothers to receive their babies. Newborns were kept with their mothers for warmth, and long-term exclusive breastfeeding, co-sleeping, slings and other technologies kept baby and mother close during a year or more of external gestation (McKenna 2003; Montague 1971; Trevathan and McKenna 2003).

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Figure 3. Childbirth woodcut showing an upright birthing position in Europe during the Middle Ages (From When Midwifery Became the Male Physician’s Province: The Sixteenth Century Handbook: The Rose Garden for Pregnant Women and Midwives by Eucharius Rosslin, 1513 (Rosslin and Arons 1994: 31). Book is out of print.

These basic cultural adaptations were normative until the huge social changes associated with industrialization moved birth from home to hospital and fundamentally changed the cultural face of birth, while doing little to reduce mortality and morbidity (Cassidy 2006; Wertz and Wertz [1977] 1989; Wilson 1996). In fact, it was the industrialization of birth, not birth itself, that gave women the fear of birth they have today (Cassidy 2006; Ulrich 1990; Wertz and Wertz 1989; Wilson 1995). Before the widespread acceptance of germ theory, the large, unsanitary lying-in hospitals of industrialized nations produced massive epidemics of puerperal or childbirth fever in the 18^th, 19^th and early 20^th centuries (Crawford 1990; Leavitt 1986; Pollock 1990, 1997). Women died by the thousands in the lying-in hospitals of Europe and the United States until the germ theory of disease became accepted in the late 19^th and early 20^th centuries. As a result, massive precautions were taken in hospitals to prevent or decrease puerperal fever and other infections with a primary focus on attempts at sterilizing, standardizing and managing the birth process. Birthing mothers were painted from breasts to knees with orange iodine, forbidden to touch their own infants, and separated from them after birth, sometimes for days, even though more infections started (and still start) in nurseries than in babies kept with their mothers (Bertini et al. 2006; James et al. 2008; McDonald et al. 2007; Nguyen et al. 2007). Ritualized procedures like enemas and pubic shaving were instituted under the premise that they would prevent infections. It has taken decades of research to show definitively that such practices do not in fact decrease rates of infection; they were implemented because of cultural categories and unfounded beliefs and are still common in developing countries (Cuervo, Rodriguez, and Delgado 2000; Baservi and Lavender 2001; Reveiz, Gaitan, and Cuervo 2007).

Over the last 40 years, the interventions that were introduced into the birthplace during industrialization have multiplied as societies like the United States have embraced high-tech, invasive solutions. As a result, much of our knowledge of unmedicated birth has been lost (Davis-Floyd 2001b). Physicians have been de-skilled and often no longer know how to attend normal deliveries patiently. After all, why learn how to attend a vaginal breech birth when a cesarean is so much easier (for the physician), and often more lucrative, to perform? As birth became more medicalized around the world, in most places, midwives lost their prestige as the guardians and guides at normal deliveries, becoming subordinated to physicians and trained out of traditional practices toward more industrial and technocratic approaches to birth.

Yet a midwifery revival is taking place — as more and more midwives realize what is being lost, they are working to regain their positions as the keepers and researchers of knowledge about physiologic birth, speaking and practicing outside the dominant paradigm, holding open a conceptual space where technocratic birth may be challenged (Cheyney 2008; Davis-Floyd 1992, 1997, 2001a, 2003, 2004; Davis-Floyd and Johnson 2006; Downe 2004). Biomedical hegemony, or the power-laden rule by cultural consent that constructs some models as authoritative (Jordan 1997) and others (like the midwifery models of care) as fringe, retrogressive and uncivilized, means that today, birth looks quite similar all over the world, yet quite different from the kind of births the wives of the first four little pigs would have experienced.

Today, as a result of the transformation of birth during the industrial and technocratic eras, women are not allowed to eat, drink, or walk around during labor. Dressed in hospital gowns and hooked up to intravenous lines that often carry pitocin[vii], prophylactic antibiotics and narcotics for pain, they give birth flat on their backs or in semi-sitting positions. The most notable differences in the contemporary medical treatment of birth have little to do with the specific customs of particular cultures, but instead, are more closely tied to the vast disparities between resource-rich and resource-poor countries. In most high-income nations, women receive significantly more interventions with pharmaceuticals and technologies applied at a higher rate, in more attractive and humane hospital settings. In most low-income nations, women receive less expensive and often outdated interventions like shaving, enemas, and episiotomies without the benefits of expensive interior decorating. In both rich and poor countries, cesarean rates are rising exponentially without a concomitant improvement in maternal and fetal health outcomes (Althabe et al. 2006; Wagner 2006). Cultural differences and traditions have been largely obscured by the highly influential and heavily standardized biomedical hospital procedures now common in almost all industrialized and industrializing nations.[viii] Technology has tamed the big bad wolf, damming, controlling and homogenizing the raw, elemental power of birth. However, the rapidly rising rates of iatrogenic morbidity, and in some places, the rising rates of perinatal and maternal mortality due to excessive obstetrical intervention (Betran et al. 2007, Liu et al. 2007, Villar et al. 2006, 2007) suggest that perhaps we have lost something in the process. What does the big bad wolf still have to teach us?

preModern Birthing Patterns and Why they Matter

Returning to the discordance hypothesis as applied to childbirth and the lens of Evolutionary Medicine, we have identified several areas where the conditions under which human childbirth evolved differ so substantially from the cultural norms enforced under technocratic models of birth that they require closer examination. Cross-cultural midwifery approaches, with their often-explicit rejection of the key components of the technocratic model, combined with their subversive application of time-honored behaviors and premodern traditions, provide an important point of comparison for critically examining contemporary, technocratic practices. The cross-cultural midwifery norms, for example, of encouraging movement in labor, upright pushing positions, the provision of intensive emotional support during labor, along with active encouragement of long-term breastfeeding and co-sleeping adaptive complexes are associated with significantly improved psychosocial and clinical outcomes for both mother and baby (McKenna, Mosko and Richard 1999; McKenna and McDade 2005).

We propose that midwifery and other low-tech, high-touch models of care that attempt to preserve “natural” (read those with a long history in human and non-human primates) birthing practices, produce the positive outcomes documented in so many studies, because they reduce the discordance between evolutionary biology and recent culture. The do this via a mechanism that promotes working with, rather than against, the evolved biological and psychosocial needs of human mothers (Anderson and Murphy 1995; Durand 1992; Fullerton, Navarro, and Young 2007; Janssen, Holt, and Myers 1994; Janssen et al. 2002; Johnson and Daviss 2005; Murphy and Fullerton 1998; Rooks 1997; Schlenzka 1999). A closer examination of the premodern, reclaimed midwifery practices listed above, through the lens of Evolutionary Medicine, provides a clear, evidence-based template for the reform of contemporary, technocratic models of birth.

Unrestrained Movement in Labor Followed by Upright, “Physiologic” Pushing

Freedom of movement in labor used to be a cross-cultural norm, as it is in our closest living primate relatives, and the notion that women should lie in bed with their ability to self-comfort hindered by tubes and devices for fetal monitoring or intravenous fluid delivery is relatively recent and one that makes little sense from an evolutionary perspective (Trevathan 1999). There is a large body of clinical research that documents the value of upright postures and mobility during the first stage of labor (the stage where the cervix dilates) for speeding and easing the complicated descent through the pelvis that is unique to humans (Bodner-Adler et al. 2003; Gupta and Hofmeyr 2004; Gupta and Nikodem 2000). Upright postures maximize the dimensions of the pelvis, while improving blood flow to the baby by preventing compression of the large vessels that run along the mother’s spine, supplying the uterus with oxygenated blood. Women who deliver outside the technocratic model with midwives or holistic physicians tend to labor and push in upright positions in accordance with the physiologic urges that come with an unmedicated second stage (the stage where the baby moves down through the birth canal and is born) (Cheyney 2005; Davis-Floyd et al. 2009). Epidural rates of close to 80% in U.S. hospitals (Declercq et al. 2006), however, prevent most women from utilizing the well-documented benefits of upright labor and pushing positions like squatting that optimize the curve of the human birth canal called the Curve of Carus (Figures 4 and 5).

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Figure 4. Changes in the Curve of Carus with Maternal Positioning (from Sutton and Scott 1996:55). This book is out of print.

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Figure 5. Homebirth mother reclaiming a premodern birthing position, assisted by midwives, assisted by the comforting effects of water made possible by the high-tech, hot tub (Photo by Peter Gonzalez).

Technocratic models of pushing rely instead on a technique called “laboring down,” meaning that epidurally administered medications are stopped or slowed during pushing so that mothers can regain enough sensation to feel and follow the physiologic urge to push. However, because the numbing and temporarily paralyzing effects of spinal or epidural anesthesia take a variable time to recede, women often begin to feel the urge to push and yet cannot move freely to maximize their efforts.  This means that most women who deliver under the technocratic model do so in a semi-sitting position with restricted movement. Many will, of course, still go on to birth vaginally. However, for those women with a tighter fit, the inability to move into more upright pushing positions, as well as the reduced ability to feel the urge to push, may mean the difference between a vaginal and a surgical delivery. Non-physiologic pushing, we argue, partially explains the high rates of cesarean delivery and associated maternal and neonatal morbidity that characterizes modern, technocratic obstetrics (Althabe et al. 2006). [Editor’s note: See the chapter by Travis Harvey and Lila Buckley that suggests that fear of childbirth pain is the prime motivation for cesarean in Chinese women.]

Obligate Midwifery, Continuous Labor Support and the Avoidance of “Intimate Strangers”

The intimacy of time-intensive, continuous labor support provided by birth attendants who are a part of a woman’s community or have come to know her well over the course of her pregnancy may play an additionally decisive role in how human birth unfolds. The calming presence of a familiar midwife or other companion may, for example, help to mitigate levels of stress hormones like cortisol and epinephrine that are known to inhibit the effects of oxytocin — the hormone that stimulates labor contractions (Jolly 1999). The complex evolutionary relationships between hormones produced during fear and/or pain responses and those that stimulate labor combine to produce what have been called the “white coat” and “weekend” effects in humans and in non-human primates, respectively. These effects are characterized by the lessening or complete cessation of labor contractions when women and other primates feel afraid or anxious in response to being observed by doctors (“white coats”) and/or researchers. Where women experience a decrease in labor contractions in response to fear or uncertainty (compensated for in the hospital by the administration of pitocin), non-human primate mothers who live in captivity are often able to delay delivery until their attendants leave the holding facility (hence the “weekend” effect).

The release of adrenaline and cortisol in response to fear and stress, and the consequent slowing of labor, may have served an adaptive function in the past because such mechanisms prevent mammals — humans included — from delivering fragile infants under conditions of predatory danger. However, fears of pain, the hospital, specific procedures (like the placement of an IV catheter), or even just the feeling of self-consciousness that can come with laboring in front of “intimate strangers”, and the contraction-dampening effects of stress hormones are less beneficial in a technocratic environment where delivery must occur according to a relatively rigid time schedule to be considered “normal”. If human childbirth evolved under conditions of obligate midwifery as proposed by Trevathan, and with the underlying assumption that we still occupy Paleolithic bodies, then midwifery and other holistic models of care that focus on trust, building relationships, and reducing maternal stress hormones through intensive emotional and psychosocial support during labor partially explain the excellent outcomes associated with homebirth and other alternative models of care cited above. Current technocratic approaches vastly underestimate the evolved psychosocial and physiological needs of women in labor.

Low Intervention Birth – Long-term Breastfeeding – Co-sleeping Adaptive Complex

The intimacy and connectedness that facilitate human childbirth have also been extended and applied to early parenting behaviors and mother-baby coevolutionary patterns among primates. James McKenna (2003), an evolutionary biologist who focuses on early infant sleeping, breastfeeding and breathing patterns, has examined contemporary Western childrearing practices like solitary sleeping and scheduled nursing from the perspective of evolutionary medicine. His work challenges the basic assumption that solitary sleep should be considered “normal” for human babies, concluding instead that an understanding of evolutionary biology and cross-cultural and cross-species comparisons suggests that there are benefits to parent-infant co-sleeping and long-term, on-demand nursing (McKenna and McDade 2005; McKenna and Mosko 2001). These benefits include the promotion of early bonding, growth and neurological development in the newborn and, perhaps most importantly, the regulation of breathing patterns in altricial infants especially during stages of deeper sleep. Safe co-sleeping and nighttime breastfeeding may also be protective against Sudden Infant Death Syndrome (SIDS) in some contexts. McKenna argues that long-term breastfeeding and parent-infant co-sleeping are part of an adaptive complex for primates that evolved to allow for intensive parental investment, social learning and rapid postnatal brain growth in altricial infants (McKenna, Mosko and Richard 1999).

A growing number of birth and early parenting activists around the world are beginning to question the decline in continuous contact in childrearing that characterized parenting practices until four decades ago, when “plastic babysitter” technologies like monitors, swings, cribs and car seats began to replace continuous physical contact (DeLoache and Gottlieb 200; Hrdy 1999; Small 1999, 2001). Midwives and holistic pediatricians who value the external gestation period described by McKenna (2003) and others (Montague 1971; Trevathan and McKenna 2003) argue that more high-touch, alternative parenting practices often produce babies that are healthier (emotionally and physically) than bottle-fed, solitary-crib-sleeping and stroller-carried infants that are the norm under the technocratic paradigm.

Because we see birthing behaviors as inextricably linked to mother-baby co-evolution and early parenting adaptations like exclusive, on-demand breastfeeding and sensory proximity of mother and baby during sleep, we propose an extension of McKenna’s (2003) breastfeeding-co-sleeping adaptive complex to include low-intervention, physiologic birth as an approach that helps to decrease the discordance between human biology and our technocractic culture. The alertness of unmedicated infants, combined with the evolutionary and premodern cultural norm of keeping the mother-baby-unit intact in the hours immediately following birth, facilitates the cascade of hormonally regulated mother-baby bonding that promotes exclusive and long-term breastfeeding (Ludington-Hoe, Hadeed, and Anderson et al. 1991a, 1991b; McKenna 2003; Odent 2007; Trevathan and McKenna 2003).

***

We have reviewed what we see as remarkable similarities in human birth mechanisms and cultural practices over time and argued that, pre-Industrial Revolution, these similarities were an outgrowth of our common evolutionary heritage as bipedal primates. With industrialization, there emerged a fear-based need to control nature that, along with the hegemony of biomedicine, again produced relatively uniform cross-cultural birthing practices, though the later differ significantly from premodern norms. While we acknowledge the multiple culturally-mediated differences in the ritual treatment of birth, we are also struck by the remarkable similarities in premodern birthing practices in hunting-gathering, horticultural, agricultural, and pastoral societies. These births were characterized by freedom of movement, upright positions, midwives (or female relatives) in attendance, and breastfeeding and co-sleeping during the external gestation period.  Our common evolutionary heritage as bipedal primates and the normal, instinctive physiology of birth were relatively honored in premodern societies.

In striking contrast, birth in the industrial and technocratic eras, while very similar cross-culturally, looks very different from what our the first four little pig mothers would have experienced — women flat on their backs, hooked up to intravenous lines and monitors and cared for by “intimate strangers”. This transformation away from what evolutionary biology might predict increases the discordance between the evolved physiology of human childbirth and contemporary cultural interventions. Using the lens of Evolutionary Medicine, we have identified several areas where premodern birthing and childrearing patterns can provide a corrective to current technocratic approaches that, we argue, do little to honor the Upper Paleolithic bodies we occupy. These areas include:

• structural-and institution-level changes needed to facilitate unrestricted movement in labor
• upright physiologic positions for pushing
• continuous labor support
• increased provider-mother connection through continuity of care
• removal of cultural and protocol constraints that inhibit the honoring of human external gestations through exclusive, long-term, on-demand nursing and technologies like co-sleepers and slings that increases vital, tactile stimulation of our infants.

Evolutionary approaches, while certainly not without limitations in that they carry their own set of contestable presuppositions, are valuable in as far as they provide yet another way of critically examining birth in cultures that supervalue science. We encourage biomedical researchers and clinical practitioners to consider not only the proximate or immediate contexts of an individual woman’s pregnancy, but also the larger, evolutionary history of our species that has shaped our biology and, to some extent, our culture and behaviors. In addition, we advocate a deeper and more explicit acknowledgment of the fact that recent human evolution has not unfolded within a power vacuum. Rather, the influences of industrialism, technocracy, and gendered power inequities have generated a biomedical hegemony that has been perpetrated around the world through both colonialism and the maladaptive imitation of what appears to be “best” because it is modern. Adjusting our critical lens to see birth within the larger and more holistic contexts of cross-cultural and evolutionary perspectives, we can combine the best of what technological innovations have to offer, while also embracing the wild beauty and instinctive power of the big bad wolf in the birthplace (Figure 6).

<<put figure 6 here>>

Figure 6. An untamed, physiologic, midwife-attended birth in Porto Alegre, Brazil, 2007 (Photograph by Ricardo Jones, MD).

Robbie Davis-Floyd

Melissa Cheyney

References

Anderson, R. E., and R. Murphy. “Outcomes of 11,788 Planned Home Births Attended by Certified Nurse Midwives: A Retrospective Descriptive Study.” Journal of Nurse Midwifery 40(1995): 483-492.

Allison, Anthony C. “Protection Afforded by Sickle-Cell Trait Against Malarial Infection.” British Medical Journal 1(1954): 290-294.

Althabe, F., et al. “Cesarean Section Rates and Maternal and Neonatal Mortality.” Birth 33(2006): 270.

Armelagos, G., P. Brown, and B. Turner. “Evolutionary, Historical and Political Economic Perspectives on Health and Disease.” Social Science and Medicine 61.4(2005): 755-765.

Basevi, V., and T. Lavender. “Routine Perineal Shaving on Admission in Labour.” Cochrane Database of Systematic Reviews 1(2001): CD001236.

Beall, Cynthia M., and A. Theodore Steegmann, Jr. “Human Adaptation to Climate: Temperature, Ultraviolet Radiation, and Altitude.” Human Biology: An Evolutionary and Biocultural Perspective. Ed. Sara Stinson, Barry Bogin, Rebecca Huss-Ashmore, and Dennis O’Rourke. New York: Wiley-Liss, Inc. 2000. 163-224.

Bertini, G., P. Nicoletti, F. Scopetti, P. Manoocher, C. Dani and G. Orefici. “Staphylococcus Aureus Epidemic in a Neonatal Nursery: A Strategy of Infection Control.” European Journal of Pediatrics 165.8(2006): 530-5.

Betrán, Ana, Mario Merialdi, Jeremy A. Lauer, Wang Bing-shun, Jane Thomas, Paul Van Look, and Marsden Wagner.“Rates of Caesarean Section: Analysis of Global, Regional and National Estimates.” Pediatric and Perinatal Epidemiology 21(2007): 98-113.

Biesele, B. 1997. “An Ideal of Unassisted Birth: Hunting, Healing, and Transformation among the Kalahari Ju/’hoansi,” Childbirth and Authoritative Knowledge: Cross Cultural Perspectives. Ed. R. Davis-Floyd and C. Sargent. Berkeley: University of California Press. 474-499.

Block, J. Pushed: The Painful Truth about Childbirth and Modern Maternity Care. Cambridge, Massachusetts: DaCapo Lifelong Books, 2007.

Bodner-Alder, B., K. Bodner, O. Kimberger, P. Lozanov, P. Husslein, and K. Mayerhofer. “Women’s Position During Labour: Influence on Maternal and Neonatal Outcome.” Wiener Klinische Wochenschrift 115.19-20(2003): 720-3.

Byford, Julia. Dealing with Death Beginning with Birth: Women’s Health and Childbirth on Misima Island, Papua New Guinea. Ph.D. Dissertation. Canberra: Australian National University, 1999.

Cassidy, Tina. Birth: The Surprising History of How We Are Born. New York: Atlantic Monthly Press, 2006.

Cheyney, Melissa. Darwin and the American Homebirth Movement: Toward an Evolutionary Obstetrics. Paper Presented at the American Anthropological Association Meetings. Chicago, Illinois, 2003.

—. In Transition: A Biocultural Analysis of Homebirth Midwifery in the United States. Unpublished Ph.D. Dissertation. Eugene: University of Oregon, 2005.

—. “Homebirth as Systems-Challenging Praxis: Knowledge, Power and Intimacy in the Birthplace.” Qualitative Health Research 18.2(2008): 254-267.

Crawford, P. “The Construction and Experience of Maternity in Seventeenth-Century England.” Women as Mothers in Pre-industrial England. Ed. V. Fildes. London: Routledge, 1990. 3-38.

Cuervo, L. G., M.N. Rodriguez, and M. B. Delgado. “Enemas during Labor.” Cochrane Database of Systematic Reviews 2(2000): CD000330.

Davis-Floyd, Robbie. Birth as an American Rite of Passage. Berkeley: University of California Press, 1992.

—. “Intuition as Authoritative Knowledge in Midwifery and Homebirth,” Childbirth as Authoritative Knowledge: Cross-Cultural Perspectives. Ed. R. Davis-Floyd and C. Sargent, Berkeley: University of California Press, 1997. 315-349.

—. “The Technocratic, Humanistic, and Holistic Models of Birth.” International Journal of Gynecology and Obstetrics 75.1(2001a): S5-S23.

—. “La Partera Profesional: Articulating Identity and Cultural Space for a New Kind of Midwife in Mexico.” Daughters of Time: The Shifting Identities of Contemporary Midwives, Medical Anthropology. Ed. Robbie Davis-Floyd, Sheila Cosminsky, and Stacy L Pigg. Medical Anthropology special 2 part issue. 20.2-3(2001b): 185-243.

—. “Home Birth Emergencies in the U.S. and Mexico: The Trouble with Transport.” Reproduction Gone Awry, Social Science and Medicine. Ed. Gwynne Jenkins and Marcia Inhorn. 56.9(2003): 1913-1931.

—. Birth as an American Rite of Passage, 2^nd edition. Berkeley and London: University of California Press, 2004.

Davis-Floyd, R., and G. St. John. From Doctor to Healer: The Transformative Journey. New Brunswick, New Jersey: Rutgers University Press, 1998.

Davis-Floyd, R. and C.B. Johnson. Mainstreaming Midwives: The Politics of Change. New York: Routledge, 2006.

Davis-Floyd, Robbie, Lesley Barclay, Betty-Anne Daviss, and Jan Tritten, eds. 2009. Birth Models That Work. Berkeley: University of California Press.

Declerq, Eugene, Carol Sakala, Maureen Corry, and Sandra Appelbaum. Listening to Mothers II: Report of the Second National US Survey of Women’s Childbearing Experiences, Executive Summary. New York: Childbirth Connection, 2006.

DeLoache, Judy, and Alma Gottlieb.. A World of Babies: Imagined Childcare Guides for Seven Societies. Cambridge: Cambridge University Press, 2000.

DeVries, Raymond.. A Pleasing Birth: Midwives and Maternity Care in the Netherlands. Philadelphia: Temple University Press, 2004.

DeVries, R., C. Benoit, E. van Teijlingen, and S. Wrede, eds.. Birth by Design: Pregnancy, Maternity Care and Midwifery in North America and Europe. New York: Routledge, 2001.

Downe, Soo, ed.. Normal Childbirth: Evidence and Debate. Edinburgh: Churchill Livingstone, 2004.

Durand, M.. “The Safety of Home Birth: The Farm Study.” American Journal of Public Health 82.3(1992): 450-453.

Durham, WH.. Coevolution: Genes, Culture, and Human Diversity. Stanford, California: Stanford University Press, 1991.

Eaton, S.B., S.B. Eaton III, and L. Cordain.. “Evolution, diet, and health.” Human Diet: Its Origin and Evolution. Ed. P.S. Ungar and M.F. Teaford. Westport, Connecticut: Bergin and Garvey, 2002. 7-17.

Engelmann, G.. Labor Among Primitive Peoples. New York: AMS Press, [1882] 1977.

Fullerton, J., A. Navarro, and S. Young.. “Outcomes of Planned Home Births: An Integrative Review.” Journal of Midwifery and Women’s Health 52.4(2007): 323-333.

Goer, H., and R. Wheeler.. The Thinking Woman’s Guide to a Better Birth. New York: Pedigree Books, 1999.

Goodman, A., and T. Leatherman.. “Traversing the Chasm between Biology and Culture: An Introduction.” Building a New Biocultural Synthesis: Political-Economic Perspectives on Human Biology. Ed. A. Goodman and T. Leatherman,. Ann Arbor: University of Michigan Press, 1998. 3-42.

Gupta, J., and G. Hofmeyr.. “Position for Women During Second Stage of Labour” Cochrane Database of Systematic Reviews 1(2004): CD002006.

Gupta, J., and C. Nikodem. “Maternal Posture in Labour.” European Journal of Obstetrics, Gynecology, and Reproductive Biology 92.2(2000): 273-7.

Hewlett, Barry S., Annalisa De Silvestri, and C. Rosalba Guglielmino.. “Semes and Genes in Africa.” Current Anthropology 42.2(2002): 313-321.

Hodnett, E., S. Gates, G.J. Hofmeyr, and C. Sakala.. “Continuous Support for Women during Childbirth.” Cochrane Database of Systematic Reviews 3(2005): CD003766.

Hrdy, S. B.. Mother Nature: Maternal Instincts and How They Shape the Human Species. New York: Ballantine Books, 1999.

James, L., et al. “Methicillin-Resistant Staphylococcus Aureus Infections among Healthy Full-Term Newborns.” Archives of Disease in Childhood, Fetal and Neonatal Edition 93.1(2008): F40-4.

Janssen, P., V. Holt, and S. Myers.. “Licensed Midwife-Attended, Out-of-Hospital Births in Washington State: Are They Safe?” Birth 21.3(1994): 141-148.

Janssen, P., S. Lee, E. Ryan, D. Etches, D. Farquharson, D. Peacock, and M. Klein.. “Outcomes of Planned Home Births Versus Planned Hospital Births After Regulation of Midwifery in British Columbia.” Canadian Medical Association Journal 166.3(2002): 315-323.

Johnson, K.C. and B.A. Daviss.. “Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America.” British Medical Journal 330.7505(2005): 1416-1422.

Jolly, A.. Lucy’s Legacy: Sex and Intelligence in Human Evolution. Cambridge, Massachusetts: Harvard University Press, 1999.

Jordan, Brigitte.. “Authoritative Knowledge and Its Construction.” Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives. Ed. Robbie-Davis-Floyd and Carolyn F. Sargent. Berkeley: University of California Press, 1997. 55-79.

Katz, SH.. “Food and Biocultural Evolution: A Model for the Investigation of Modern Nutritional Problems.” Nutritional Anthropology. Ed. FE Johnson, New York: Alan R. Liss, 1987. 41-63.

Klein, M., S. et al.. “Epidural Analgesia Use as a Marker for Physician Approach to Birth: Implication for Maternal and Newborn Outcomes.” Birth 28.4(2001): 243-248.

Konner, M., and M. Shostack.. “Timing and Management of Birth among the !Kung: Biocultural Interaction in Reproductive Adaptation.” Cultural Anthropology 2.1(1987): 11-28.

Krogman, W.. “The Scars of Human Evolution.” Scientific American 185(1951): 54-57.

Kroeger, Mary, and Linda Smith.. The Impact of Birth Practices on Breastfeeding: Protecting the Mother and Baby Continuum. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2004.

Leavitt, J.W.. “Under the Shadow of Maternity: American Women’s Responses to Death and Debility Fears in Nineteenth-Century Childbirth.” Feminist Studies 12.1(1986): 129-154.

Lewin, R., and R. Foley.. Principles of Human Evolution, 2^nd edition. Oxford: Blackwell Publishers, 2004.

Liu, S., R.M. Liston, K.S. Joseph, et al.. Maternal Mortality and Severe Morbidity Associated with Low-Risk Planned Cesarean Delivery Versus Planned Vaginal Delivery at Term. Candaian Medical Association Journal 176(2007): 455-460.

Lovejoy, O. C.. “The Evolution of Human Walking.” Scientific American 259.5 (November 1988): 118, 122–123, 125.

Ludington-Hoe, S., A. Hadeed, and G. Anderson. “Physiologic Responses to Skin-to-Skin Contact in Hospitalized Premature Infants.” Journal of Perinatology 11.1(1991a.): 19-24.

—. “Randomized Trials of Cardiorespiratory, Thermal and State Effects of Kangaroo Care for Preterm Infants.” Paper presented at the biennial meetings of the Society for Research in Child Development. Seattle, Washington, 1991b..

McDonald, J.R., et al.. “Methicillin-Resistant Staphylococcus Aureus Outbreak in an Intensive Care Nursery: Potential for Interinstitutional Spread.” The Pediatric Infectious Disease Journal 26.8(2007): 678-683.

McDougall, Ian, Francis Brown, and John Fleagle.. “Stratigraphic Placement and Age of Modern Humans from Kibish, Ethiopia.” Nature 433(2005): 733-736.

McKenna, J.. “Sudden Infant Death Syndrome in Cross-cultural Perspective: Is Infant-Parent Sleeping Protective?.” The Manner Born: Birth Rites in Cross-cultural Perspective. Ed. L. Dundes. Walnut Creek, California: Altamira Press, 2003. 163-178.

McKenna, J. and T. McDade. 2005. Why Babies Should Never Sleep Alone: A Review of the Cosleeping Controversy in Relationship to SIDS, Bedsharing and Breast Feeding. Paediatric Respiratory Review 6(2): 134-152.

McKenna, J. and S. Mosko. 2001. “Mother-infant co-sleeping: Toward a new scientific beginning.” Sudden Infant Death Syndrome: Problems, Progress and Possibilities. Ed. R.Byerd and H. Krous, 258-272. New York: Arnold.

McKenna, J., S. Mosko and C. Richard.. “Breastfeeding and Mother-Infant Cosleeping in Relation to SIDS Prevention.” Evolutionary Medicine. Ed. W. Trevathan, E.O. Wilson and J. McKenna. New York: Oxford University Press, 1999. 53-74.

Montague, A.. Touching: The Human Significance of Skin. New York: Harper and Row Publishers, 1971.

Murphy, P. and J. Fullerton.. “Outcomes of Intended Home Births in Nurse-Midwifery Practice: A Prospective Descriptive Study.” Obstetrics and Gynecology 92.3(1998): 461-470.

Nguyen, D.M., E. Bancroft, L. Mascola, R. Guerara and L. Yasuda.. “Risk Factors for Neonatal Methicillin-Resistant Staphylococcus Aureus Infection in a Well-Infant Nursery.” Infection Control and Hospital Epidemiology 28.4(2007): 406-11.

Odent, Michel.. Birth and Breastfeeding. Forest Row, East Sussex: Clairview Books, 2007.

Pollock, Linda A.. “Embarking on a Rough Passage: The Experience of Pregnancy in Early-Modern Society.” Women as Mothers in Pre-Industrial England. Ed. V. Fildes. London: Routledge, 1990. 39-67.

—. “Childbearing and Female Bonding in Early Modern England.” Social History 22(1997): 287-306.

Reveiz, L., H. G. Gaitan and L. G. Cuervo.. “Enemas During Labour.” Cochrane Database of Systematic Reviews 4(2007): CD000330.

Rooks, J.. Midwifery and Childbirth in America. Philadelphia: Temple University Press, 1997.

Rosenberg, K.. “The Evolution of Modern Human Childbirth.” American Journal of Physical Anthropology 35(1992): 89-124.

—. “Comments. Response to D. Walrath. 2003. Rethinking Pelvic Typologies and the Human Birth Mechanism.” Current Anthropology  44.1(2003): 5-31.

Rosenberg, K. and W. Trevathan.. “Bipedalism and Human Birth: The Obstetrical Dilemma Revisited.” Evolutionary Anthropology 4(1996): 161-168.

—. “The Evolution of Human Birth.” New Look at Human Evolution.  Special Edition of Scientific American November 2001: 72-77.

Rosslin, E. and W. Arons.. When Midwifery Became the Male Physician’s Province: The Sixteenth Century Handbook: The Rose Garden for Pregnant Women and Midwives. North Carolina: McFarland and Company, 1994.

Schlenzka, P.. Safety of Alternative Approaches to Childbirth. Unpublished Ph.D. Dissertation. Palo Alto, California: Stanford University, 1999.

Shostack, M.. Nisa: The Life and Words of a !Kung Woman. Cambridge, Massachusetts: Harvard University Press, 1981.

Small, Meredith F.. Our Babies, Ourselves: How Biology and Culture Shape the Way We Parent. New York: Anchor Books, 1999.

—. Kids: How Biology and Culture Shape the Way We Can Raise Young Children. New York: Anchor Books, 2001.

Stearns, S., R. Nesse and D. Haig.. “Introducing Evolutionary Thinking for Health and Medicine.” Evolution in Health and Disease. Ed. S. Stearns and J. Koella. Oxford: Oxford University Press, 2008. 1-16.

Stoller, M.. “The Obstetric Pelvis and Mechanism of Labor in Nonhuman Primates.” American Journal of Physical Anthropology 20(1995): 204.

Sutton, J. and P. Scott. Understanding and Teaching Optimal Foetal Positioning. New Zealand: Birth Concepts, 1996.

Trevathan, W.. Human Birth: An Evolutionary Perspective.  New York: Aldine de Gruyter, 1987.

—. “Fetal Emergence Patterns in Evolutionary Perspective.” American Anthropologist 90(1988): 674-681.

—. “An Evolutionary Perspective on Authoritative Knowledge About Birth.” Childbirth and Authoritative Knowledge. Ed. R. Davis-Floyd, and C. Sargent. Berkeley: University of California Press, 1997. 80-90.

—. “Evolutionary Obstetrics.” Evolutionary Medicine. Ed. Trevathan, W., E. O. Smith, and J. McKenna. New York: Oxford University Press, 1999. 183-208.

Trevathan, W. and J. McKenna. “Evolutionary Environments of Human Birth and Infancy: Insights to Apply to Contemporary Life.” Children’s Environments 11(2003 [1994]): 88-104.

Trevathan, W., and K. Rosenberg.. “The Shoulders Follow the Head: Postcranial Constraints on Human Childbirth.” Journal of Human Evolution 39(2000): 583-586.

Trevathan, W., E. O. Smith, and J. McKenna, eds.. Evolutionary Medicine. New York: Oxford University Press, 1999.

—. Evolutionary Medicine and Health: New Perspectives. New York: Oxford University Press, 2008.

Ulrich, Laurel Thatcher.. A Midwife’s Tale. New York: Vintage Books, 1990.

Villar, J., E., et al.. “Caesarean Delivery Rates and Pregnancy Outcomes: The 2005 WHO Global Survey on Maternal and Perinatal Health in Latin America.” The Lancet 367.9525(2006): 1819-1829.

Villar, J., et al.. “Maternal and Neonatal Individual Risks and Benefits Associated with Caesarean Delivery: Multicentre Prospective Study.” British Medical Journal 335.1025(2007): 1-11.

Wagner, M.. Born in the USA: How a Broken Maternity System Must Be Fixed To Put Mothers and Babies First. Berkeley: University of California Press, 2006.

Walrath, D.. “Rethinking Pelvic Typologies and the Human Birth Mechanism.” Current Anthropology 44.1(2003): 5-31.

—. “Gender, Genes, and the Evolution of Human Birth.” Feminist Anthropology: Past Present and Future. Ed. P. Geller and M. Stockett. Philadelphia: University of Pennsylvania Press, 2006.pages?

Washburn, S.. Tools and Human Evolution. Scientific American 203(1960): 3-15.

Wertz, R.W., and D.C. Wertz. Lying-In: A History of Childbirth in America. New York: Free Press, [1977] 1989..

White, T.D., B. Asfaw, D. DeGusta, H. Gilbert, G.D. Richards, G. Suwa, and F.C. Howell.. “Pleistocene Homo sapiens from Middle Awash, Ethiopia.” Nature 423(2003): 742-747.

Williams, G., and R. Nesse. The Dawn of Darwinian Medicine. Quarterly Review of Biology 66(1991): 1-22.

Wilson, Adrian. The Making of Man-Midwifery: Childbirth in England 1660-1770. Cambridge, Massachusetts: Harvard University Press, 1995.

>? ?K  ??=MsoNormal style=’margin-top:4.0pt;margin-right:0in;margin-bottom:4.0pt; margin-left:.3in;text-indent:-.3in’>  1992.  Birth as an American Rite of Passage. Berkeley, Los Angeles, and London: University  of California Press.

1994. “The Technocratic Body: American Childbirth as Cultural Expression.” Social Science and Medicine 38(8):1125-1140. Also available at <www.davis-floyd.com>.

1998. “The Ups, Downs, and Interlinkages of Nurse- and Direct-Entry Midwifery.” In Getting an Education: Paths to Becoming a Midwife, eds. Jan Tritten and Joel Southern, pp. 67-118. Eugene OR: Midwifery Today. Also available at <www.davis-floyd.com>.

Davis-Floyd, Robbie E. and Elizabeth Davis.  1997. “Intuition as Authoritative Knowledge. ” In Childbirth and Authoritative Knowledge: Crosscultural Perspectives, eds. Robbie Davis-Floyd and Carolyn Sargent, pp. 315-349.  Berkeley: University of California Press. Also available at <www.davis-floyd.com>.

Davis-Floyd, Robbie E. and Gloria St. John. 1998. From Doctor to Healer: The Transformative Journey. New Brunswick NJ:Rutgers U. Press.

Davis-Floyd, Robbie E., and Joseph Dumit. 1998. Cyborg Babies: From Techno-Sex to Techno-Tots. New York: Routledge.

Davis-Floyd, Robbie and P. Sven Arvidson. 1997. Intuition–The Inside Story: Interdisciplinary Perspectives. New York: Routledge.

Eisenberg, David M., R.C. Kessler, C. Foster, F.E. Norlock, D.R. Calkins, T.L. Delbanco. 1993. “Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use.” New England Journal of Medicine 328:246-252.

Eisler, Rianne. 1995. Sacred Pleasure: Sex, Myth, and the Politics of the Body.  HarperSanFrancisco.

Enkin, Murray, Marc Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and Justus Hofmeyr. 2000.  A Guide to Effective Care in Pregnancy and Childbirth. 3^rd edition. New York: Oxford University Press.

Friedson, Elliot. 1967. Review Essay:“Health Factories: The New Industrial Sociology,” Social Problems 14(Spring):493-400.

Good, Mary-Jo Delvecchio. 1995. American Medicine: The Quest for Competence. Berkeley: University of California Press.

Good, Byron and Mary-Jo Delvecchio Good. 1993. “’Learning Medicine’: The Construction of Medical Education at Harvard Medical School.” In Knowledge, Power, and Practice: The Anthropology of Medicine and Everyday Life, eds. Shirley Lindenbaum and Margaret Lock, pp. 81-107. Berkeley: U. of California Press.

Goer, Henci.  1995.  Obstetric Myths versus Research Realities.  Westport CT: Bergin and Garvey.

—–1999. The Thinking Woman’s Guide to a Better Birth. New York: Perigree/Penguin.

Harrison, Michelle. 1982. A Woman in Residence. New York: Random House.

Jordan, Brigitte. 1993 [1978])  Birth in Four Cultures: A Cross-Cultural Investigation of Childbirth in Yucatan, Holland, Sweden and the United States, 4th edition, revised and updated by Robbie Davis-Floyd. Prospect Heights, Ill.: Waveland Press.

Kennell, John

1982  “The Physiologic Effects of a Supportive Companion (Doula) During Labor.” In Birth: Interaction and Attachment  ed. Marshall H. Klaus and Martha O. Robertson, pp 92-105. New Jersey: Johnson and Johnson.

Kennell, John, Marshall Klaus, Susan McGrath, Steven Robertson, and Clark Hinckley

1988 “Medical Intervention: The Effect of Social Support During Labor.” Pediatric Research April:211 (Abstract #61).

Klaus, Marshall H., John Kennell, Phyllis Klaus. 1993. Mothering the Mother : How a Doula Can Help You Have a Shorter, Easier, and Healthier Birth. Addison Wesley.

Kleinman, Arthur. 1988. The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books.

Kunisch, Judith. 1989. “Electronic Fetal Monitors: Marketing Forces and the Resulting Controversy.” In Healing Technology: Feminist Perspectives, ed. Kathryn Strother Ratcliff, pp. 41-60. Ann Arbor: University of Michigan Press.

Merchant, Carolyn 1983  The Death of Nature: Women, Ecology, and the Scientific Revolution. San Francisco: Harper & Row.

Naisbitt, John. 1980. Megatrends: Ten New Directions Transforming Our lives. New York: Warner Books.

Pert, Candace. 1993. “The Chemical Communicators.” In Healing and the Mind, eds Bill Moyers and Betty Sue Flowers, pp. 177-194. New York: Doubleday.

Pollack, Ron. 1995. “Worthless Promises: Drug Companies Keep Boosting Prices.” Oakland Tribune. July 7.

Potter, Joe C., Elza Berquo, Ignez H. O. Perpetuo MD, Ondina Fachel Leal, Marta Rovery Souza, Maria Celia de Carvalho Formiga, and Kristine L. Hopkins. 2001. “Unwanted Cesarean Sections among Public and Private Patients in Brazil.” Unpublished ms.

Reynolds, Peter C. 1991  Stealing Fire: The Mythology of the Technocracy. Palo Alto, Calif.: Iconic Anthropology Press.

Rooks, Judith. 1997. Midwifery and Childbirth in America. Philadelphia: Temple University Press.

Smith, Robert C. 1996. The Patient’s Story: Integrated Patient-Doctor Interviewing. Boston: Little, Brown and Co.

Sosa, R., J. Kennell, S. Robertson, and J. Urrutia

1980  “The Effect of a Supportive Companion on Perinatal Problems, Length of Labor, and Mother-Infant Interaction.” New EnglandJournal of Medicine 303:597-600.

Spiegel, David.  1993. “Social Support: How Friends, Family, and Groups Can Help.” In Mind-Body Medicine: How To Use Your Mind for Better Health, eds. Daniel Goleman and Joel Gurin, pp. 331-349. Yonkers, New York: Consumer Reports Books.

Spiegel, David, J. R. Bloom, H.C. Kramer, and E. Gottheil, 1989. “Effect of Psychosocial Treatment on Survival of Patients with Metastatic Breast Cancer.” Lancet 2:888-891.

Starhawk. 1989. The Spiral Dance: A Rebirth of the Ancient Religion of the Great Goddess. HarperSanFrancisco.

Tresolini, Carol P. and the Pew-Fetzer Task Force on Advancing Psychosocial Health Education. 1994. Health Professions Education and Relationship-Centered Care. San Francisco CA: Pew Health Professions Commission.

Wagner, Marsden. 1997. “Confessions of a Dissident.” In Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives, eds. Robbie Davis-Floyd and Carolyn Sargent, pp.366-396.  Berkeley: University of California Press.

Wheatley, Margaret. 1992. Leadership and the New Science: Learning about Organization from an Orderly Universe. San Francisco: Berrett-Koehler Publishers.

Wiseman, R. and Marilyn Schlitz. 1996. “Experimenter Effects and the Remote Detection of Staring.” Annual Proceedings of the Parapsychological Convention, San Diego, California.

Zukav, Gary. 2000. Soul Stories. New York: Simon and Shuster.

Author Bio:

Robbie Davis-Floyd, Ph.D, a Research Fellow in the Department of Anthropology, University of Texas (Austin), is an internationally known cultural anthropologist specializing in medical, ritual, and gender studies, and the anthropology of reproduction. She is the author of numerous articles and of Birth as an American Rite of Passage (1992); co-author of From Doctor to Healer: The Transformative Journey and The Power of Ritual (forthcoming), and coeditor of eight collections, including Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives (1997); Cyborg Babies: From Techno-Sex to Techno-Tots (1998); Reconceiving Midwives: The New Canadian Model of Care (forthcoming); and Midwives in Mexico: Continuity, Controversy, and Change (forthcoming). Funded by the Wenner-Gren Foundation for Anthropological Research, she has recently completed a major research project on the development of direct-entry midwifery in the United States, the results of which will appear in Mainstreaming Midwives: The Politics of Change. Her studies of contemporary transformations in Mexican midwifery are ongoing.

Contact information:

Robbie E. Davis-Floyd, Ph.D.

Research Fellow, Dept. of Anthropology, University of Texas at Austin

804 Crystal Creek Drive, Austin, Texas 78746

<davis-floyd@mail.utexas.edu>  <www.davis-floyd.com>

Home and Office: 512-263-2212   Mobile/VoiceMail: 512-426-8969

Robbie Davis-Floyd

This article was published in Midwifery Today 69 (Spring): 9-13, 2004.

Copyright is held both by Midwifery Today and by Robbie Davis-Floyd.

Both give permission for the replication of this article for educational purposes.

            This special issue of Midwifery Today focuses on midwifery knowledge. The following articles in it will address the specifics of this body of knowledge. But first, it is important to take a broader look at the differences between open and closed knowledge systems. Why? Because any knowledge system whose adherents wish it to remain responsive to changing events in a rapidly changing world must remain open to absorbing new information and adapting itself to that new information. To achieve an open knowledge system, one must first understand what it means for a knowledge system to be “closed.”

How Knowledge Begins

When a baby is gestating in the mother’s womb, neural circuits are being formed in its brain.  This process begins in early pregnancy and continues as the baby grows, until by the time of birth the baby’s developing brain already contains millions of pathways and connections.            Much of the information that flows along these circuits is cultural. As it develops, the baby receives enormous amounts of cultural information from the mother’s activities—when she goes to sleep, when she wakes, how she moves during the day, her speech patterns, her emotions, etc. So we begin to learn before we are born the most basic patterns of the culture we are born into. From then on, the cultural information most easily processed by the baby after birth is information that conforms to the cultural rhythms to which it is already accustomed. Yet the potential always exists in babies and in children for the easy accommodation of entirely new information. In other words, the brains of babies and children are open systems, readily able to create synaptic connections that generate entirely new neural networks that can process entirely new information. That is why it is so easy for the young to learn new languages, for example: their brain structures are so open to absorbing new information that they have no resistance to it.

A neural pathway at high magnification   The development of neural networks in a baby’s brain from birth to age 2

Stage One Thinking/Naïve Realism

If a child grows up in one culture and is exposed for the first twenty or so years of his or her life only to the rhythms, patterns, language, and belief system of that culture, her neural networks will become permanently set in those terms. After that, learning a new language or internalizing the norms and values of a different culture or belief system becomes increasingly difficult over time. Why? Because integrating new information always requires the formation of entirely new neural pathways in the brain. For a child, that process is effortless; for adults whose neural structures are already set, that process requires enormous amounts of time, energy, and concentrated effort to create new bridges across the synaptic gaps between what they already know and what they desire to learn.

Individuals who are never required to “think beyond” the belief systems of the cultures in which they are raised can over time lose the ability to process new information and can become neuro-cognitively rigid in their thinking. More precisely, humans never really lose that ability, but they can become resistant to it, unwilling to put in the time and energy it would take to develop those new neural pathways. Such individuals are subject to what some brain theorists have called Stage One Thinking.¹ For Stage One thinkers, the world is as their culture defines it. There is only one possible set of interpretations of reality, and that set of interpretations IS reality. In other words, theirs is a closed system. Anthropologists call this way of thinking “naïve realism”—the notion that “my way is the only way there is.” Most members of small-scale societies, before their massive exposure to Western culture, were naïve realists. In modern societies, all religious fundamentalists are naïve realists—they are completely convinced and certain that their way of knowing is right and is (or should be) “the only way.”

Stage One Thinking: The Rigid Mind–“Everything in its place”

Across cultures and throughout history, ritual has played a critical role in the creation of Stage One thinkers. Rituals enact a society or group’s core values and beliefs. Through rhythmic repetition and the use of powerful core symbols, ritual constantly works to imprint these core beliefs and the behaviors that accompany them in the minds and bodies of its participants.

Stage Two Thinking/Ethnocentrism

Stage Two thinkers are what anthropologist call “ethnocentric.” Ethnocentrists know that other ways of knowing and believing exist, and may be willing to acknowledge that it’s OK for others to think differently. But they are entirely certain that their way is better. At best, ethnocentric Stage Two thinkers feel pity for everyone else who simply doesn’t understand how much better their way is. At worst, ethnocentrists try to wipe out those who don’t believe as they do, considering the existence of other ways of knowing a threat to their own or an heretical abomination (consider the Crusades, for example). Ethnocentrism, like naïve realism, is a closed system, constantly reinforced by the rituals that enact and sustain that system.

Stage Three Thinking/Cultural Relativism  

In dramatic contrast, Stage Three thinkers are entirely open. They come to a realization at some point in their lives that every culture and religion has created their own story about the nature and structure of reality, and who is to say whose story is right? In anthropological terms, Stage Three thinkers are cultural relativists who come to see every story about reality as relative to every other story. Nobody is “right,” nobody has a lock on truth, so every knowledge system must be understood in terms of its ecological, historical, and political context, and must be respected as legitimate in its own right. This kind of cultural relativism can sound ideal—it entails respect for, appreciation of, and understanding of every story that every culture or religion tells. Such tolerance! No bigotism, no racism, no ethnocentrism, no judgment.

And yet it is not ideal in a global sense. In some cultures, such as those of rural Pakistan, men are entitled to beat their wives every night. In some cultures, torture of political prisoners is normal. In some cultures, like that of the contemporary US, putting millions of people in prison for relatively harmless crimes is the norm. In Western biomedicine, which has spread all over the world, women are routinely abused and harmed in the name of a science which is not science but biomedical belief and tradition. By what standard can cultural relativists say that such culturally accepted behaviors are not OK?

Stage Four Thinking/Global Humanism 

This dilemma posed by cultural relativism has led to an increased global focus on the development of Stage Four thinking, which anthropologists call global humanism. Stage Four/global humanist thinkers recognize the intrinsic integrity and value of every cultural and religious story, yet seek a higher standard that can be applied in every context to ensure the rights of individuals, most particularly the poorer and weaker members of society. No one should be beaten, or raped, or abused. Everyone should have access to clean water and good nutrition and effective health care and good pay for their work. Such things seem desirable goals to global humanists, yet they do not exist in many places. So global humanists seek to think beyond even cultural relativism, seeking universal standards that work for everyone. They want to validate and legitimate every culture while devaluing and discouraging practices that hurt people who do not deserve to be hurt in this higher sense. They are acutely aware that they are on an almost impossible mission, yet one that must be attempted anyway for the good of all. Knowing that totalitarian systems are always harmful, and that no one system can ever really be perfect, they understand that they must keep their knowledge systems open to new information, engaging in bioethical discussion and debate, trying to figure things out without assuming superiority for any one system.

These first two are MC Escher prints representing the fluidity and unknowability of reality. Stage Four thinkers can relate: they recognize reality’s ambiguity and fuzziness, and they know that categories are not solid, things can fade into and out of each other. The world is not black and white but many-colored. Things are not in their places because there is no “place.”

Stage Four thinkers do develop and perform rituals, but such rituals are usually very fluid attempts to express and enact larger, more global values. Since the beliefs of Stage Four thinkers are open to flux and change, the rituals they create tend to constantly change as well, or to be spontaneous enactments of something going on in the moment. Think here of the closing rituals at Midwifery Today conferences, which tend to consist of hand-holding and songs that occur to people to sing in celebration of midwives and women. These are very unlike the rigid, pre-set rituals performed in churches, temples, synagogues, etc. that enact very specific and relatively unchanging sets of beliefs.

The Four Stages of Cognition

The following diagram is my attempt to illustrate the differences between these four stages of cognition. The black circle indicates how for Stage One thinkers (naïve realists), there is only one way of perceiving the world. Stage Two thinkers (ethnocentrists) still come out of one way of thinking, are aware of other ways, may find them threatening, amusing, or interesting, yet consider them essentially irrelevant to real knowledge or truth: “our way is best.” Both Stage One and Stage Two systems are closed. Stage Three thinkers (cultural relativists) are usually raised in one system, yet give credence and legitimacy to all systems and are open to learning more, as indicated by the little lines extending out from the circles. Stage Four thinkers (global humanists) try to weave a hologram out of all systems that has its own internal cohesion in terms of standards of behavior that work for everyone, yet are always open to new ideas and always willing to rethink the holograms they weave to accommodate new information and to broaden the systems of meaning they weave.

The Four Stages of Cognition

Midwives, Midwifery Knowledge, and the Four Stages of Cognition

Stage One/Naïve Realist Midwifery Systems

Many traditional midwives, and some professional midwives, are Stage One thinkers. They are socialized during their midwifery training to one way of thinking and knowing about birth, have no exposure to other ways, and thus have no incentive to “think beyond” what they are sure they know about birth. Such “naïve realist” midwives can practice within their communities, whether traditional or hospital-based, for their lifetimes, without ever questioning their practices and the beliefs that underlie them. Such midwives still exist, yet are rare in the contemporary world, in which it is becoming increasingly difficult to avoid exposure to other ways of thinking and knowing.

Stage Two/Ethnocentric Midwifery Systems

It is far more possible for thousands of contemporary midwives to be ethnocentric rather than naively realistic. Ethnocentric midwifery knowledge and practice systems can be (1) indigenous or (2) biomedical.

(1) Indigenous midwives, if left alone, are most likely to be Stage One thinkers. But most traditional midwives are in some way exposed to biomedicine, which has been massively adopted in developing countries as the most “modern” and progressive system. Unfortunately, this exposure has most often taken the form of TBA training courses, which “train” traditional midwives in biomedical ways of thinking and practicing. These trainings are highly ethnocentric: the biomedical practitioners who do the teaching are usually not interested in what the midwives know or how they practice, but rather in teaching them “the best way,” which in their minds is the biomedical way.

Biomedicine is itself an extremely ethnocentric and relatively closed Stage Two system. Biomedical practitioners are constantly exposed to new information, yet they tend to incorporate only the kinds of new information that fit within their pre-existing knowledge system. Physicians, for example, are socialized into biomedical ways of thinking, knowing, and believing for at least four years of medical school, three years of residency, and often more if they go on into subspecialties. Their neural pathways are established in terms of what I call the technocratic model of medicine. Confronted with information that does not match what they learned during their training—in other words, information that does not flow easily along their pre-established neural pathways—they are most likely to ignore or discount such information. An obstetrician who reads a study comparing epidurals with other types of pain medication can easily process that kind of information, for example, but the same obstetrician presented with multiple studies that demonstrate the benefits of doulas, being in water, massage, and constant changes in position for pain relief will be likely to discount this kind of information. To process it, he would have to be willing to take the time and energy it would require to develop thousands of brand new synaptic connections and neural pathways along which this new information could flow and become integrated into his cognitive system. Most obstetricians can barely keep up with the information that comes across their desks every day that updates them on the latest drugs and technologies (simply amplifying things they already know). Entrenched in a belief system that relies on drugs and technological interventions to manage birth, they see no reason to exert the much greater amounts of energy it would take to assimilate information from outside their technocratic paradigm. This is also true of thousands of professional midwives around the world, who work hard to learn accepted biomedical ways and then are thrust into busy practices. Overworked, overstressed, and often underpaid, they too are unwilling to open their cognitive systems to processing information that contradicts the biomedical approaches they are taught.

The drawing below metaphorically illustrates the multiple possibilities such ethnocentric/Stage Two practitioners have for dealing with new information: it can flow along their established neural pathways and be assimilated (filed in accessible filing cabinets, for example), or it can be thrown down one of those tubes into oblivion, or it could be filed way in the back, where the synaptic connections stop, in a filing cabinet labeled “information I don’t want to process but might be useful sometime.”

Bodily habituation to closed systems. The diagrams I have offered to illustrate my points are of the mind. Yet the most effective and enduring kinds of learning have to do with our bodies. When you sit in a classroom and listen to lectures, or read books, you are learning didactically—through your mind. When you take a blood pressure or insert an IV or do a pelvic exam the same way a thousand times, you are learning with your body. Body knowing is the hardest kind of learning to change because it involves habituation. Becoming physically habituated to doing things the same way all the time means that your learning process becomes ingrained not only in your brain but also in the cells and muscles of your hands and arms, legs and feet, posture and movement. This kind of knowing is out of mental consciousness and thus cannot be overcome by mental exposure to studies that contradict it.

How do you gain confidence that a woman’s labor is under control? You hook her up to the monitor and assume that the information that flows through it is telling you all you need to know. How do you resuscitate a baby in distress? You cut the cord and rush to the table attached to the wall where the equipment you think you need is attached. How do you deal with what you have been taught is prolonged pushing? You cut an episiotomy and perhaps grab the forceps or the vacuum extractor. You don’t have to think about it—your body just moves to do it. Birth is not a good catalyst for change in such cases, as most babies come out alive and relatively healthy most of the time anyway. So the more you do it that way, the more it becomes the only way you can imagine doing it.

It is ironic that science, which was supposed to be the foundation of obstetrics, does not support most standard obstetrical practices. Yet science has been used by obstetricians for 150 years to justify the interventions they invented and then increasingly performed. Science used ethnocentrically for Stage Two biomedical thinkers is a blinder for what is really medical tradition, passed down from teacher to student through apprenticeship/experiential learning.

Stage Three/Cultural Relativist Midwifery Systems

I have no data at all to support this assertion, but it seems to me that very few midwives in the contemporary world are true cultural relativists. Midwives deal with life and death, and know that their decisions can result in either one. Stage One midwives make decisions based on the only knowledge they have; Stage Two midwives make decisions based on the knowledge they are sure is best. But of thousands of midwives I have talked with, I can’t think of who bases her decisions on no standards at all. Postpartum hemorrhages must be stopped if at all possible. Babies in transverse lie cannot be born unless the midwife does something. Stage One and Stage Two midwives will deal with such complications as their belief systems dictate. But midwives with open minds and systems fluid enough to encompass multiple cultural realities will not be content to approach such complications in whatever way the culture of the woman they are attending would dictate. If they know a way that is scientifically proven to have better efficacy than a traditional way (whether traditional in a biomedical or an indigenous sense), they will apply it. The decisions they make in life-crisis situations are not based on a “whatever the culture says” attitude, but rather on a “whatever works” attitude. And what midwives with open cognitive systems know about what works will constantly change as they are exposed to new information, whether it comes from science, from traditional midwifery, or from a workshop they just attended the day before.

Stage Four/Gobal Humanist Midwifery Systems

In today’s rapidly changing and highly fluid world, to be truly effective, midwives must remain constantly open to the new information that is constantly emerging from science and from the increasingly availability of midwifery knowledge from multiple systems—allopathic, indigenous, traditional, biomedical, alternative or complementary, etc. Sometimes the best option for a birth complication might be a homeopathic remedy, sometimes it might be a position used by traditional midwives, sometimes it might be a cesarean section. The Stage Four midwife will keep her system open to new learning from many sources. And she will seek the highest moral and ethical standards, which involve giving compassionate, woman-centered care responsive to the needs of the individual regardless of what the system dictates.

Why Many Midwives Do Not Give Stage Four/Globally Humanistic Care

Cognitive openness and humanistic standards are not easy to maintain, especially in a busy and stressful practice. Even those Stage Four midwives who want to remain open to new learning and new ways of thinking find that the more stress they are under, the less able and willing they are to process new information. Often they simply don’t have the energy or the time. Persistent stress can reduce even highly fluid, Stage Four thinkers to Stage Two or Stage One levels by causing cognitive overload and the development of “tunnel vision”–the need to shut out most stimuli and focus on one thing only. In other words, stress can make fluid thinkers become rigid, if only for a while. How often have you thought, on an especially stressful day, “just don’t tell me one more thing”? Usually rest will restore Stage Four thinkers to their normal fluid state. But if the stress continues for too long or becomes too intense, anyone can disintegrate into Substage–a condition of hysteria, panic, or even full-fledged nervous breakdown (also known as “losing it”).

Performing rituals can stabilize individuals under stress at Stage One, thereby preventing them from degenerating into Substage. (When the airplane falters, you start to pray. When the crops fail, you make offerings to the gods. When labor slows, you administer pitocin and hook up the monitor.) Stage One rituals can generate a sense that everything is under control (even if it isn’t). Practitioners facing what they see as constant potential crises in childbirth use such Stage One rituals preventatively, so that things always feel or seem to be under control.

Let’s take a quick look at what women studied by anthropologists all over the world have said about professional midwives working under high levels of stress in Third World countries:

• “They shave you.”
• “They cut you.”
• “They leave you alone.”
• “They don’t let your family members in to be with you.”
• “They yell at you and sometimes, they slap you.”

Perhaps most midwives who practice in these ways at first approached midwifery with high ideals of serving women, just as most obstetricians do. But if you are practicing in a rural clinic in Papua New Guinea or a huge hospital in India, where supplies are limited or non-existent, there are more women than you can possibly care for, there is often no running water and little or no food available for the women, you are treated as inferior by physicians and nastily by nurses who resent your authority, and you are paid so little you can barely support your family, it is most likely that your ideals will fade away in face of unbearable realities. You will shut down cognitively and focus on finding any bits of pleasure or relaxation you can—in other words, you will take every opportunity to drink coffee with your colleagues and ignore the women screaming for your help in the next room. Such are the effects of stress, overwork, underpay, and professional devaluation. Many anthropologists have noted that midwives new to work in such places are often initially horrified by the behavior of their elders and work harder to support and care for the women, yet a few months or years later, will be behaving exactly like the colleagues they initially abhorred.²

What about midwives in the developed world, where technology, supplies, clean water, and food, are readily available, the pay is reasonable, and schedules offer time off to be with one’s family? Indeed, it is this kind of midwife who is most likely to care about moving beyond rigid knowledge systems to create a more open, fluid, and individually responsive style of midwifery care. And yet even First World professional midwives are likely to succumb to the pressures of biomedical socialization and habituation to certain routines, to practice defensively to avoid accusations of malpractice, to conform to institutional systems rather than take the time and energy to fight them.

For one example, in the UK 70,000 professional midwives attend 70% of births. To American professional midwives, this situation seems ideal. Yet the Stage Four midwifery thinkers in the UK note sadly that most of those 70,000 midwives have become the source of, not the solution to, the problem. Habituated to hospital birth and biomedical routines, most British midwives have fought rather than welcomed the British government’s mandate for more home births. Mavis Kirkham and others have documented how such midwives move among their patients giving vague information, refusing to answer specific questions, offering little or no one-on-one support, and dealing with patient requests by answering “Sister wouldn’t like it”—“Sister” meaning the starched and unbending head midwife who runs her clinic more like a business than a support service.

How Midwives Can Foster Stage Four Thinking for Themselves and Other Midwives

(1) Attendance at midwifery conferences. When a midwife goes away to a conference, she is free from the daily pressures of her practice to take in new information. She is exposed to ways of thinking, knowing, and practicing that may not match her own. The midwives in the developed world who tend to become rigid in their practices rarely attend such conferences; they are the ones who most need to attend.

Over the past twelve years, I have attended hundreds of midwifery conferences, and have watched how midwives “get their juice” through being there. Midwifery Today conferences are particularly salient in developing and maintaining Stage Four thinking, as their organizer, Jan Tritten, makes every effort to include all types of midwives—professional, traditional, nurse-, direct-entry—on her programs so that every Midwifery Today conference provides opportunities for midwives to be exposed to the ways other midwives think and know. MANA and ACNM also provide many such opportunities—their conferences include workshops that range from the highly technical to the highly holistic. Particularly exciting are conferences held in countries where midwives are beginning to move outside their normative practices, such as the home birth conferences recently held in Spain. ICM conventions bring together professional midwives from all over the world, and every time slot on the program offers at least a dozen sessions appealing to every possible midwifery knowledge, skill, special interest, or cultural approach. Small-scale regional midwifery conferences allow midwives living in relatively close proximity to share common interests and expand their knowledge bases about their own history and political situations.

Every midwifery conference I have ever attended has offered its participants many ways to “think beyond” established paradigms and practices; thus I encourage every practicing and student midwife to attend as many such conferences as she practically can.

(2) Learning from women. Midwives who practice the same way for many years are usually midwives who have stopped listening to mothers. Every woman a midwife attends can bring something new to her knowledge and practice. I have interviewed hundreds of midwives about their education and practice, and have often been struck by the changes in practice that can result from listening carefully to and learning from just one woman, who perhaps is unusual but who can teach the midwife herself something new about how best to provide woman-centered care.

(3) Learning from midwives. Midwives have lots of stories to tell, and they tend to be excellent story-tellers. When midwives get together and tell stories, they are not just engaging in chit-chat, but are sharing important aspects of what they learn and how they learn it, of what they know and how they use that knowledge, whether it is didactically obtained or intuited in the moment. When obstetricians get together and discuss birth, the stories they tell are usually stories of pathologies that they find intrinsically interesting because of the puzzles they present, or crises in which they saved or failed to save a life. In dramatic contrast, midwives tend to prefer to tell stories of normal birth, or of how they helped a birth that could have become pathological stay normal (a process I call “normalizing uniqueness”). So much  midwifery lore and knowledge is encoded in these stories: listen to them, record them, write books and articles full of them so that others can learn what your stories have to teach!

[Note to editor: This paragraph could be cut if necessary] It is fascinating to me that the earliest midwives to write down midwifery knowledge, like Sarah Stone in Britain in 1737, were not able or did not think to abstract what they knew into categories like “how to handle a post-partum hemorrhage.” Rather, they told the stories of the births they attended. The first British midwife to write abstractly about midwifery knowledge, Elizabeth Nihell in 1760, had been taught and heavily influenced by William Smellie, one of the early male midwives.³ That is one reason why Ina May Gaskin’s Spiritual Midwifery has been so important and influential for so many midwives around the world: she told stories, and in the telling one can see how her knowledge developed through her individual experiences with the women she attended.⁴ Her second book, Ina May’s Guide to Childbirth, offers many stories written by the couples she attended.⁵ Into these stories, Ina May interjects in her own words the points at which she had a flash of intuition or a “hunch” that such-and-such might be a good thing to do, and tried it out. The stories allow us to witness her learning process in action and observe how her Stage Four thinking abilities kept her open to learning directly from women and from her own intuition, experientially, in the moment.

(4) Attention to the scientific evidence. The body of scientific evidence supporting many traditional and professional midwifery practices is ever-growing. Every midwife should keep up with it, as so much of it reinforces what has become internationally known as “the midwifery model of care.” Real science is differs fundamentally from biomedical tradition. Every Stage Four midwife should have science at her command, all references ready to counteract every biomedical objection to the kind of care she wishes to give.

(5) Attention to other healing philosophies and modalities. Naturopathy, chiropractic, homeopathy, Reiki, breath therapy, massage therapy, pre- and perinatal psychology, Ayurveda, Chinese medicine, and many other types of “complementary” health care, as well as many indigenous knowledge systems, have much to offer the contemporary professional midwife. It is not possible for every midwife to know all of these systems, but it is possible to be open to what they can offer by learning about them, incorporating one or some of them, and finding practitioners to whom clients can be referred.

Conclusion

Around the world, midwives are under siege as the power and influence of biomedicine grows. Traditional midwives are in danger of extinction and professional midwives are too often ethnocentric servants to biomedical ways of knowing and practicing. Yet in every country, there are dozens and sometimes thousands of midwives, both traditional and professional, who are Stage Four global humanists striving to think beyond established paradigms and practices. Such midwives are constantly working to combine the best of indigenous, allopathic, and alternative knowledge systems to create fluid and open midwifery knowledge systems responsive to women’s needs and desires, to ideas and information from other midwives and health care workers, to scientific evidence, and to “whatever works” from wherever it can be learned. If you are a midwife practicing in the 21^st century, you have two brand new advantages that your historical counterparts did not have: (1) access to information from a rich variety of sources; and (2) strength in local, national, and international organization. I ask you to utilize these strengths, acknowledge your limitations (remember that stress can take you “down” both physically and cognitively), and strive to keep your knowledge systems open to the learning that this new world can multiply provide.

Endnotes

1. The “four stages of cognition” schema I present here can be found in Schroder, H. M., M. Driver, and S. Streufert, Human Information Processing (New York: Holt, Rinehart, and Winston), 1967. The combination of this theory with the anthropological concepts of naïve realism, ethnocentrism, cultural relativism, and global humanism is entirely my own. Further discussion of this combination can be found in Davis-Floyd, Robbie and Gloria St. John, From Doctor to Healer: The Transformative Journey, New Brunswick NJ: Rutgers University Press, 1998 and Davis-Floyd, Robbie and Charles Laughlin, The Anatomy of Ritual (New York: Random House/Schocken), n.d. (forthcoming).

2. The anthropological studies I draw on are too many to be listed here. Partial references can be found in Davis-Floyd, Robbie, “Mutual Accommodation or Biomedical Hegemony,” Midwifery Today, March 2000, pp 12-17, 68-9. Full references to and descriptions of many of these works can be found in Davis-Floyd, Robbie, Sheila Cosminsky, and Stacy Leigh Pigg, “Introduction” to Daughters of Time: The Shifting Identities of Contemporary Midwives” (a special triple issue of Medical Anthropology 20:2-3/4, 2001). This Introduction is also available at www.davis-floyd.com

­ 3. Stone, Sarah, A Complete Practice of Midwifery, Consisting of Upwards of Forty Cases or Observations in That Valuable Art, London: printed for T. Cooper, 1737; Nihell, Elizabeth, A Treatise on the Art of Midwifery. Setting Forth Various Abuses therein, especially as to the Practice with Instruments: The Whole Serving to put all Rational Inquiries in a fair Way of very safely forming their own Judgement upon the Question; Which it is best to employ, In Cases of Pregnancy and Lying-In, a Man-Midwive, or, a Midwife, London: A. Morley, 1760. Stone and Nihell’s works are described and compared by Herrle-Fanning in Body Talk: Rhetoric, Technology, Reproduction, edited by Mary M. Lay, Laura J. Gurak, Clare Gravon, and Cynthia Myntti. Madison: University of Wisconsin Press, 2000.

4. Gaskin, Ina May, Spiritual Midwifery. Summertown, Tennessee: The Book Publishing Company, 1977.

5. Gaskin, Ina May, Ina May’s Guide to Childbirth. New York: Bantam, 2003.

Author Bio

Robbie Davis-Floyd, PhD, a cultural/medical anthropologist specializing in the anthropology of reproduction, is Senior Research Fellow in the Dept. of Anthropology, University of Texas Austin. An international speaker, she is author of over 80 articles and of Birth as an American Rite of Passage (1992); coauthor of From Doctor to Healer: The Transformative Journey (1998), and The Anatomy of Ritual (forthcoming); and coeditor of eight collections, including Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives (1997); Cyborg Babies: From Techno-Sex to Techno-Tots (1998); and Mainstreaming Midwives: The Politics of Change (2005). Her research on global trends and transformations in health care, childbirth, obstetrics, and midwifery is ongoing. She can be reached via email at davis-floyd@mail.utexas.edu. Her website, which contains most of her published articles and descriptions of her books, is www.davis-floyd.com.

The Trouble with Transport

Robbie Davis-Floyd Ph.D.

This article appears in a special issue of Social Science and Medicine, called Reproduction Gone Awry,

edited by Marcia Inhorn and Gwynne Jenkins, Vol. 56, No. 9, 2003, pp. 1913-1931.

Abstract: Proponents of the global Safe Motherhood Initiative stress that primary keys to safe home birth include transport to the hospital in cases of need and effective care on arrival. In this article, which is based on interviews with American direct-entry midwives and Mexican traditional midwives, I examine what happens when transport occurs, how the outcomes of prior transports affect future decision-making, and how the lessons derived from the transport experiences of birthing women and midwives in the U.S.and Mexicocould be translated into improvements in maternity care. My focus is on home birth in urban areas in Mexicoand the US. In both countries, biomedicine and home-birth midwifery exist in separate cultural domains and are based on distinctively different knowledge systems. When a midwife transports a client to the hospital, she brings specific prior knowledge that can be vital to the mother’s successful treatment by the hospital system. But the culture of biomedicine in general tends not to understand or recognize as valid the knowledge of midwifery. The tensions and dysfunctions that often result are displayed in midwives’ transport stories, which I identify as a narrative genre and analyze to show how reproduction can go unnecessarily awry when domains of knowledge conflict and existing power structures ensure that only one kind of knowledge counts. This article describes: (1) dis-articulations that occur when there is no correspondence of information or action between the midwife and the hospital staff; and (2) fractured articulations of biomedical and midwifery knowledge systems that result from partial and incomplete correspondences; contrasts these two kinds of disjuncture with the smooth articulation of systems that results when mutual accommodation characterizes the interactions between midwife and medical personnel; and links these American and Mexican transport stories to their international context, describing how they index crosscultural markers, and suggest solutions, for “the trouble with transport.”

Key Words: Childbirth, home birth, midwives, hospital, transport, US,Mexico

Introduction

In Mexico, home birth, while diminishing in frequency, still exists as a vital tradition and viable cultural option for many women; in the US, it was almost obliterated by the 1950s but in recent decades has formed the focus of a social movement of midwives, mothers, and childbirth activists dedicated to maintaining home birth as a viable option. As proponents of the global Safe Motherhood Initiative have long stressed, in both the developing world where home birth is often a necessity, and the developed world where it is a choice, primary keys to safe home birth include transport to the hospital in cases of need and effective care on arrival (Fullerton, 2000). In this article, I examine what happens when transport occurs, how the outcomes of prior transports affect future decision-making, and how the lessons derived from the transport experiences of birthing women and midwives in theU.S. andMexico could be translated into improvements in maternity care. Two aspects are critical to the viability of transport: (1) Can the mother get there? In other words, is there a hospital within reach and can a vehicle be found? (2) What happens when she arrives? The first, availability of transport, is a major issue in ruralMexico and elsewhere in the developing world and deserves separate and thorough attention. Here my focus is on home birth in urban areas in Mexico and the US, where the trouble with transport is not its lack but rather what happens when transport places the mother who had planned to give birth at home, and the midwife attending her, in interaction with biomedical personnel.

In both countries, biomedicine and home-birth midwifery exist in separate cultural domains and are based on overlapping but distinctively different knowledge systems. When a home-birth midwife arrives in the hospital with her client, she brings with her the general ways of knowing and style of practice that characterize her cultural domain, and her specific prior knowledge about the woman’s overall health, personality, desires, and labor process. This knowledge can be vital to the mother’s successful treatment by the hospital system. But the culture of biomedicine in general tends not to understand or recognize as valid the knowledge of midwifery. Thus in the hospital, the midwife may have no authoritative status. Yet she must interface with medical personnel if she is to communicate information the hospital staff may need to provide appropriate and effective care for her client. Smooth articulation of the medical and midwifery knowledge systems facilitates the safest transition for the woman and her baby, but all too often, disjuncture and dis-articulation occur. The tensions and dysfunctions that result are displayed in midwives’ transport stories, which I here identify as a narrative genre. In this article, I will seek to unpack these stories for the collision of worlds they encapsulate and the points of fracture and permeability in the crusts of those worlds that they reveal.

I will focus specifically on the transport stories told by two groups of midwives with whom I have conducted extensive interviews: American direct-entry (non-nurse) midwives who attend home births, and a small group of traditional Mexican midwives who practice in and around the large urban city of Cuernavacain the state of Morelos, just south of Mexico City. After describing these two groups of midwives and the national contexts within which they learn and practice, I will narrate some of their stories, analyzing them as cultural terrains that reveal how reproduction can go unnecessarily awry when domains of knowledge conflict and existing power structures ensure that only one kind of knowledge counts. I will describe such encounters as (1) dis-articulations that occur when there is no correspondence of information or action between the midwife and the hospital staff; and (2) fractured articulations of biomedical and midwifery knowledge systems that result from partial and incomplete correspondences. I will contrast these two kinds of disjuncture with the smooth articulation of systems that results when “mutual accommodation” (Jordan, 1993) characterizes the interactions between midwife and medical personnel. In the Conclusion, I will link these American and Mexican transport stories to their international context, describing how they index some of the crosscultural markers for “the trouble with transport.”

Articulation and Authoritative Knowledge: Biopower Meets the Home-Birth Midwife

ar.ti.cu.late vt. (1) to put together by joints; (2) to arrange in connected sequence, fit together, correlate. vi. to be jointed or connected. n. a joint in a stem or between two separable parts, as a branch and leaf [or] a node or space between two nodes

–Webster’s New World Dictionary, 2000

My use of the term articulation at various points in this article comes from Gramsci through Lawrence Grossberg. In We Gotta Get Outa This Place: Popular Conservatism and Postmodern Culture (1992, p. 54), Grossberg notes that the concept of articulation “provides a useful starting place for describing the process of forging connections between practices and effects.” His starting place will be my ending place, as most of the stories I recount below illustrate connections that could potentially have been forged but instead were either never made or only partially constituted. These disjunctures in what could have been functional, smoothly bending joints stem from the dominance of biomedicine—a hierarchical system that has sought, in general, not to articulate with home-birth midwifery but rather to eliminate it through discounting its practices and knowledge base. In Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives, Brigitte Jordan (1997, p. 56) noted that

for any particular domain several knowledge systems exist, some of which, by consensus, come to carry more weight than others, either because they explain the state of the world better for the purposes at hand (efficacy) or because they are associated with a stronger power base (structural superiority), and usually both. In many situations, equally legitimate parallel knowledge systems exist and people move easily between them, using them sequentially or in parallel fashion for particular purposes. But frequently, one kind of knowledge gains ascendance and legitimacy. A consequence of the legitimation of one kind of knowing as authoritative is the devaluation, often the dismissal of all other kinds of knowing.

Jordanmaps out what happens when one kind of knowing does gain ascendancy, thus opening up the possibility of asking what happens when an ascendant knowledge system and a devalued one must interface. Why do adherents of a dominant knowledge system sometimes dismiss what adherents of a devalued system have to say, sometimes give them partial credence, and other times honor them, act promptly on their recommendations, and include them in the process? The stories I analyze below illustrate all of these possible scenarios.

In the process of describing how Western biomedicine gained its cultural ascendancy, Michel Foucault identified the cultural authority it carries as a form of “biopower,” which he defined as “disciplines of the body,” used as “numerous and diverse techniques for achieving the subjugation of bodies and the control of populations” (1978, p. 140). This subjugation and control include the biomedicalization of bodily processes like childbirth and the development of institutions within which such processes are supposed to take place, along with formalized structures for managing them.Jordanaugments Foucault’s notion of biopower with her focus on the status of particular knowledge systems:

It is important to realize that to identify a body of knowledge as authoritative speaks, for us as analysts, in no way to the correctness of that knowledge. Rather, the label “authoritative” is intended to draw attention to its status within a particular social group and to the work it does in maintaining the group’s definition of morality and rationality. The power of authoritative knowledge is not that it is correct but that it counts. (Jordan, 1997, p. 57)

Although the midwives in the US and Mexico whom I have studied treat their own knowledge system as authoritative in the home context, they are acutely conscious of the larger and higher authority carried by biomedicine not only inside the hospital but also in the culture at large. As we will see, much of the time these midwives do not accept biomedical knowledge as truth or fact; many of their practices and much of their midwifery knowledge system constitute a radical critique of obstetrics, challenging its claims to the authority of fact and truth. But these midwives also understand that in the hospital as in the wider culture, including in courts of law, their radical critique goes largely unheard and their ways of knowing do not count. Faced with this formalized system of biopower that discounts their individualized approach to maternity care, during transport midwives nevertheless often seek to communicate what they know, in the interests of securing the care for which they brought the woman to the hospital, which they deem to be necessary for their client’s safety and well-being. So as they enter the hospital, they extend into that system what I will identify as fingers of articulation in an effort to generate a productive interface. The following detailed examination of midwives’ transport stories intends to illuminate what happens along a spectrum of possibilities from dis- to smooth articulation, from the dismissal of these outreaching fingers to their clasping by a biomedical hand. Through examining this spectrum of articulations between knowledge systems, I hope to augmentJordan’s explanations of what happens when one system of knowledge discounts another with a more nuanced consideration of how, in specific situations, the dominant system can come to take the subaltern system into partial or fully accommodative account.

Methodology

 Articulation is a continuous struggle to reposition practices wihtin a shifting field of forces.

–Lawrence Grossberg (1992, p. 54)

This article is based on my continuing research on American midwives (begun in 1995) and in Mexico (begun in 1997). The focus of this research is midwifery politics in relation to the process of professionalization that American direct-entry midwives (Davis-Floyd, 1998b, 2002a, 2003), Mexican professional midwives (Davis-Floyd, 2001a), and a small and unique group of Mexican traditional midwives (Davis-Floyd, 2001b) are undergoing.¹ This research did not specifically focus on transport stories as a genre or on transport as a salient issue. But during its course (which involved hours of formal interviewing and even more hours of “hanging out” with midwives), I heard many transport stories told, only some of which ended up on tape by luck or circumstance. Thus this article in no way pretends to constitute a comprehensive exploration of transport stories, a task I suggest to future ethnographers.² For even though they had not constituted a specific research focus, over time these transport stories began to emerge for me as a narrative genre that richly encapsulates clashes of power and ideology between the biomedical and midwifery systems and their potentially devastating consequences for mother and baby, constituting salient cathexes for the trope of “reproduction gone awry.” The particular stories I present here, told by American direct-entry midwives and Mexican traditional midwives, were chosen both for their representative nature and for the transnational similarities they index. These similarities include exclusively out-of-hospital practice and concomitant marginalization vis-à-vis the biomedical system, and thus embody the collision of worlds I seek to analyze.³ In both countries, there are a few nurse-midwives who attend both home and hospital births; their transport experiences are somewhat different, especially when they practice and carry authoritative status in both domains. I suggest them as potential subjects of a future study.⁴ The following section will describe the two groups of midwives on whom I focus here, and the larger national and transnational contexts within which they work.

Backgound and Context: Obstetrics and Midwifery in the US and Mexico

The effects of any practice are always the product of its position within a context.

–LawrenceGrossberg (1992, p. 54)

In theUSin 1999, obstetricians, together with some family practice physicians, attended approximately 92% of all births. Their discourse around childbirth centers on “managing risk”—from an obstetrical point of view, every birth is a potential disaster and must be managed authoritatively and preventively to ensure the best possible outcome. Thus most women laboring in American hospitals today are routinely hooked up to IV lines and electronic fetal monitors throughout labor. Their labors are often induced or augmented with a variety of pharmacologic agents, including pitocin and cytotec. Epidural anesthesia is commonly used to eliminate pain. Just under half of birthing women receive an episiotomy to enlarge the vaginal opening and speed delivery. Just under 30 percent of all babies in theUSare pulled out with forceps, vacuum extractors, or via Cesarean section (Ventura, Martin, Curtin, Menacker & Hamilton, 2001). As I and others have previously described (Davis-Floyd, 1992, 1994, 1998a; Martin, 1987; Rothman, 1982, 1989), the performance of birth in American hospitals tells a cultural story about the female body as a defective machine in need of assistance by technical experts and other more perfect machines. It also enacts and displays the technocracy’s supervaluation of speed, efficiency, control, high technology, and the flow of information through cybernetic systems. Technobirths are typical and normative in American hospitals through a consensual, biopowerful process jointly driven by physicians, who tend to be trained exclusively in that approach, and women, who tend also to supervalue technology, control, and most especially the elimination of labor pain (Davis-Floyd, 1994). For instance, use of epidural anesthesia necessitates the use of many other technologies to monitor for and intervene in complications associated with the epidural. In other words, while some women might make other choices if they had more information, generally speaking the interventive American approach exists by mutual agreement between women and physicians steeped in the core values and overall approach to life characteristic of their technocratic culture. Both groups believe that this approach offers both comfort and safety in the face of an unpredictable natural process that proceeds more safely when carefully controlled, in the same way that a river subject to flooding seems improved when a series of dams and floodgates are installed.

To hospital practitioners steeped in this approach, the choice for home birth appears to be a choice for pain and random chaos in contrast to order and control. Most hospital-based practitioners have never seen a home birth and know little about the knowledge base of home birth midwives, in part because of a near-total lack of contact. The many safe and woman-centered births that take place at home are invisible to the medical gaze; biomedical discourse tends to center around “botched home births.” This phrase is one I have often heard bandied about by medical practitioners who tend to assume that any home birth that ends up in the hospital must be “botched,” even if it is the result of an appropriate transport.⁵ Of course, the midwifery response is usually a sarcastic comment about enormous numbers of “botched hospital births”; women who have had “botched” hospital experiences and later choose home birth are an important source of such accounts. This trading of insults is an in-group phenomenon: hospital practitioners complain to other hospital practioners about home birth and midwives; midwives complain to other midwives about hospital practitioners. Dialogue between these groups is rare; mostly, their members inhabit separate worlds that only intersect when a home birth goes awry and a transport is the necessary result.

Throughout most of the twentieth century, the movement of birth was from home to hospital, as technomedicine became increasingly dominant and cultural notions of safety became increasingly tied to the technomedical management of birth (see DeClerq, DeVries, Viisainen, Salvesen & Wrede, 2001). Reacting to what they experienced as “over-medicalization,” in the 1970s thousands of American women began to move their births away from the hospital and back to the home; a new class of practitioners emerged to serve them in what came to be known as the lay midwifery renaissance. By the 1990s, many of these lay midwives had been practicing for over twenty years and had ample opportunity to create a distinctive knowledge base for out-of-hospital midwifery (e.g. Frye, 1995; Davis, 1997; Gaskin, 1990; Rooks, 1997, pp. 225-294). As part of their process of professionalization, they dropped the appellation “lay” in favor of the European term “direct-entry,” which indicates that they entered directly into midwifery education without passing through nursing first (see Davis-Floyd, 1998b). The exact number of direct-entry midwives practicing currently in the USis not known; educated guesses place it at around 3000. Almost all of them work exclusively out-of-hospital, attending around one percent of births.⁶ Approximately 5500 nurse-midwives practice mostly in hospitals, attending around seven percent of all births (Declerq, 2001).⁷ In 1982 a coalition of lay and nurse-midwives created a national organization, the Midwives’ Alliance of North America (MANA), whose primary purpose is to support out-of-hospital midwifery. In 1995, tired of being accused of being “ignorant” and “untrained,” and wanting to offer consumers assurance of competence, MANA members created a new national certification that could test and validate their knowledge, skills, and experience–the Certified Professional Midwife (CPM) credential (Davis-Floyd, 1998b; Rooks, 1997).⁸ At this time of writing, there are over 700 CPMs in the US, and three in Mexico. CPM certification honors multiple kinds of midwifery education, including apprenticeship, which seems to many home birth midwives to most effectively teach the experiential, intuitive, non-interventive, and trust-based approach they value as deeply as their technomedical knowledge and skills. CPMs and other independent direct-entry midwives practice legally or a-legally in 35 states and illegally in 16 states.⁹ In most alegal and illegal states, they are fighting uphill battles for legalization (Davis-Floyd & Johnson-Levitin, nd). In some states where they are licensed, their services are covered by private insurance companies and by Medicaid (and sometimes managed care). But in most states, home birth attended by direct-entry midwives is still an out-of-pocket expense—a factor that exercises a significant limitation on its growth. (In states likeWashington andFlorida where home birth is reimbursed, the percentage of home births is on the rise.) While their practices are not uniform, most direct-entry midwives practice according to specific protocols (sometimes individually arrived at, sometimes mandated by state regulation, and sometimes consensually established by local or regional midwifery associations) that include lists of specific conditions and circumstances that warrant hospital transport. These midwives are presently forming a new professional organization, tentatively named the “CPMAlliance,” to generate more uniform national standards for the increasing numbers of midwives achieving CPM certification, a process that will take some time to develop.

In Mexico, biomedicine has not only taken over childbirth but is redefining its very nature. While high technologies like electronic fetal monitors are not as readily available as in U.S. hospitals, in vaginal deliveries extreme interventions like fundal pressure (Kristeller) and manual extraction of the placenta are common, and Mexico’s Cesarean section rate (just under 40%) is one of the highest in the world (Belizán, Althabe, Barros & Alexander, 1999; Fernandez de Castillo, 1997).¹⁰ A common argument against midwifery made by government officials and MDs is that there are plenty of doctors and nurses in Mexico, that the poor are entitled to the same care as the middle class, and that therefore progress in maternal health care should entail giving everyone access to hospitals and doctors. This argument is representative of what has been called the “megarhetoric of developmental modernization” (Appadurai, 1996, p. 10), which identifies a single point in a given area toward which development should be progressing (Appiah, 1997, p. 425): in health care, that single point is Western biomedicine.

As Marcia Good Maust (2000) has shown, Mexico’s high Cesarean rates stem in large part from physicians’ deeply held belief that birth is a dangerous process that can cause harm to mothers and babies and that technological interventions like Cesarean sections are the best way to ensure the safety and wellbeing of mother and child. Such physicians see midwives as a hangover from the undeveloped past, a temporary evil that must be replaced as quickly as possible with the vanguard of the future–modern health care. In the US and other developed countries, a postmodern discourse (one that stems from multiple points of reference, that does not assume the superiority of any one method) around the benefits of professional midwifery care and certain indigenous approaches–such as walking during labor, upright positions, and herbal remedies—occasionally punctuates the national dialogue about birth. This discourse is barely heard in today’sMexico, outside of some branches of the public health sector. In theUS, nurse- and direct-entry midwives, backed by supportive consumers and often by public health officials, due to their record of good outcomes and cost-effectiveness (Rooks, 1997), are engaged in active campaigns to increase government and public awareness of the multiple benefits of midwifery care. But inMexico, there are no midwifery lobbyists to disturb legislative halls.

Nevertheless, many working-class women resist government initiatives to bring birth into clinics and hospitals, choosing instead to birth at home attended by a midwife.¹¹ Officially labeled “traditional birth attendants” (TBAs) by WHO and UNICEF, these midwives refer to themselves as parterastradicionales (“traditional midwives”: see Davis-Floyd, 2001a, b for more detail). They are usually mothers who have given birth several times and who have become midwives by being asked to attend the births of friends and relatives, slowly gaining first-hand experience of birth. Some of them undertake long apprenticeships, while others learn simply by attending births. Between 1995 and 1996, traditional midwives attended less than 17% of births in Mexico (INEGI, 1999). The majority are over 65 years of age (SSA, 1994); many are dying without training replacements (Good Maust, Güémez Pineda & Davis-Floyd, nd).¹²

Efforts to reduce maternal and perinatal mortality in the Third World by UNICEF and WHO and those engaged in implementing the Safe Motherhood Initiative have for two decades centered around “TBA training”—short, usually two-week-long courses taught by biomedical personnel, usually doctors, nurses, or professional midwives to community midwives (Jordan, 1993; Pigg, 1997). Almost always, these courses are extensions of biopower, fingers of articulation reaching from biomedicine into indigenous communities designed not to clasp hands in mutual accommodation but to alter what they encounter. Very seldom do the “trainers” enter a community and spend time there learning about indigenous birthways before they try to intervene. Rather, they attempt to educate traditional midwives in biomedical ways of thinking, most especially about conditions of risk that are deemed to necessitate transport. InMexicoand other countries, UNICEF has just discontinued funding for TBA training courses; since maternal mortality rates have not dropped after 20 years of TBA training, the conclusion is that such training is ineffective. This conclusion is based on the assumption that mothers die because midwives give them inadequate care or fail to transport them in cases of need. As I have described elsewhere (Davis-Floyd, 2000), in rural areas the unavailability of transport is often the greater problem. But refusal or deliberate delay of transport does occur; as we will see, often the reasons for this delay stem from negative prior transport experiences.

TBA training courses and other forms of exposure to biomedicine have resulted in fundamental alterations in practice for many traditional midwives in Mexico. Across the country, it is now common for them to give pitocin injections to hurry labor, to insert IVs for hydration, and to wear blue biomedical garb when attending births. Combining such practices with the traditional sobada (massage), herbal treatments, and religious beliefs,Mexico’s contemporary midwives practice at the intersection of various cultural domains.

These forces and trends have particularly influenced midwives who practice in urban areas, as my extensive interviews with seven traditional midwives who live and practice in various colónias in or around the city of Cuernavaca reveal. These urban parteras tradicionales (unlike many of their rural counterparts) have long been incorporated into the state health care system in Morelos through bi-monthly seminars on family planning and other topics; the government uses them as agents of family planning and birth control, a service desired by women which they are happy to provide. All seven went through a period of using allopathic interventions like oxytocin injections to induce stronger contractions; experiencing complications as a result, all have returned to the use of their traditional herbs. Today they routinely send women out for ultrasounds when they diagnose a breech or transverse presentation to confirm their diagnosis, and offer their clients an eclectic potpourri of traditional techniques like external version (turning the baby manually) and biomedical options like sending a woman to a doctor they know and trust for a Cesarean section. Dancing fluidly at the interface of biomedicine and their traditional systems, these midwives are strategically negotiating the boundaries between knowledge systems and creatively producing a hybrid and increasingly well-articulated knowledge system of their own. In this endeavor they are assisted by a new group of parteras profesionales (professional midwives) whom I have described elsewhere (Davis-Floyd, 2001a). These professional midwives, three of whom are CPMs, are all members of MANA and have worked to extend MANA’s support of midwives and home birth into Mexico by putting on five annual MANA Mexico conferences around the country and by recruiting as dues-paying members interested traditional and professional midwives.¹³ My Cuernavaca interviewees are members of MANA and regularly attend these conferences, often doing volunteer work on conference organization; in recent years they have also attended, via scholarships from MANA, various MANA conferences in the U.S.

Significant differences in lifeworld, knowledge base, and practice styles distinguish American direct-entry midwives from the urbanized traditional midwives ofCuernavaca, along with equally salient differences in social class and access to wealth, education, and other resources of the technocracy. But their similarities are also relevant here. The transport stories they relate below can most effectively be interpreted in light of the understanding that the members of both groups do not practice in conceptual or geographic isolation, as some midwives do, but rather exhibit all the characteristics of what I have called the “postmodern midwife”—one who balances and evaluates knowledge systems in a relativistic way, and who participates in transnational networks of community-building and information exchange (Davis-Floyd & Davis, 1997; Davis-Floyd, Cosminsky & Pigg, 2001). Like American homebirth midwives, the midwives of Morelos are busy balancing knowledge systems and constructing hybrid identities in urban areas in which they must constantly engage in strategic negotiations with physicians. Their membership in MANA gives them access to international midwifery networks; participation in these networks is helping them to form a new state association to support traditional midwifery in Morelos, and to participate in a national certification project for Mexican midwives that is currently underway (see Davis-Floyd, 2001a).

From an anthropological point of view, both the Cuernavaca midwives and American direct-entry midwives elide and confound the usual distinctions between professional and traditional midwives: some of the American home-birth midwives who are professionally licensed and certified were trained through apprenticeship or self-study; the Cuernavaca midwives, trained the same way but considered lay practioners by their government, are engaged in an unnamed but nevertheless visible process of professionalization (see Davis-Floyd, 2001b). Their ethnic, economic, and class differences are salient; yet despite these differences, and because of their mutual dedication to the welfare of women and belief in the safety and efficacy of home birth, it is fair to say that the members of both groups are inspired by the transnational ideology of home birth and “sisterhood” in midwifery that MANA seeks to foster. Both groups critique the failures and limitations of biomedicine and have a strong sense of mission about preserving home birth in the face of biomedical hegemony. They believe in women’s ability to give birth with little intervention most of the time, in the superiority of homes and birth centers as the sites of birth, and in the efficacy of their own knowledge systems and skills.¹⁴ They do not undertake transport unless they are convinced that the situation is truly in need of technomedical intervention, and when they do transport, their intent is to do all in their power to make the medical system respond in ways they consider appropriate. Thus their transports usually involve at least two people from outside the biomedical realm: the mother who needs help, and the midwife who will not abandon her even when she is no longer in charge of her care.¹⁵

All midwives who practice out-of-hospital must occasionally transport. No national statistical data on transport for Mexico is available, but in the US, home birth midwives have a transport rate of about 8% (Johnson & Daviss, 2001). In other words, 92% of their clients give birth safely at home, while 8% are transported to the hospital during or after labor for various reasons: 6% of their clients are transported for precautionary reasons like failure to progress in labor, meconium staining in the amniotic fluid (possibly but not necessarily a sign of fetal distress), or a retained placenta after the birth. Approximately 2% of their clients are transported for potentially life-threatening emergencies (Johnson and Daviss 2001). (My Cuernavaca interviewees anecdotally report similar rates.) The transport stories I have culled from my interview data and selected to recount below cluster inside that 2%; I urge my readers to keep in mind that the circumstances they recount are quite rare and not representative of the vast majority of births. These experiences are most likely to be encoded in narrative because they are so unusual and also because of their heavy emotional charge. Stories give meaning and coherence to experience; midwives who transport under frightening circumstances often need to find that coherence and to evaluate through narrative, with the benefit of hindsight, their own actions and those of the mother and the biomedical personnel.

In transport situations, there are various ways in which “awryness” can occur: (1) The fact that transport is indicated means that the natural process of birth has in some way gone awry, or seems likely to; (2) the midwife may wait too long to summon transport, either because of prior bad experiences with transport, as we will see below, or because of the midwife’s lack of knowledge of indications for transport;¹⁶ (3) the hospital staff taking the call may not understand the urgency of the mother’s problems; (4) EMTs may fail to respond appropriately, or there may be disjunctive communication between the midwives and the EMTs; (5) arrival at the hospital can go awry for the mother and the midwife if either is ignored or mistreated; (6) even well-intended biomedical interventions can at times do more damage than they fix; (7) not all natural disasters are fixable by biomedical means, so even with the very best of care, the death of mother or baby can occur. Only some of these possible levels of awryness are articulated in the stories I tell below. I selected these particular six stories because they are typical: they represent the range of possible outcomes of transport and are emblematic of many other situations and possibilities I do not have room to treat here. Since I have no way of ascertaining the truth or untruth of these stories, for the purposes of this article I take them at face value and unpack them for what they reveal about midwives’ perceptions of and the meanings midwives attribute to events as they unfold.

The Stories

 Analyzing an event involves (re)constructing it or, in Foucault’s terms, fabricating the network of relationships into with and within which it is articulated, as well as the possibilities for different articulations.

–Lawrence Grossberg (1992, p. 54)

In this section, the stories as the midwives recounted them to me are italicized; these stories are not direct quotes but my retellings (unless otherwise indicated). Contextualizing information, my analyses and interpretations, and the midwives’ additional comments, appear in regular font.

Dis-Articulation

Carrie’s First Story: Unnecessary Delay

Carrie Smiley is a Certified Professional Midwife (CPM) who has practiced in Atlanta, Georgiafor over 18 years, attending during that time over 850 births.¹⁷ Her practice is “unlawful” (meaning that it is punishable in the misdemeanor category). Most of the home births she attends are for white middle-class couples. She does prenatal care out of her own home, a two-story house at the edge of a small lake in an attractiveAtlanta suburb. She began her birth career in the late 1960s working as a volunteer in labor and delivery, and then took training as a biomedical assistant, working in labor and delivery and for a pediatrician for several years. Starting in 1977 she began attending the home births of friends; in the early 1980s she undertook a year-and-a-half apprenticeship with another home-birth midwife who later became her partner. The following episode took place in 1984, during the early years of Carrie’s home-birth midwifery practice. But it should not be regarded as dated, as it typifies many transports that presently occur, especially in “illegal” states.

Carrie and her partner are attending a mother pregnant with her first child, laboring at home and planning a home birth. After about eight hours of labor, the mother has reached ten centimeters dilation and is starting to feel the urge to push. Monitoring the baby’s heart tones, the midwives detect strong decelerations, a sign of fetal distress. Hoping to get the baby out quickly, the midwives ask the mother to push a few times to see if the baby will come down. When they realize that the mother is not going to be able to get the baby out with sufficient expediency, they get her to kneel in a knee-chest position, put her on oxygen, and call the EMTs. When ten minutes pass and the EMTs have not yet arrived, the midwives help the mother into their car, planning on driving her to the hospital themselves. Just as they are ready to go, the ambulance pulls up and blocks the driveway. Announcing, “We’re here now, we’ll take it from here,” the paramedics pull the mother out of the midwife’s car and help her into the ambulance. But they refuse to heed the midwives, who are urging that they must rush the mother to the hospital, insisting that first they have to get a history. Asking questions like “have you had any nausea during this pregnancy?” the EMTs are wasting precious time. Frantic at the delay, and knowing the baby might be suffering from oxygen deprivation, the midwives ask the paramedics to put the mother on oxygen. They refuse, wanting to continue with the history, so the midwives get their own oxygen tank out of the car, at which point the medics finally accede and hook the mother up to the ambulance oxygen tank. As the ambulance starts toward the hospital, the midwife riding with the mother asks her to get on her hands and knees to relieve any possible cord compression, but the paramedics get upset and turn the mother flat on her back. Knowing that this position will exacerbate cord compression and reduce blood and oxygen flow to the baby, the midwife compromises by turning the mother on her side, and continues to listen to the fetal heart tones.

            Arriving at the hospital, the midwives are told that there are several obstetricians present in the hospital, but only the one on-call is allowed to treat a “walk-in” and he is not in-house and will have to be called. Increasingly frantic, the midwives insist to the nurse in the ER that the baby is in distress. The nurse auscultates the heart tones, records them at 130, announcing this to the midwives and the mother, and tells the midwives that “Everything is fine; we will take over from here.” She will not look at the records the midwives brought, which show the heart fluctuations, nor pay heed to their insistence that this is an emergency. The midwives are not allowed to remain with the mother in the ER or to accompany her to labor and delivery. Instead they are sent to the waiting room. Carrie says, “Every time we went outside the room, we noticed that everyone seemed to be looking at us and talking about us.”

Terrified that they will be arrested and sent to jail, the midwives finally head home. Later they learn that it took the doctor on-call one hour and 45 minutes to show up. In the meantime, the nurses caught the baby, who was stillborn. The cause of death was listed on the hospital record as “prolonged fetal distress.” The EMT records said that the mother had been antagonistic and refused oxygen, which the midwives insist is untrue. The nurses said the mother refused the electronic fetal monitor. The hospital pushes the mother to file criminal charges against the midwives, but the mother tells the hospital personnel that this death is clearly the hospital’s fault, that the midwives acted appropriately and bear no blame, and that if the hospital should try to harass the midwives in any way, she will sue the hospital, not the midwives.

In Carrie’s view, she and her partner did their best. Trained to detect fetal heart rate decelerations and to recognize which ones are dangerous, they responded appropriately to the signs of fetal distress. But in retrospect, Carrie wishes that they had taken the woman to the hospital themselves. When I asked her why they called 911 in the first place, Carrie responded, “We were really dumb—we thought that was the appropriate thing to do.”

From Carrie’s point of view, blocking the driveway and announcing “We’ll take it from here” demonstrated the EMTs’ arrogant and authoritative attitude, which at first glance seemed to leave no further role for the midwives to play. She feels that she and her partner demonstrated strength in their refusal to accept this dismissal. Rather, they flexibly and creatively tried to work with the EMTs to help the mother get what they felt she needed. Frustrated by their inability to convince the EMTs of the need for haste, they experienced their success in getting the mother back on oxygen as a small victory. They had good reason to believe that the baby was oxygen-deprived, so when the EMTs refused to act, the midwives resorted to the non-verbal but nonetheless eloquent strategy of getting their own oxygen tank out of the car, figuring that the EMTs would rather use their own oxygen than accept it from the midwives.

One possible reason for the baby’s lack of oxygen might have been that the cord was compressed. Cord compression is usually exacerbated when a woman lies flat on her back, so the midwives wanted to put the mother on her hands and knees in the ambulance, as this is the position most likely to take the most pressure off the cord. (In addition, the flat on the back position can cause supine hypotension (low blood pressure) in women because it occludes the vena cava, resulting in inadequate circulation of blood (which carries oxygen) to the placenta and baby). But a woman on her hands and knees in an ambulance is a strange and unsettling sight and most likely did not match the medic’s internal maps of proper patient position or behavior, or of safety while driving. So the midwives had to give up on the most physiologic position; here again they creatively compromised, finding a position that minimizes both cord and vena cava compression while not challenging the medics’ views of how a patient should be positioned. For Carrie and her partner, these stand as examples of midwives’ ability to think around situations to get the system to meet the woman’s needs. Such creativity has been demonstrated to be typical of subaltern groups, who must be as aware of the features of the dominant group as of their own in order to successfully navigate inside the dominant system (Schaef, 1992).

Several obstetricians present in a hospital, but only the one on-call is allowed to treat “walk-ins,” and that one is not in the hospital: here Carrie’s voice dripped with sarcasm. For her this situation evidences hospitals’ tendencies to be highly structured, category-oriented, and rule-bound. Her outside gaze notes that people who have a place inside the biomedical system, having contracted with a private obstetrician, are more likely to get an immediate response than the anomalous, un-placed “walk-in.” The fact that the nurses would not look at the midwives’ records seems analogous to the medics’ refusal to heed the midwives’ insistence on haste. Instead, the EMTs wanted to take a history, which of course the midwives already had. But the information the midwives had obtained did not count for these biomedical personnel, who valued only the knowledge they themselves obtained. It seems to Carrie that reality as defined by biomedical categories (taking a history, allowing only one OB to attend a walk-in, counting only information obtained by biomedical personnel) was more salient here than reality as the midwives, the mother, and the stillborn baby experienced it.

Tragically, the mother’s refusal to be put on the electronic monitor denied the biomedical system an indicator on which it might have acted. This refusal probably stemmed from the distrust of the biomedical system and its technology that led the mother to plan a home birth in the first place. When the ER nurse announced that the heart tones were at 130, the mother took this news to mean that the problem had resolved itself and “everything was fine.” Carrie later learned that in the labor and delivery unit the fetal heart rate decelerations were noted and recorded by the nurses who were auscultating the mother, but for some reason they never told the mother that they could hear the decelerations, so she continued in the belief that the heart tones were still OK. Emphatically, Carrie stated that if the midwives had been allowed to remain with the mother, they would have convinced her to allow the monitor; she said “We would have done everything from cutting a huge episiotomy to jumping on her tummy to get that baby out. But we were sent away.”

Carrie’s sarcasm extends to the “lie” the EMTs told on their official records, a lie she is sure they told to cover themselves in case of lawsuit. It is likely that the paramedics assumed that as biomedically trained practitioners, their word carried more authority and cultural weight than the words of the midwives and the mother, so their notes were more likely to be seen as valid. Practicing inside a hegemonic cultural space can facilitate one’s claim to truth. Practicing outside that space not only calls one’s veracity automatically into question, but also puts one at risk of legal action: Carrie and her partner feared being sent to jail since their practice is unlawful in Georgia. They have dealt with this threat through their excellent outcomes, on which they keep careful statistics; through obtaining CPM certification, which is not recognized in Georgia but at least shows that they have been tested and have demonstrated the requisite competence; and through publicity: every few years, a local paper publishes a several-page spread on Carrie and her practice, showing pictures of her and of the happy couples she has attended. She feels that this high level of visibility affords her far more protection in the form of community support than would remaining underground.

Reality is as one perceives it and the effects of any given event depend not on the actual circumstances of that event but on how they are narrated. On both sides of this particular biomedical/midwifery//biopower/counterpower fence, opinions were formed or reinforced by this experience. We can imagine that the story that circulated among hospital personnel about this birth was very different from the one the midwives tell: chances are it was a story about another botched home birth attended by irresponsible midwives. On the midwifery side, it was one more story about the absurdity of biomedical bureaucracies and the arrogance and narrowmindedness of biomedical personnel–nurses, physicians, and EMTs alike. And it was a story about the dedication and loyalty of the midwives’ clients: when I asked Carrie why the mother did not sue the hospital, she responded, “Because she knew that if she did, the hospital would come after us.”

Later Carrie added, “Before this experience, I always thought that if you have a problem, you call the paramedics. Now I know that if you want a problem, you call the paramedics.” She notes that this experience made her much savvier about the limitations of the biomedical system. Specifically, it taught her and her partner to always make sure they transported only to hospitals with on-call physicians in-house, and not to involve the paramedics if there was any way the midwives could transport the client on their own. And, as we will see below, it led Carrie over time to work to develop a network of relationships with individuals in the hospitals to which she now transports in order to enhance her ability to prevent this kind of disarticulation of systems, and to facilitate the kind of smooth articulation that can save lives.

Luz’s Story: A Transnational Parallel with a Different Ending

Laura de la Luz Gomez (“Luz” for short) is a traditional midwife of over 30 years’ experience who attends home births in the impoverished barrio of Santa Laura, just north of the city of Cuernavaca in the state of Morelos, Mexico. Luz and her family live in a crowded one-room house made of wood and corrugated tin, with a dirt floor. They are building a much bigger house of brick and cement next door; they have been working on it for 25 years and it is finally near completion. Years ago, Luz and her family chose to pour the resources they could have put into the house into the construction of a birth center behind their one-room shack. The shack is hot, small, and unadorned; the cement-floored, freshly painted birth center is spacious, cool, and breezy. Two double beds allow family members to keep women company during labor; Luz’s autoclave and midwifery equipment rest on the table in between the beds. The women of her barrio like this birth center and prefer it to their own houses. There Luz attends four to five births per month. In the summer of 1999, Luz told me the following story.

A woman who had not come to Luz for prenatal care showed up on her doorstep one day in labor. Luz does not like to attend women she has not seen before, but nevertheless took her in. Listening to the baby’s heart tones through her fetoscope, Luz heard the heartbeat drop from 135 to 100, then rise back to 135, then drop again. She called a taxi¹⁸ and transported the mother to the hospital, where she carefully explained to the nurse on duty that this was an emergency. In spite of her entreaties, she and the laboring woman were ignored. Luz insisted to the nurse that the baby was suffering, and the nurse said “How do you know that?” “Because I am a midwife with thirty years’ experience,” Luz replied, “and I checked this patient and I know she needs to be in the hospital because the baby’s heart tones show distress. And she has just come to me for the first time with no prenatal care, and you tell us to refer in such cases, and so for these two reasons I am referring.” “Sit down for half an hour,” responded the nurse. “The doctors will be with you when they can.” “No, call the doctor now!” insisted Luz. “The baby is in danger, it is very big and is not coming down, she needs a Cesarean.” Luz continued:

We were there one hour and a half waiting. I could hear the doctors laughing and laughing down the hall—they were drinking their coffees. When I knocked on the door, they were putting away the cups. And still they made us wait. And I got really angry and I said to her husband, “Do you have money?” And he said, “Well, I’ve been working so I have some.” And I said “OK, well go and get it, because you’re going to need it—I am taking her away from here.” And so I called the doctor who is a friend of mine at a sanatorio (private clinic), and he said “OK, you can bring her in and I will do the Cesarean.” And we took that woman to his clinic and he did the Cesarean. It cost a lot, but we got out of that problem, didn’t we? They tell us to “refer at the first points of alarm,” so that the baby or the mother won’t die because of my ineptitude. Ha! El plan de trabajo mio es lograr a que viva la gente, no a que se muera.” (My plan of work is to succeed at people living, not dying.)

Like Carrie’s story, Luz’s story is about a midwife responding appropriately to dropping heart tones yet being ignored by biomedical personnel. In both stories, the midwives express their efforts to get attention and their enormous frustration at being ignored. Luz went so far as to appropriate the lexicon of TBA trainings when she listed to the nurse not one but two reasons for referral. “You tell us to refer in such cases”: the plural “you” indexes the biomedical trainers who told her that she should send patients to whom she has not provided prenatal care to the hospital if they show up in labor, and that consistent fetal heart decelerations are an indication for transport. Taking the biomedical system at its collective word, Luz used those same words to try to get the system to respond. Yet like Carrie and her partner, in spite of the “thirty years of experience” Luz invoked in an attempt to garner authority, she was ignored—an act that constituted a de facto dismissal of Luz from having any kind of authority, and which she resented deeply.

Not willing to sit passively and wait, Luz went so far as to knock on the door of the doctors’ lounge, and was again dismissed. As in Carrie’s case, this hospital was not going to respond smoothly or quickly to a “walk-in.” But there was some benefit in trying, as this second dismissal convinced Luz that she was never going to get anywhere in that hospital, a realization that inspired her to search for an alternative. Exhibiting a creativity in hostile circumstances parallel to that of Carrie and her partner, but with better results, Luz conceived the idea to take the woman to a doctor she trusted and often worked with. His practice was private and would require financial payment, while the hospital, as part of the Mexican public health system, would have been free. So a prerequisite was to ask the woman’s husband if he had money and could pay for the Cesarean. His affirmative answer freed Luz to implement her plan that mother and child should “live and not die.”

Like Carrie’s story, Luz’s experience highlights the frustration midwives often feel at the lack of obstetrical recognition or valuation of their knowledge. Midwives see themselves as guardians of the normal. They are skilled at recognizing when a situation deviates from the normal and lands in the realm of obstetricians, who are experts in the abnormal. From a midwife’s point of view, this professional demarcation system might work well if midwives’ knowledge about normal and their ability to diagnose abnormal were regarded as authoritative by nurses and obstetricians. But as we have seen, in the face of biopower and biomedical knowledge, the midwife’s knowledge and attempt to generate a response from the medical system often simply do not count; in this case, dis-articulation—no response from the hospital to the midwife–was the result.

The fascinating difference between Luz’s story and Carrie’s lies in their endings. In Carrie’s story, the disarticulation of systems ended in the baby’s death, and might have done so in Luz’s story as well. But Luz found the opportunity to seek a smoother articulation. Over years of practice and referral, she had built a mutually respectful relationship with one obstetrician who did not question her diagnosis, but rather was immediately ready to respond. So she was able to create a radically different ending to this otherwise very similar story. Luz said, “What happens is that the politics are against us, so we have to be as creative as we can.”

Fractured Articulations

Lana’s Story: An Inaudible Voice

Lana Lane, an American direct-entry midwife, learned midwifery through a two-year apprenticeship inFairbanks, during which, with her mentor, she attended over 100 births. Shortly after finishing her training in 1985, she moved toWasilla,Alaska, where she went into partnership with Susan Eakin. By then the direct-entry midwives ofAlaskahad achieved their legislation and were practicing legally. This story, told to me by Lana’s partner Susan, took place the following year.

Arriving at the home of a woman in early labor who lived less than five minutes away from a tertiary care center in Anchorage, Lana performed a vaginal exam to check the degree of cervical effacement, dilation, and station (the position of the baby’s head), and suddenly found the umbilical cord in her hand. Susan said, “The cord was just below the baby’s head. Lana tried to slip it up away from the vaginal opening, hoping the head would block it, which can sometimes be done if too much cord doesn’t wash down. But the cord just kept slipping, so all Lana could do was keep the cord from being pinched (which would cut off the baby’s blood and oxygen supply) by splinting it between her fingers and pushing the head off it.” While the mother crouched on her knees and prayed, Lana maintained the head in place, telling her partners to administer oxygen to the mother and the father to call 911. He held the phone for Lana as she described the situation and begged them to have an operating room ready. At that point, the baby’s heart tones were fine. The ambulance arrived in two minutes. The EMTs were cooperative and did not question the midwife’s judgment. Lana straddled the stretcher below the mother, applying counter-pressure to the baby’s head with one hand and with the other using the Doppler to monitor heart tones that were steadily dropping. They were inside the hospital within minutes. But upon arrival, they found that nothing had been done to prepare for the Cesarean. For thirty minutes, Lana knelt on the stretcher holding the head in place and listening to the heart tones drop—50, 40, 30. She lost her voice from screaming for the hospital staff to hurry. But by the time the Cesarean was finally performed, the baby had died.

A prolapsed cord is life threatening to the baby—when the cord is in front of the baby’s head, it is compressed, thereby cutting off blood and oxygen circulation to the baby. Unless the baby can be birthed immediately or a Cesarean quickly performed, the baby is likely to die. In this situation, wherever it occurs, the mother must get into the knee-chest position, which takes the pressure off the cord, while the practitioner kneels behind her and applies counter-pressure to the baby’s head so that the cord is not compressed between the head and the woman’s pelvis. Keeping her hand inside the mother’s vagina, the practitioner must hold up the baby’s head until the baby is removed by Cesarean—a dramatic scenario to say the least, the success of which depends on how quickly the Cesarean is performed.

This story resonates with pain; indeed Lana’s partner Susan, who first recounted it to me, was crying as she spoke. She did not know exactly why Lana’s pleas for speed were ignored, but she felt sure that it had something to do with the hospital staff’s disapproval of home birth. The worst case scenario would interpret hospital personnel as deliberately ignoring this “walk-in” from outside to prioritize the women inside and/or to punish her for trying to give birth at home. Prior and subsequent experiences have ensured that Susan holds this worst-case view. She said:

In my opinion, the reason no one came to the rescue is because it was a planned home birth gone bad. I don’t think they “believed” Lana knew a thing. More than once we’ve been forced to wait on circumstances they would normally be scampering to fix. I could tell you several stories in which the medical staff tried to hang us, instead of acknowledging that we transported appropriately.

In contrast, the scenario that attributes the best intentions to the hospital practitioners has to do with the logistics of hospital procedures. When a cord prolapse occurs in hospital, the practitioner who identifies it issues a crash call, the obstetrical team flies into action, and when all goes well the baby is delivered by Cesarean within ten minutes. But getting everything in place for a Cesarean is very expensive in terms of the personnel and equipment needed, and most hospitals have experiences of doctors, paramedics, nurses, and/or midwives telling them to prepare for a Cesarean when one really isn’t needed. Setting up unnecessarily ties up rooms, obstetricians, and anesthesiologists and may keep them from being available if needed elsewhere. Thus it is logical that a hospital would want to assess the situation before taking action, especially on the word of a person unknown to them (which might include a private physician) (Judith Rooks, personal communication¹⁹).

This transport took place in 1986 but cannot be dismissed as anachronistic—similar scenarios still play out around the country, especially in states where midwives practice illegally but also in states where they are legal but not well accepted by or well known to biomedical practitioners. It illustrates the dysfunctions generated by partial, fractured articulations between the biomedical and home-birth midwifery systems. The biomedical system’s first response was appropriate—the EMTs supported the midwife to continue her work and did not challenge the validity of her knowledge or approach. And on the phone the hospital promised a response. But somewhere between the promise and the mother and midwife kneeling on the stretcher in the hall, a fracture occurred in what had promised to be a system of smooth articulation, and it was the baby who fell through the crack. Both the worst-case scenario (that the hospital deliberately delayed action to punish the midwives and the mother for attempting a home birth) and the best-case scenario (that, given the expense and difficulty of preparing the OR, hospital practitioners didn’t feel they could risk taking these unknown midwives at their word) point up the importance of prior dialogue and relationship between the hospital and the midwives in order to establish mutual trust and systems of smooth articulation well in advance of this kind of emergency.

Marisa’s Story: A Public Humiliation

Marisa Salinas defines her primary identity as that of a traditional midwife; she also is a registered nurse. Her friend and colleague Laura de la Luz lives to the far north of Cuernavaca, while Marisa’s residence is in a barrio called Tejalpa to the east of the city on the road to Tepoztlán and Cuautla. Marisa became a traditional midwife because she resented the subordination of the nursing role, and found allopathic biomedicine entirely too interventionist for her taste. She attends four to five births a month, mostly in women’s homes but also in the bedroom she uses as a birth center; she has a separate room for prenatal exams. Every time I have visited, wild herbs lie drying on the prenatal exam table, a visual elision of boundaries and juxtaposition of worlds that is characteristic of the hybrid nature of these midwives’ practices.

            One night Marisa received a phone call from the family of a distant cousin of her husband, from a small rural town. The cousin was six months pregnant and the family was worried about her and wanted to know if they could bring her to Marisa for a check-up. Thinking they mean at some future date, Marisa agreed. At about six the next morning the woman arrived on her doorstep. Marisa was already in her nursing uniform, about to head out on a campaign to offer Pap screens to rural women. She didn’t like the way the woman looked, and immediately took her blood pressure; the diastolic pressure was 170, suggestive of pre-eclampsia. Marisa immediately called a taxi and accompanied the woman to the hospital. By the time they arrived, the woman was convulsing. The hospital staff put her into intensive care, while Marisa waited outside in the waiting room:

And every so often the doctor came out and told me that I am this thing and that thing, saying “Useless midwives, why do you take these cases when they are serious and high-risk?” yelling at me in front of all the people in the waiting room. And the second time he came out he said more things to me and threatened me and in truth made me feel very bad. “Don’t leave,” he said. “Because if she dies right now we’re going to see about you.” And I got scared. I didn’t do anything besides take her blood pressure and bring her straight to the hospital. And after a while her family arrived and I told them that she started convulsing all of a sudden. I told them that I hadn’t done anything, that I had been headed somewhere else and took a detour to accompany her.

And finally the family spoke with the doctor and explained everything to him, and I spoke with another doctor there who knows me and has always helped us midwives. That first doctor was a real despot. And yes he finally apologized to me, because the doctor who is kind to me and respects me is the head of obstetrics at that hospital, and made him apologize. But he apologized to me in private in a little back room, and he insulted me in public in front of everyone. The whole thing made me feel sick. But in the end they did save her life and the baby’s life. In the ultimate case I wasn’t the one who was important, right? She was, and the baby was. But yes, my morale did go way down. What did I do wrong? Why would I keep her here and have her die on me? That despot wouldn’t even let me tell him what I had found.

As a nurse, Marisa has often served as first assistant at Cesareans; she has good relationships with several physicians who respect her, and so the doctor’s belittling remarks took her by surprise. Even worse than the insults, from her point of view, was the doctor’s complete unwillingness to listen to the facts of the case; he blamed and judged her without even knowing what had happened. As with Carrie, Luz, and Lana, the midwife’s knowledge and prior experience did not count–in Marisa’s case, indeed, did not exist inside the system. The other midwives at least verbalized what they knew, even if they were not heeded, while Marisa’s voice had no chance to be heard. So even in this case, where the hospital recognized the gravity of the situation and immediately took over the care of the woman in appropriate ways with a good outcome for mother and child, the midwife was punished. As she told me the story, which took place six months before our interview in summer 2000, Marisa’s face turned red and tears came to her eyes. She was grateful that the doctor and hospital staff saved the life of mother and child, but kept returning to the personal damage done to her. The doctor’s apology seemed to her too little and too late—the humiliation was public, the apology forced and done in private.

From the biomedical point of view, it is important to understand that the doctor’s specific question, “Useless midwives, why do you take cases that are serious and high-risk?” reflects his understanding that traditional midwives are taught a series of risk factors in training courses and told that they should always refer such cases. Earlier we saw Luz mention two of these risk factors as reasons for transport: fetal heart rate decelerations and unknown prior history. Pre-eclampsia is another such risk factor. Although in this particular case, the doctor’s insult was unfounded, he had other reasons to make it. The traditional midwives I have interviewed in Cuernavaca often do take high risk cases, choosing to ignore the protocols they have been taught, because of the circumstances under which they practice. Dona Alina Garcia, one of the most respected traditional midwives in Morelos and Marisa’s close friend and mentor, explains:

In a given moment the woman comes knocking on my door with eight or nine centimeters of dilation, and I can’t turn her away even if it is a case of high-risk—I have to attend her. And we have moved forward with plants, with massage, we give all that is within our reach to give health to the parturient woman so that everything turns out well. . . . When the case is high risk because the baby comes breech, in the moment of the birth we have to be doing maniobras [hand maneuvers] to turn it, and if it can’t be done, we have to receive it as it comes, even if the person never went to a prenatal consult. . . . A low-lying placenta is a high-risk case, right? What we do is push the placenta to one side and the baby can come through and be born. Only when really the placenta comes first, and then the baby—placenta previa–then we have to take her to the hospital, because that truly is a case of high-risk.

Marisa too acknowledges that she has often attended women that would be labeled high-risk by the biomedical system. For example, it is not uncommon for poor Mexican women to avoid prenatal care—they don’t like the long waits at the hospital and the impersonal treatment they receive, so many of them just don’t go. Perhaps such a mother would prefer receiving prenatal care from a midwife, but she may not feel she can afford it or that it is really necessary, especially if she has had other children already. So then she comes to the midwife in labor, having avoided paying for prenatal care but preferring to pay for a midwife-attended birth over having a hospital birth for free. Or perhaps the midwife lives close by, and labor comes on precipitously, and there is no time to reach the hospital. So then, as Dona Alina says, what is the midwife to do? These midwives share an ethic of care that involves service to women; most traditional Mexican midwives (and some American direct-entry midwives) will not violate that ethic by turning away a laboring woman they have not attended prenatally before they even check her. And if they check her and encounter a problem that they feel they can handle, especially later in labor, they are very likely not to transport in order to save the woman from the otherwise inevitable Cesarean.

Although many Mexican traditional midwives accept the notion of biomedical superiority and devalue their own skills in relation to biomedicine, Marisa and her postmodern colleagues in Morelos do not. Like American direct-entry midwives, they see their own knowledge system as more appropriate than technomedicine for all normal and some high-risk births, and they engage in a radical critique of technomedical limitations, pointing out that most doctors have no idea how to deliver breeches, much less turn them, or to deal with low-lying placentas. They simply perform a Cesarean in anomalous cases. Women who come to traditional midwives in urban areas are usually there because they do not want to have a Cesarean birth, which has become almost normative in urban Mexican hospitals. Urban women who go to a traditional midwife could have gotten biomedical care for free; they want her care badly enough to pay for it. The postmodern midwives of Morelos charge around fifteen American dollars for a birth—a far cry from the two or three thousand dollars American direct-entry midwives often charge. But for the urban and rural poor who seek the traditional midwives out, their fees, even though usually offered on a sliding scale, can still be a challenge to pay. Home- or birth-center birth with a traditional midwife in an urban area like Cuernavaca, where hospital birth has long been the norm, is thus a deeply desired alternative choice in the same way that it is in the United States. It was the existence of this alternative, which many doctors would like to elimate in the cities at least, combined with the even more provocative willingness of midwives to ignore the protocols they are taught in their training courses, that had the doctor already so angry at traditional midwives in general that he blew up at Marisa without even bothering to learn the facts of this particular case. His knowledge system insists that Cesareans are the solution in almost all high-risk situations, and that the midwives’ maniobras are both ineffective and dangerous. This physician’s successful management of the mother’s eclamptic seizure, which the midwife could not manage, is of course one of the lifesaving skills that allows him to maintain his belief that only his knowledge counts.

It is worth noting that in each of the earlier stories, the biomedical staff would have had to trust the midwife’s knowledge to take quicker action, as the complications resulted from fetal heart rate anomalies detected by the midwives but not by biomedical staff, and a cord prolapse that only the midwife had confirmed by touch. We can speculate that the reason why Marisa’s cousin got such quick attention when the other women we have heard about did not was the visible, unmistakable, and dramatic nature of her condition, which required no reliance at all on the midwife’s knowledge to diagnose.

As in Carrie’s story, the threat of legal action against the midwife hovers in the air in Marisa’s story. Unlike Carrie, Marisa practices legally with her identification card from the health department, issued to her upon completion of her two-week TBA training course. She also relies on her nursing registration for various aspects of her practice. There is no national certification as yet available for Mexican midwives; Marisa is highly supportive of midwives’ current efforts to create one (see Davis-Floyd, 2001a), as she has longed for years to be able to prove her worth to the physicians in town. In the meantime, like the other traditional midwives in Cuernavaca I have interviewed, she continually augments her education through workshops and seminars given by various organizations and continuing education courses at local universities. The walls of her prenatal exam room are covered with framed certificates from these courses; she showed me a large drawer full of others she intends to frame. Such certificates are proudly displayed by all of my interviewees in Mexico as visible evidence of their commitment to education and their ongoing quest to improve themselves as practitioners. Sadly, Marisa noted that while these certificates do carry weight with her clients, she didn’t suppose they would make a difference to the “despot doctor.” She was truly terrified by his threat to “see about you” should the woman die; as I noted above, although Marisa and her colleagues practice legally, when there is a death they are often arrested and put in jail before an investigation is complete. In Marisa’s story, as she is the first to point out, the mother’s transition from midwife to hospital was smooth; the fracture ocurred in the interaction, or lack of it, between the midwife and the doctor. This fracture made Marisa realize that the certificates on her wall cannot protect her from biopowerful devaluation, and gave her a great deal of impetus to address this fracture by working to increase midwife power through supporting the formation of a midwives’ association and the legal fund its members hope to generate.

Marisa’s story finds a transnational echo in one told to me by Dina Farraw, an American CPM from Arkansas, who transported a client after a home birth for a retained placenta. The doctor did remove the placenta, but only after sternly telling the woman and her husband that it was “child abuse” to give birth at home with midwives. This insulting remark was most likely made out of sincere beliefs that midwives are ignorant and that home birth is a highly risky enterprise. The statistics on the safety of home birth in theUSare not taught in medical school, and most obstetricians are simply unaware of the good outcomes home birth midwives generally achieve (Rooks, 1997, pp. 345-384). Of course, it is ironic that the doctor’s belief in the midwives’ ignorance stems from his own. The hegemony of obstetrics has forced midwives to educate themselves in its ideology and assumptions, protocols and lexicon to enhance their chances of successfully interfacing with it and of being able to defend their actions in its terms. In contrast, the marginality of midwifery has allowed obstetricians to remain ignorant about it. Obstetricians tend to be unilingual in the language and technologies of biopraxis, while my midwife interviewees on both sides of the border tend to be multilingual. They manipulate the lexicons of both obstetrics and midwifery, as well as of various folk systems of practice and belief that inform the lifeworlds of the clients they attend. Midwives thus transgress and elide professional boundaries on a daily basis, while obstetricians tend to reinforce them. Fractures in attempts at articulation (like these doctors’ insulting remarks) often result from this kind of obstetrical boundary reinforcement.

In both theU.S.andMexico, a few physicians are willing to elide and transgress professional boundaries in order to support home birth midwives. Such support can be costly: In the U.S., some physicians have lost their hospital privileges, their insurance, and their ability to practice in their communities as punishment for working with home birth midwives, including a very recent case in the state of Massachusetts. Of course, the more physicians supportive of home-birth midwifery are marginalized within biomedicine, the less ability they have to create needed structures for smooth articulation.

Smooth Articulation

It is important to remember that for all the transports that go awry, many others go smoothly and most do not result in anyone’s death even when they are characterized by fractured articulations. Very few urban midwives in Mexico and the U.S. ever lose a mother, but out of every 1000 births, two or three babies will die no matter where they are born or who attends them. In the US, home birth data indicate that babies whose births start out at home do not die at any higher rates than babies whose births start out in the hospital–there is no added risk to home birth (Rooks, 1997; Macdorman & Singh, 1998; Johnson & Daviss, 2001). As I noted above, only 2% of transports are true emergencies; the same emergencies happen in hospitals. But clearly, transports that involve fracture or dis-articulation between biomedicine and midwifery can amplify the problems already generated by the complication that motivated the transport; sometimes those disjunctures alone are enough to cause a death that would not otherwise have occurred. On the other hand, when a home-birth transport is treated as effectively as a problem that takes place within a hospital, the chances for survival of mother and baby are greatly enhanced. This more positive scenario requires smooth articulation between the biomedical and home-birth midwifery systems, which the following two stories will illustrate. They both come from Carrie Smiley, the afore-mentioned CPM from Atlanta, Georgia.*

A mother pregnant with her second child, whose first birth had been very fast, started bleeding during mild early labor with contractions six to eight minutes apart. Carrie had sent her for an ultrasound at 34 weeks, which had been normal, so she knew she was not dealing with a placenta previa (the placenta does not move after 34 weeks). Carrie noted that “If the mother had not had ultrasound, there is no way I could have checked her with that much bleeding at home.” (In a case of true placenta previa, doing a cervical check can cause harm.) Carrie checked the baby’s heart tones, which sounded good. Carrie was concerned by the dark red color of the blood, which indicated that it was not from a superficial cause. She called the hospital and talked to the nurse-midwife who works for Carrie’s back-up doctor, telling her it looked like some kind of placental abruption might be occurring. They drove the mother to the hospital, where the nurse welcomed them into the labor and delivery unit and put the mother on an electronic fetal monitor, hooked up an IV, and drew blood to type and screen in case she had to have a Cesarean. The baby’s heart tones remained steady and strong. The doctor came in about ten minutes after they arrived and said to Carrie and the nurse, “It looks like you have everything under control.” Carrie expressed her concern about the color of the blood, but the doctor was not worried. He stayed for only about five minutes. After he left, the mother labored for another three hours. She spent time in the jacuzzi, sat on the toilet and then the birth ball for a while; eventually, she got in bed to try to rest. Carrie and the nurse-midwife turned off all the lights in the room. When pushing contractions kicked in, the mother pushed for about ten minutes, as Carrie recalls, and delivered on her hands and knees while the nurse-midwife caught the baby. The baby stayed with the mother. The placenta came fairly quickly after the birth; when Carrie and the CNM examined it, they could see a five centimeter clot on it—an indication that the placenta had partially detached in that area and had been bleeding from that place for a while. (If a placenta detaches uniformly after the birth, there will not be many clots on it unless it has been sitting in the uterus for quite a while, but if there is a partial separation, there will be clotting or additional clotting at the site of the partial separation.) The mother and baby went home the next morning. After the birth, the doctor told Carrie that she probably could have stayed at home for this one. And Carrie told him, “You have to realize that it’s important for me to transport sooner rather than later when I have the option.” And he said “You are right—I don’t always see it from your side.”

In the hospital, a partial placental separation is not cause for major alarm, since facilities for a Cesarean are there at hand. But home birth midwives like Carrie prefer to err on the side of caution—if you see too much bleeding to feel OK about it, you transport. A primary ingredient in Carrie’s willingness to transport early rather than late is the excellent relationship she has established over time with this doctor and this particular hospital. She said,

Since the early years of my practice, over time we have built up a lot of really good rapport, so that we have a lot of unoffficial back-up [it can’t be official as Carrie’s practice is not legal or licensed in Georgia.] We now have a doctor who is providing backup for us in that during the pregnancy he will see the mothers if we need him too–if we need an ultrasound he’ll do one in the office. He says he doesn’t like home birth but also he doesn’t like the fact that many doctors are refusing to see home birth mothers. He says everybody deserves good medical care when necessary. And if something comes up in labor, we can call the nurse-midwives who are always in-house. They listen to what we have to say on the phone and have everything set up when we arrive–the operating room ready, the doctor already in-house. So it is a really good situation—there are no animosities or repercussions or “attitudes” toward home birth mothers. The doctors aren’t exactly thrilled–they have said to the CNMs, “I wish you’d quit being so nice to these midwives so they’ll quit bringing women in.” And the CNMS have answered, “Would you rather leave them at home?” And the hospital is wonderful! It has no newborn nursery—I would consider them mother-baby friendly. The babies are never taken away from the moms unless they are really in trouble and need to be in the NICU.

Carrie’s experiences point out that different kinds of articulations can happen in the same location as the actors come to know and develop trust in each other over time.

In 1978 with the first publication of Birth in Four Cultures, Brigitte Jordan issued a call for the replacement of top-down, culturally inappropriate obstetrical systems with models of mutual accommodation between biomedical and indigenous systems–a plea that is equally significant for non-indigenous home-birth midwifery systems. Both Luz’s earlier story about transferring a patient from an unsupportive hospital to a private clinic with a physician who knew and trusted her, and Carrie’s story above illustrate the positive results of this sort of mutual accommodation. Nurse-midwives are especially well-placed to achieve it, as they inherently straddle and bridge (and occasionally fall into the fissures beween) biomedicine and home-birth midwifery. Establishing close relationships with home birth midwives who are not legal is simultaneously a transgressive and a boundary-spanning act. This prior communication between Carrie, the nurse-midwives, and the supportive physician certainly facilitated the smooth articulation of systems that both of these stories illustrate. Carrie feels that the key to this sort of smooth articulation is mutual respect and a cooperative attitude on the part of all concerned. Carrie’s long and safe practice in her community has earned her this kind of respect from the hospital practitioners who know her best. She notes that it can take years to build up this kind of relationship, especially with physicians who start out mistrusting midwives. Once established, though, such relationships tend to last. Many home birth midwives, including Carrie, Susan, Dina, Marisa, and Luz, do presently enjoy mutually accommodating relationships with one or two supportive physicians that they have worked hard to build over the years. But they note that such smooth articulations are jeopardized when the supportive MD moves away or retires and is replaced by a younger doctor “with an attitude,” as Carrie puts it, and then the midwife has to start all over again on the process of building trust. And most of my interviewees cannot always count on the availability of the physicians who support them; thus, even those who have spent years building good reputations and good relations with certain physicians sometimes still have to deal with fractured articulations during transport.

But in Carrie’s case, because of her long-term relationship with the nurse-midwives in her local hospital, the articulation between her knowledge system and that of the hospital and its practitioners is so smooth that she is more than willing to transport even for situations that have nothing to do with risk but rather with the mother’s comfort alone, as the following short story shows:

A primapara [mother giving birth for the first time] had pulled a muscle in her back at end of pregnancy and was in a lot of pain as a result; she called Carrie to her home in the middle of the night. Carrie arrived to find the mother was in very early labor, at two centimeters dilation, but with close to unbearable pain from the back spasms. Carrie spent hours trying to relieve the pain in her back with showers and warm compresses and massage. She said,

After a while we were running into brick walls as far as pain relief for the spasms, so we decided to go into the hospital where they have jacuzzis in the labor rooms. By the time we got there, she was 6 centimeters. The nurse-midwives who received us told her she was doing great. The jets did good counter-pressure on the back pain. They never started an IV and she had no pain medication. The baby’s heart tones always sounded great. I was able to catch the baby as “the grandmother” on the chart—the nurse working with us had had her babies at home, and the nurse-midwife was very supportive and felt this mom really deserved the continuity. The baby was fine and the family went home twelve hours after the birth.

As these two stories illustrate, smooth articulation between knowledge systems proceeds through points of overlap, transition, and communication that facilitate the seamless flow of information and linked, imbricated decision-making in which the actions taken by one person or group build on the information supplied by another. The relationships between Carrie and the hospital-based CNMs encompass such points, as do the relationships between theCuernavacamidwives and their supportive MDs. When this kind of decision-making takes place within the top-down biomedical system, such imbrication requires a rejection of its tendency to discount or dismiss as irrelevant other ways of knowing. Such rejections can and do take place at the level of the individual even when the system as a whole remains dismissive.

What motivates or inspires a physician to reject the top-down system and give credence to home-birth midwifery knowledge? In my experience, the ingredients key to an individual’s rejection of biomedical hegemony in favor of mutual accommodation include: (1) exposure to midwifery care; (2) exposure to midwives; (3) attention to the scientific evidence.

Exposure to midwifery care. Some doctors train in hospitals where nurse-midwives practice and thus are able to observe first-hand the benefits of midwifery care. Physicians I have interviewed are often awed by the midwife-attended births they witness, which are often visually and audibly nothing like previous births they have seen. Women attended by midwives in hospitals are more likely than women attended by physicians to give birth in upright positions, without an episiotomy, and with a great deal of hands-on support. Nurturance and consideration tend to characterize the midwife’s approach to the mother; shared decision-making takes place in a context of mutual respect. Physicians who do not ordinarily witness this kind of birth can find the experience transformative, can become imbued with a desire to incorporate this kind of respectful, humanistic approach into their own practice, and will be more likely to work with nurse-midwives in the future from a partnership, rather than a hierarchical, perspective. Occasionally a brave physician will venture outside hospital bounds and observe a midwife-attended home birth—an experience that tends to be emotionally evocative and ideologically transformative (see, for example, Wagner, 1997).

More profoundly, it is important to note that clinicians judge other clinicians as individuals, not just as members of a class or category; individual judgments can overcome prejudices based on subcultural differences. Does a practitioner give good care, make good decisions, communicate accurately? Individual practitioners decide the answers on the basis of experience. All clinical practitioners constantly gather experience and information, and react differently to a comment, order, or action from someone they trust as opposed to someone whose judgment has been faulty in the past or whom they do not know. Midwives work best with the doctors they have come to trust as a result of experience, and vice versa. But most doctors have little or no experience of working with home birth midwives; the experience they do have may be skewed if it comes only during emergency transports (see footnote 6). Lack of experience with working together creates problems that exacerbate and perpetuate lack of experience with working together (Judith Rooks, personal communication).

Exposure to midwives. Postmodern midwives in theU.S. andMexico, I can say without overstatement, tend to have huge hearts, impressive personalities, a strong sense of commitment and dedication to serving women, a secure sense of their own self- and professional worth, and a large fund of knowledge about parturition that seamlessly permeates their conversation. Simply spending time with them can turn a hospital practitioner from an opponent to a supporter. InU.S. communities where smooth articulation characterizes transport, home and hospital midwives, and sometimes physicians, often participate in periodic potluck dinners where models of mutual accommodation begin to emerge over casseroles and drinks. Hospital midwives who develop respect for and good relationships with home birth midwives often transmit this trust to the physicians with whom they work, in a kind of spillover effect that paves the way for future smooth articulations during transport. This kind of socializing, facilitated in theU.S. by the middle-class status shared by participants, is far less likely to occur inCuernavaca, where differences in social status between physicians and traditional midwives are more extreme.

Attention to the scientific evidence. There is increasing emphasis these days on “evidence-based medicine” (Rooks, 1999). As we have seen, midwifery tends to be more evidence-based than obstetrics because midwives are generally less interventive than physicians (Frye, 1995; Davis, 1997; Gaskin, 1990; Rooks, 1997) and the scientific evidence (Rooks, 1997, pp. 345-384; Macdorman & Singh, 1998; Goer, 1999; Enkin, Kierse, Neilson, Crowther, Duley, Hodnett & Hofmeyr, 2001) shows that many common interventions do more damage than good. Any doctor who actually looks at the evidence instead of relying solely on what he is taught by biomedical tradition will take note of the benefits of midwifery care, and will thus be less likely to assume a blanket superiority for obstetrics.

Crosscultural Perspectives on Transport

            Articulation is the production of identity on top of difference, of unities out of fragments, of structures across practices. Articulation links this practice to that effect, this text to that meaning, this meaning to that reality, this experience to those politics. . . And these links are themselves articulated into larger structures.

–LawrenceGrossberg, (1992, p. 54)

The experience of transport looms large in the minds of midwives because it is so emotionally loaded for them: they transport in hopes of resolving a situation they feel they cannot or should not handle at home, with hopes and prayers for a good reception most especially for the mother, but also for themselves. A positive reception in the hospital reinforces midwives’ sense of themselves as competent practitioners and elicits in them feelings both of pride in their good judgment and of gratitude toward the biomedical system for its efforts; a negative reception can leave the midwife and the mother emotionally scarred. Once burned, twice shy, they may in the future try too hard to avoid another transport, with potentially unfortunate results. Crosscultural research provides multiple examples (e.g., Allen, 2002; Barnes-Josiah, Myntti & Augustin, 1998; Iskandar, Atom, Hull, Dharmaputra & Aswar, 1996; Graham, 1999; Kroeger, 1996). For one brief example, Deborah Barnes-Josiah and her colleagues (1998) have shown that in Haiti, community midwives who have been badly treated in hospitals, or whose clients have received inadequate care after transport, try in the future to avoid transport by coping with emergencies at home as best they can, often until it is too late to seek help. If disaster befalls, the midwife is handed the blame, with no account taken of the prior experiences that generated her avoidance behavior.

The solution to the trouble with transport that the governments of developing countries have generally sought to implement usually involves the goal of eliminating home birth and traditional midwifery in favor of hospital or clinic birth attended by physicians and/or or professional midwives trained in two-year government-approved courses (Hsu, 2002; Jenkins, 2001; Sargent, 1989). Yet for a variety of reasons (see Davis-Floyd, 2000), women in many countries continue to choose their traditional attendants. Certainly, as Roger and Patricia Jeffrey pointed out in 1993, it is important not to romanticize indigenous midwifery and indigenous midwives; some indigenous customs are beneficial and some are not; some traditional midwives are competent practitioners within their own systems and some are not. Similar notes can be sounded about Western obstetricians: some intervene inappropriately, ignoring the evidence, while others exercise a more balanced and judicious approach. The transport stories I have recounted here should not be simplistically interpreted to indicate that all midwives are good and all biopowerful practitioners are bad or vice versa, but rather as ways of illuminating points of disjuncture and fracture, as well as models of smoothness, in the cross-boundary articulation of disparate knowledge systems.

Today in most developed countries, the home birth rate hovers around one percent. That home birth might be more widely chosen in the developed world if it were more readily available is indicated by the Netherlands, where the home birth rate has never dropped below 30% (Weigers, 1997), and New Zealand, where in recent years it has risen to 12% as the result of a strong alliance between midwives and consumers that has generated active government support. These two countries stand as models of what I would name seamless articulation—their midwives practice and their health care systems fully support birth in all settings, creating ease of choice and continuity of care across what in most other countries can only be seen as the home/hospital divide (DeVries, van Teijlingen, Wrede, & Benoit, 2001). In Europe as in the US, active movements seek to restore home birth as a viable option, with variable success. Meanwhile, in the developing world, home birth rates continue to decline in response to the pressures of modernization, yet millions of women still give birth at home, some because there is no other option, some out of active rejection of their region’s biomedical system, and others out of philosphical choice.

Home birth was both normal and normative for most of human history. But with the advent of biomedicine in the industrialized West, hospital birth became normative and home birth for most women ceased to exist as a viable or even thinkable option. In the developing world, this process is still unfolding; in countries like Mexico, it has already taken root to the extent that while home birth remains normative in rural areas, in the cities it has become an alternative and marginalized choice as it is in most of the developed world. Nevertheless, some women still make that choice, and traditional midwives continue to serve them, only now, like American midwives, these urbanized traditional midwives are developing hybrid techniques that reflect the mutiple systems of knowledge that intersect in their practices. They value the knowledge systems they are creating and the sometimes lifesaving knowledge system of biomedicine; yet the biomedical system, generally speaking, values only itself. Thus for both Mexican and American home birth midwives, biomedicine stands at once as the ultimate recourse and the ultimate enemy, often with no guarantees in any given transport as to which aspect will manifest.

The six transport stories I have recounted and analyzed here are fractals for thousands of others that shed light on the trouble- and stress-full interface between the worlds of biomedicine and home-birth midwifery. Spiraling beyond the bounds of the specific situations they recount, they index both the myriad possiblities for tragedy inherent in one knowledge system’s closed dismissal of its marginalized competitor, and the enhanced possibilties for more positive outcomes when members of that system open its boundaries to admit the fingers of articulation extended by practitioners from the outside. When parallel fingers reach out from the inside, taking account of midwives’ information, acting on their recommendations, and encouraging them to remain with the mother to provide ongoing support, the result can be what Grossberg (1992, p. 57) terms “active structures . . . that cut across domains and planes.” Further elaboration of such structures of smooth articulation could extend individualized links and nodes across the hospital/home divide, ending the dis-articulations, and mending the fractures, that generate much of the trouble with transport.

Acknowledgments

For their invaluable assistance in analyzing the transport stories, I wish to thank Sara Wickham RM, a home-birth midwife and midwifery instructor in the UK; Richard Jennings CNM, a hospital-based midwife in New York; Debbie Pulley CPM, a home-birth midwife in Georgia; William Camann MD, an obstetric anesthesiologist in Boston; and Judith Rooks CNM, an epidemiologist and expert on midwifery who also provided extremely helpful general editorial assistance. Many thanks also to Brigitte Jordan, Gwynne Jenkins, Marcia Inhorn, and three anonymous reviewers for their excellent editorial assistance. I wish to express my appreciation to the Wenner-Gren Foundation for Anthropological Research for its support of this research through grants #6015 and #6427.

Endnotes

1. During the course of this research, I have interviewed approximately 50 nurse-midwives, 45 nurse-midwifery students; 50 direct-entry midwives, 30 direct-entry midwifery students, 20 Mexican professional midwives, and 7 traditional midwives in Morelos who are professionalizing. I found both groups of Mexican midwives through my participation in conferences in theUSandMexicoput on by the Midwives’ Alliance of North America (MANA) (see Davis-Floyd, 2001a for more detail). I have also spoken informally or conducted short interviews with over 100 traditional Mexican midwives from all over the country.

2. Further research should include thorough quantitative and qualitative research on the treatment of transported women and its specific outcomes.

3. Other factors involved in the marginalized status these midwives hold in relation to physicians include differences in formal education, credentialling, and social class with wealth as proxy; inMexicoespecially, gender is also an important factor (Judith Rooks, personal communication, 2001).

4. Ideally, nurse-midwives’ transport experiences should be seamless but often are not. While there is excellent data on the statistical outcomes of nurse-midwife-attended births in the U.S., including home-hospital transports (Macdorman & Singh, 1998), I know of no research on American nurse-midwives’ transport experiences. In Mexico, nurse-midwives do not really exist as a class of practitioners. Rather, nurses who choose to specialize in obstetrics undergo an additional year of university training. Officially titled Licenciadas en Enfermeria y Obstetricia (colloquially known as las LEOs), these women mostly work as high-tech labor and delivery nurses, in addition to performing administrative work and teaching. But they do attend births and function like American nurse-midwives in a few private hospitals and clinics in centralMexico.

5. Medical practitioners who only see problematic home births that are transported to the hospital tend to think that all home births are “botched.” The rate of problems derives as a function of a numerator (number of cases with problems) and a denominator (total number of cases–the majority–that have good outcomes). If one only sees the numerator, it is impossible to realize that the rate of transports is actually very low compared to the number of successful home births.

6. In theU.S.there were 23,232 home births in 1998 and 23,518 in 1999–an increase of 1.2%. Midwives are not the only practitioners who attend home births. Of 23,518 home births reported onU.S.birth certificates in 1999, 2,476 (10.5 %) were attended by a physician, 12,123 (51.5%) by a midwife, and 8,524 (36.2 %) by someone else. Some, but not all of the “other” attendants were probably midwives practicing without legal authority (Ventura et al., 2001).

7. Nurse-midwives began their long struggle for legitimation in the 1920s. In 1955 they created a national association, the American College of Nurse-Midwives (ACNM), whose members have worked hard for decades to achieve legal and medical acceptance of their profession. Certified nurse-midwives (CNMs) are legal, licensed, and regulated in all states. Most of the 5500 or so practicing nurse-midwives attend births in hospitals; appromimately 200 of them attend births at home. The ACNM officially supports home births, and many of its members would like to be able to attend them. But ACNM-certified midwives must have physician backup and insurance and many are unable to attain these for out-of-hospital birth. For hospital births their services are covered by private insurance companies in all states, as well as by Medicaid and managed care. They attend 7% of American births; 96% of the births they attend take place in hospitals (Rooks, 1997; Paine, Dower & O’Neil, 1999, p. 343; Curtin, 1999, pp. 349-352).

8. MANA members created the North American Registry of Midwives (NARM) which in turn created CPM certification, issuing its first certificates in 1994.

9. CPMs and other direct-entry midwives are legal, regulated, and licensed, registered, or certified in 17 states; legal through judicial interpretation or statutory inference or a-legal in 18 states; effectively prohibited in 7 states where licensure is required but unavailable; and illegal in 9 states. For updates on these numbers, see <www.mana.org/narm>.

10. In public hospitals inMexico, the Cesarean rate increased from 13% in 1990 to 25% in 1997 – and from 25% to 37% inMexico City(Secretaría de Salud, 1998); in private hospitals the national average in 1997 was 52% (Comité Promotor por una Maternidad sin Riesgos, 1997). Recent research indicates the doctor-driven nature of this excess of Cesareans, which social scientists are now calling an “iatrogenic epidemic” (Castro, Heimberger, and Langer, n. d.).

11. Home birth is almost completely non-existent as an option for middle-class women, most of whom would not think of using the services of a traditional midwife; see Davis-Floyd, 2001a for exceptions.

12. Young people in Mexico today in general prefer to seek formal education into a profession, and see the hospital as the progressive place to go for birth (see also Fraser, 1995).

13. As of June 2001, MANA has 67 dues-paying members in Mexico, most of whom are either professional direct-entry midwives (see Davis-Floyd, 2001a) or urban traditional midwives in the state of Morelos. The annual conferences these MANA members in Mexicohave been putting on since 1995 are attended by hundreds of traditional midwives from all over the country.

14. MyCuernavaca interviewees keep notebooks recording their outcomes, and turn statistical forms into the Department of Health. It would be an excellent research project to compile their statistical data, including the outcomes of their transports.

15. A caveat: To my knowledge, most home birth midwives who transport enter the hospital and stay with their clients for as long as they are allowed to stay. But I have heard critiques from some hospital practitioners of home birth midwives who “dump their clients at the hospital door and take off.” Such midwives usually live in states where their practice is illegal or in places where local hospital personnel are known to be particularly negative and unreceptive. Leaving their clients at the door can be viewed as an extreme form of disarticulation stemming from midwives’ fear that any interaction with the hospital system at best will result in serious harassment and at worst will send them to jail—a powerful argument for the legalization of midwifery, which certainly facilitates the development of systems of smooth articulation.

16. Some midwives fail to transport because of lack of familiarity with medical indications for transport. I cannot speak to such situations here, because all of my interviewees for this article—American direct-entry midwives and the professionalizing traditional midwives ofCuernavaca–were thoroughly schooled in indications for transport.

17. All names are pseudonyms.

18. MyCuernavacainterviewees almost never call 911 for an ambulance because of long delays in arrival. Taxi drivers fees are low and they arrive quickly because they are familiar with local neighborhoods and rarely get lost, in contrast to paramedics.

19. Judith Rooks CNM, MPH is an epidemiologist and expert on midwifery care. She is the author of Midwives and Childbirth in America (1997), the definitive book on the subject.

References

Allen, D. R. (2002). Managing motherhood, managing risk: Fertility and danger in rural Tanzania.Ann Arbor:University ofMichigan Press.

anthropology of medicine in everyday life (pp. 7-31).Berkeley andLondon:

Appadurai, A. (1996). Modernity at large: Cultural dimensions of globalization.Minneapolis:University ofMinnesota Press.

Appiah, K. A. (1997).  Is the “post-” in “postcolonial” the “post-” in postmodern? In A. McClintock, A. Mufti, & E. Shohat(Eds.), Dangerous liaisons: Gender, nation, and postcolonial perspectives (pp. 420-444).Minneapolis:

Barnes-Josiah, D., Myntti, C., & Augustin, A. (1998). The three delays as a framework for examining maternal mortality in Haiti. Social Science & Medicine 46:981-993.

Belizán, J. M., Althabe, F., Barros, F. C., & Alexander, S. (1999). Rates and implications of Caesarean sections in Latin America: Ecological study. British Biomedical Journal 319:1397-1400. Available: www.bmj.com/cgi/content/full/319/7222/1397#art.

Castro, A., Heimberge, A., & Langer A. (n.d.). Iatrogenic epidemic: How health care professionals contribute to the high proportion of Cesarean sections inMexico. Unpublished manuscript.

Comité Promotor por una Maternidad sin Riesgos. (1997). Cesáreas: Tendencias actuales y perspectivas.Secretaría de Salud,Mexico.

Curtin, S. C. (1999). Recent changes in birth attendant, place of birth, and the use of obstetric interventions. Journal of Nurse-Midwifery 44(4): 349-354.

Davis, E. (1997). Heart and hands: A midwife’s guide to pregnancy and birth (3^rd ed.).Berkeley,CA: Celestial Arts.

Davis-Floyd, R. (1992). Birth as an American rite of passage.Berkeley:University ofCalifornia Press.

Davis-Floyd, R. (1994).  The technocratic body: American childbirth as cultural expression. Social Science & Medicine 38(8):1125-1140.

Davis-Floyd, R. (1998a). From technobirth to cyborg babies: Reflections on the emergent discourse of a holistic anthropologist. In R. Davis-Floyd & J. Dumit (Eds.), Cyborg babies: From techno-sex to techno-tots (pp. 255-283).New York: Routledge.

Davis-Floyd, R. (1998b). The ups, downs, and interlinkages of nurse- and direct-entry midwifery: Status, practice, and education. In J. Tritten & J. Southern (Eds.), Getting an education: Paths to becoming a midwife (4^th ed) (pp. 67-118).Eugene,OR: Midwifery Today. Available: www.midwiferytoday.com

Davis-Floyd, R. (2000, March). Global issues in midwifery: Mutual accommodation or biomedical hegemony? Midwifery Today, 12-17, 68-69.

Davis-Floyd, R. (2001a). La partera profesional: Articulating identity and cultural space for a new kind of midwife in Mexico. In R. Davis-Floyd, S. Cosminsky & S. L. Pigg (Eds.) Daughters of time: The shifting identities of contemporary midwives [Special issue] Medical Anthropology 20(2-3):185-243.

Davis-Floyd, R. (2001b, November). Las parteras de Morelos: The strategic negotiation of knowledge systems by postmodern midwives inMexico. Paper presented at the meeting of the American Anthropological Association,Washington,D.C.

Davis-Floyd, R. (2002). Southern discomfort: American midwifery as a cautionary tale. In I. Bourgeault, C. Benoit & R. Davis-Floyd (Eds.) Reconceiving midwifery: The new Canadian model of care.Ann Arbor:University ofMichigan Press.

Davis-Floyd, R. (2003). Qualified commodification: Consuming midwifery care. In J. Taylor, D. Wozniack & L. Layne (Eds.) Consuming Motherhood.

Davis-Floyd, R., Cosminsky, S. & Pigg, S. L. (Eds.). (2001). Daughters of time: The shifting identities of contemporary midwives [Special issue] Medical Anthropology 20(2-3/4).

Davis-Floyd, R. & Davis, E. (1997). Intuition as authoritative knowledge in midwifery and home birth. In R. Davis-Floyd & C. Sargent (Eds.) Childbirth and authoritative knowledge: Cross-cultural perspectives (pp. 315-349).Berkeley:University ofCalifornia Press.

Davis-Floyd, R. & Johnson-Levitin, C. (Eds.). (n.d.) Mainstreaming midwives: The politics of change.New York: Routledge.

Declerq, E. (2001). CNM birth attendance in the United States, 1998. Journal of Midwifery and Women’s Health 46(1):31.

DeClerq, E., DeVries, R., Viisainen, K., Salvesen, H. B., & Wrede, S. (2001). Where to give birth? Politics and the place of birth. In R. DeVries, E. van Teijlingen, S. Wrede & C. Benoit (Eds.). Birth by design: Pregnancy, maternity care and midwifery in North America and Europe (pp. 7-27).New York: Routledge.

DeVries, R., van Teijlingen, E., Wrede, S. & Benoit, C. (Eds.). (2001). Birth by design: Pregnancy, maternity care and midwifery in North America and Europe.New York: Routledge.

Enkin, M., Kierse, M. J. N. C., Neilson, J., Crowther, C., Duley, L., Hodnett, E. & Hofmeyr, J. (2000). A Guide to effective care in pregnancy and childbirth (3^rd ed.).New York:OxfordUniversity Press.

Fernandez de Castillo, C. (1997). Las cesareas en el sector privado. In Cesareas: Tendencias actuales y perspectivas.Mexico D.F.: IMES: Comité Promotor por una Maternidad sin Riesgos enMexico.

Foucault, M. (1978). The history of sexuality: An introduction (Vol. 1) (R. Hurley, Trans.).New York: Random House.

Fraser, G. (1995). Modern bodies, modern minds: Midwifery and reproductive change in an African American community. In F. Ginsburg & R. Rapp (Eds.), Conceiving the new world order: The global

Frye, A. (1995). Holistic midwifery: A comprehensive textbook for midwives in home birth practice (Vol. I), Care during pregnancy.Portland,OR: Labyrs Press.

Fullerton, J. (Ed.). (2000). Skilled attendance at delivery: A review of the evidence.New York: Family Care International.

Gaskin, I.M. (1990). Spiritual midwifery (3^rd ed.).Summertown,TN: The Book Publishing Company.

Goer, H. (1999). The thinking woman’s guide to a better birth.New York: Penguin Putnam/Perigree.

Good Maust, M. (2000). Making bodies: Cesarean narratives in Merida, Yucatan. Unpublished doctoral dissertation,University ofFlorida,Gainesville.

Good Maust, M., Güémez Pineda, M. & Davis-Floyd, R. (n.d.). Midwives in Mexico: Continuity, controversy, and change.Austin:University ofTexas Press, forthcoming.

Graham ,S. (1999). Traditional birth attendants in Karamoja, Uganda. Unpublished doctoral dissertation,SouthBankUniversity,London.

Grossberg, L. (1992). We gotta get outa this place: Popular conservatism and postmodern culture.New York: Routledge.

Hsu C. (2001). Making midwives: The logics of midwifery training in St. Lucia. In R. Davis-Floyd, S. Cosminsky& S. L. Pigg. (Eds.). (2001). Daughters of time: The shifting identities of contemporary midwives [Special issue] Medical Anthropology 20(4).

Instituto Nacional de Estadistica, Geografia e Informatica (INEGI). (1999). Encuesta Nacional de la Dinamica Demografica 1997. INEGI,Aguascalientes. Available: www.inegi.gob.mx

Iskandar, M., Atom, B., Hull, T., Dharmaputra, N. & Azwar, Y. (1996). Unraveling the mysteries of maternal death in West Java: Reexamining the witnesses. Depok: Center for Health Research, Research InstituteUniversity ofIndonesia.

Jeffery, R. & Jeffery, P. M. (1993). Traditional birth attendants in rural North India: The social organization of childbearing. In S. Lindenbaum & M. Lock (Eds.), Knowledge, power, and practice: The

Jenkins, G. (2001). Modernization and postmodernization in the changing roles and identities of midwives in rural Costa Rica. In R. Davis-Floyd, S. Cosminsky& S. L. Pigg. (Eds.). (2001). Daughters of time: The shifting identities of contemporary midwives [Special issue] Medical Anthropology 20(2-3).

Johnson, K. C. & Daviss, B. A. (2001, October). Results of the CPM Statistics Project 2000: A prospective study of births by Certified Professional Midwives In North America. Abstract presented at the annual meeting of the American Public Health Association, Atlanta,GA.

Jordan, B. (1993). Birth in four cultures (Rev. ed.).Prospect Heights,IL: Waveland Press.

Jordan, B. (1997). Authoritative knowledge and its construction. In R. Davis-Floyd & C. Sargent (Eds.), Childbirth and authoritative knowledge: Cross-cultural perspectives (pp. 55-79).Berkeley:University ofCalifornia Press.

Kroeger, M. (1996). Final consultant report. CHN III Project, Provincial Department of Health CentralJava,Indonesia.

MacDorman, M. & Singh, G. (1998). Midwifery care, social and biomedical risk factors, and birth outcomes in the USA. Journal of Epidemiology and Community Health 52:310-317.

Martin, E. (1987). The woman in the body.Boston: Beacon Press.

Paine, L.  L., Dower, C. M. & O’Neil, E. (1999). Midwifery in the 21^st century: Recommendations from the Pew Health Professions Commission/UCSF Center for the Health Professions 1998 Taskforce on Midwifery. Journal of Nurse Midwifery 44(4):341-348.

Pigg, S. L. (1997). Authority in translation: Finding, knowing, naming, and training “Traditional birth attendants” in Nepal. In R. Davis-Floyd & C. Sargent (Eds.), Childbirth and authoritative knowledge: Cross-cultural perspectives (pp. 233-262).Berkeley:University ofCalifornia Press.

politics of change (pp 42-58).Berkeley:University ofCalifornia Press.

Rooks, J. P. (1997). Midwifery and childbirth in America.Philadelphia:TempleUniversity Press.

Rooks, J. P. (1999). Evidence-based practice and its applications to childbirth care for low-risk women. Journal of Nurse- Midwifery 44(4):355-369.

Rothman, B. K. (1982). In labor: Women and power in the birthplace.New York: W.W. Norton.

Rothman, B. K. (1989). Recreating motherhood: Ideology and technology in patriarchal society.New York: W. W. Norton.

Sargent, C. (1989). Maternity, medicine, and power: Reproductive decisions in urban Benin.Berkeley:University ofCalifornia Press.

Schaef, A. (1992). Women’s reality (Rev. ed.).San Francisco: Harper.

Secretária de Programación y Presupuesto. (1979). Encuesta Mexicana de fecundidad, primer informe nacional.Mexico: Secretaria de Programacion y Presupuesto.

Secretaria de Salud (SSA—this agency was formerly known as the Secretaria de Salud y Asistencia, and is still abbreviated as SSA). (1994). La partera tradicional en la atencion materno infantil en Mexico. Available: www.ssa.gob.mx.

UniversityofCaliforniaPress.

UniversityofMinnesotaPress.

Ventura, S. J., Martin, J. A., Curtin, S. C., Menacker, R. & Hamilton, B. E. (2001). Births: Final data for 1999. National Vital Statistics Reports 49:1.Hyattsville,Maryland:NationalCenter for Health Statistics.

Wagner, M. (1997). Confessions of a dissident. In R. Davis-Floyd & C. Sargent (Eds.) Childbirth and authoritative knowledge: Cross-cultural perspectives (pp. 366-396).Berkeley:University ofCalifornia Press.

Weigers, T. (1997). Home or hospital birth: A prospective study of midwifery care in the Netherlands. Unpublished doctoral disseration:LeidenUniversity, NIVEL,Utrecht.

Robbie E. Davis-Floyd

This article appears as Chapter 22 in Unhealthy Health Policy: A Critical Anthropological Examination,

eds. Arachu Castro and Merrill Singer.AltamiraPress, pp. 329-350, 2004.

            As proponents of the global Safe Motherhood Initiative have long stressed, in both the developing world where home birth is often a necessity, and the developed world where it is a choice, primary keys to safe home birth include transport to the hospital in cases of need and effective care on arrival (Fullerton 2000). In this chapter, I examine what happens in the United States when transport occurs, how the outcomes of prior transports affect future decision making, and how the lessons derived from the transport experiences of U.S. birthing women and midwives could be translated into improvements in maternity care. In the developing world, two aspects are critical to the viability of transport: (1) Can the mother get there? In other words, is there a hospital within reach, and can a vehicle be found? And (2) What happens when she arrives? In the United States, where some form of transport is almost always available, the latter issue is by far the most salient.America’s trouble with transport is not its lack but rather what happens when it places the mother who had planned to give birth at home, and the midwife attending her, in interaction with biomedical personnel.

In the United States, as elsewhere, biomedicine and home birth midwifery exist in separate cultural domains and are based on overlapping but distinctively different knowledge systems. When a home birth midwife arrives in the hospital with her client, she brings with her the general ways of knowing and style of practice that characterize her cultural domain, and her specific prior knowledge about the woman’s overall health, personality, desires, and labor process. This knowledge can be vital to the mother’s successful treatment by the hospital system. But the culture of biomedicine in general tends not to understand or recognize as valid the knowledge of midwifery. Thus in the hospital, the midwife may have no authoritative status. Yet she must interface with medical personnel if she is to communicate information that the hospital staff may need to provide appropriate and effective care for her client. Smooth articulation of the medical and midwifery knowledge systems facilitates the safest transition for the woman and her baby, but, all too often, disjuncture and disarticulation occur. The tensions and dysfunctions that result are displayed in midwives’ transport stories, which I here identify as a narrative genre. In this chapter, I unpack these stories for the collision of worlds they encapsulate and the points of fracture and permeability in the crusts of those worlds that they reveal.

I focus specifically on the transport stories told by American midwives with whom I have conducted extensive interviews. I narrate six of these stories, analyzing them as cultural terrains that reveal how childbirth can go unnecessarily awry when domains of knowledge conflict and existing power structures ensure that only one kind of knowledge counts. I describe such encounters as (1) disarticulations that occur when there is no correspondence of information or action between the midwife and the hospital staff;, and (2) fractured articulations of biomedical and midwifery knowledge systems that result from partial and incomplete correspondences. I contrast these two kinds of disjuncture with the smooth articulation of systems that results when “mutual accommodation” (Jordan 1993) characterizes the interactions between midwife and medical personnel. In the conclusion, I link these U.S. transport stories to their international context, describing how they index some of the cross-cultural markers for “the trouble with transport.”

Articulation and Authoritative Knowledge: Biopower Meets the Home Birth Midwife

ar.ti.cu.late vt. (1) to put together by joints; (2) to arrange in connected sequence, fit together, correlate. vi. to be jointed or connected. n. a joint in a stem or between two separable parts, as a branch and leaf [or] a node or space between two nodes.  —Webster’s New World Dictionary, 2000

My use of the term “articulation” in this chapter comes from Gramsci through Lawrence Grossberg (1992:54), who notes that the concept of articulation “provides a useful starting place for describing the process of forging connections between practices and effects.” His starting place will be my ending place, as most of the stories I recount below illustrate connections that could potentially have been forged but instead were either never made or only partially constituted. These disjunctures in what could have been functional, smoothly bending joints stem from the dominance of biomedicine—a hierarchical system that has sought, in general, not to articulate with home birth midwifery but rather to eliminate it through discounting its practices and knowledge base. In Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives, Brigitte Jordan (1997:56) noted that

for any particular domain several knowledge systems exist, some of which, by consensus, come to carry more weight than others, either because they explain the state of the world better for the purposes at hand (efficacy) or because they are associated with a stronger power base (structural superiority), and usually both. In many situations, equally legitimate parallel knowledge systems exist and people move easily between them, using them sequentially or in parallel fashion for particular purposes. But frequently, one kind of knowledge gains ascendance and legitimacy. A consequence of the legitimation of one kind of knowing as authoritative is the devaluation, often the dismissal of all other kinds of knowing.

Jordan(1997) maps out what happens when one kind of knowing does gain ascendancy, thus opening up the possibility of asking what happens when an ascendant knowledge system and a devalued one must interface. Why do adherents of a dominant knowledge system sometimes dismiss what adherents of a devalued system have to say, sometimes give them partial credence, and other times honor them, act promptly on their recommendations, and include them in the process? The stories I analyze below illustrate all of these possible scenarios.

In the process of describing how Western biomedicine gained its cultural ascendancy, Michel Foucault identified the cultural authority it carries as a form of “biopower,” which he defined as “disciplines of the body,” used as “numerous and diverse techniques for achieving the subjugation of bodies and the control of populations” (1978:140). This subjugation and control include the biomedicalization of bodily processes like childbirth and the development of institutions within which such processes are supposed to take place, along with formalized structures for managing them.Jordan augments Foucault’s notion of biopower with her focus on the status of particular knowledge systems:

It is important to realize that to identify a body of knowledge as authoritative speaks, for us as analysts, in no way to the correctness of that knowledge. Rather, the label “authoritative” is intended to draw attention to its status within a particular social group and to the work it does in maintaining the group’s definition of morality and rationality. The power of authoritative knowledge is not that it is correct but that it counts. (Jordan 1997: 57)

Although the American home birth midwives whom I have studied treat their own knowledge system as authoritative in the home context, they are acutely conscious of the larger and more valued authority carried by biomedicine not only inside the hospital but also in the culture at large. Much of the time, these midwives do not accept biomedical knowledge as truth or fact; many of their practices and much of their midwifery knowledge system constitute a radical critique of obstetrics, challenging its claims to the authority of fact and truth. But these midwives also understand that in the hospital as in the wider culture, including in courts of law, their radical critique goes largely unheard and their ways of knowing do not count. Faced with a formalized system of biopower that discounts their individualized approach to maternity care, during transport midwives nevertheless often seek to communicate what they know, in the interests of securing the care for which they brought the woman to the hospital—care that they deem to be necessary for their client’s safety and well-being. So as they enter the hospital, they extend into that system what I identify as fingers of articulation in an effort to generate a productive interface. The following detailed examination of midwives’ transport stories intends to illuminate what happens along a spectrum of possibilities from disarticulation to smooth articulation, from the dismissal of these outreaching fingers to their clasping by a biomedical hand. Through examining this spectrum of articulations between knowledge systems, I hope to augmentJordan’s explanations of what happens when one system of knowledge discounts another with a more nuanced consideration of how, in specific situations, the dominant system can come to take the subaltern system into partial or fully accommodative account.

Methodology

This chapter is based on my continuing research on American midwives (begun in 1995). The focus of much of this research has been midwifery education, praxis, politics, and status within the American technocracy (Benoit et al. 2001; Davis-Floyd, 1998, 2003, 2004, in press; Davis-Floyd and Johnson2005). This research did not specifically focus on transport stories as a genre or on transport as a salient issue. But during its course, I heard many transport stories told. Over time, these transport stories began to emerge for me as a narrative genre that richly encapsulates clashes of power and ideology between the biomedical and midwifery systems and their potentially devastating consequences for mother and baby. The particular stories I present here embody the collision of worlds I seek to analyze. It is important to note that in the United States, there are approximately 200 nurse-midwives (out of over 6000 CNMs in practice) who attend both home and hospital births; their transport experiences are somewhat different, especially when they practice and carry authoritative status in both domains. I suggest them as potential subjects of a future study.¹ Because of the political problematics of midwifery practice and especially of transport, all names I utilize are pseudonyms.

Background and Context: Obstetrics and Midwifery in the United States

From an obstetrical point of view, every birth is a potential disaster and must be managed authoritatively and preventively to ensure the best possible outcome. Thus, most women laboring in American hospitals today are routinely hooked up to intravenous lines and electronic fetal monitors throughout labor. Their labors are often induced or augmented with a variety of pharmacologic agents, including pitocin and cytotec. Epidural anesthesia is commonly used to eliminate pain. Just under half of birthing women receive an episiotomy to enlarge the vaginal opening and speed delivery. Just under 30 percent of all babies in the United States are pulled out with forceps, vacuum extractors, or via cesarean section (Ventura, Martin, Curtin, Menacker, and Hamilton 2001). As various social scientists have previously described (Davis-Floyd 1992; Martin 1987; Rothman 1982, 1989), the performance of birth in American hospitals tells a cultural story about the female body as a defective machine in need of assistance by technical experts and other, more perfect machines; this has also been documented in Mexico (Castro 1999). It also enacts and displays the technocracy’s supervaluation of speed, efficiency, control, high technology, and the flow of information through cybernetic systems. Technobirths are typical and normative in American hospitals through a consensual, biopowerful process jointly driven by physicians, who tend to be trained exclusively in that approach, and women, who tend to also to supervalue technology, control, and most especially the elimination of labor pain (Davis-Floyd 1994). For instance, the use of epidural anesthesia necessitates the use of many other technologies to monitor for and intervene in complications associated with the epidural. In other words, while some women might make other choices if they had more information, generally speaking the interventive American approach exists by mutual agreement between women and physicians steeped in the core values and overall approach to life characteristic of their technocratic culture. Both groups believe that this approach offers both comfort and safety in the face of an unpredictable natural process that proceeds more safely when carefully controlled, in the same way that a river subject to flooding seems improved when a series of dams and floodgates are installed.

To hospital-based practitioners, the choice for home birth appears to be a choice for danger, pain, and random chaos in contrast to order and control. Most hospital-based practitioners have never seen a home birth and know little about the knowledge base of home birth midwives, in part because of a near-total lack of contact. The many safe and woman-centered births that take place at home are invisible to the medical gaze; biomedical discourse tends to center around “botched home births.” This phrase is often bandied about by medical practitioners who tend to assume that any home birth that ends up in the hospital must be “botched,” even if it is the result of an appropriate transport.² The midwifery response is usually a sarcastic comment about enormous numbers of “botched hospital births”; women who have had “botched” hospital experiences and later choose home birth are an important source of such accounts. This trading of insults is an in-group phenomenon: hospital practitioners complain to other hospital practitioners about home birth and midwives; midwives complain to other midwives about hospital practitioners. Dialogue between these groups is rare. Mostly, their members inhabit separate worlds that only intersect when a home birth goes awry and a transport is the necessary result.

From an anthropological point of view, U.S. direct-entry midwives elide and confound the usual international distinctions between professional and traditional midwives: some of the American home birth midwives who are professionally licensed and certified were trained through apprenticeship or self-study (Benoit et al. 2001; Davis-Floyd 1998); others are nurse-midwives trained in university-based programs. Despite these differences, and because of their mutual dedication to the welfare of women and belief in the safety and efficacy of home birth, it is fair to say that all home birth midwives in the United States are inspired by a transnational ideology of home birth and “sisterhood” in midwifery. All home birth midwives critique the failures and limitations of biomedicine and have a strong sense of mission about preserving home birth in the face of biomedical hegemony. They believe in women’s ability to give birth with little intervention most of the time, in the superiority of homes and birth centers as the sites of birth, and in the efficacy of their own knowledge systems and skills. They do not undertake transport unless they are convinced that the situation is truly in need of technomedical intervention, and when they do transport, their intent is to do all in their power to make the medical system respond in ways they consider appropriate. Thus, their transports usually involve at least two people from outside the biomedical realm: the mother who needs help, and the midwife who will not abandon her even when she is no longer in charge of her care.³

All midwives who practice out of hospital must occasionally transport. In the United States, home birth midwives have a transport rate of about 12 percent (Johnson and Daviss 2001).⁴ In other words, 88 percent of their clients give birth safely at home, while 12 percent are transported to the hospital during or after labor for various reasons: 6 percent (six out of 100) are transported for precautionary reasons like failure to progress in labor, meconium staining in the amniotic fluid (possibly but not necessarily a sign of fetal distress), or a retained placenta after the birth. 3.6 percent (3-4 out of 100) are transported for potentially life-threatening emergencies (Johnson and Daviss 2001). The transport stories I have culled from my interview data and selected to recount below cluster inside that 3-4 percent; I urge my readers to keep in mind that the circumstances they recount are quite rare and not representative of the vast majority of births. These experiences are most likely to be encoded in narrative because they are so unusual and also because of their heavy emotional charge. Stories give meaning and coherence to experience; midwives who transport under frightening circumstances often need to find that coherence and to evaluate through narrative, with the benefit of hindsight, their own actions and those of the mother and the biomedical personnel.

In transport situations, there are various ways in which things can go wrong: (1) the fact that transport is indicated means that the natural process of birth has in some way gone awry, or seems likely to; (2) the midwife may wait too long to summon transport, usually because of prior bad experiences with transport; (3) the hospital staff taking the call may not understand the urgency of the mother’s problems; (4) emergency medical technicians (EMTs) may fail to respond appropriately, or there may be disjunctive communication between the midwives and the EMTs; (5) arrival at the hospital can go awry for the mother and the midwife if either is ignored or mistreated; (6) even well-intended biomedical interventions can at times do more damage than they fix; and (7) not all natural disasters are fixable by biomedical means, so even with the very best of care, the death of the mother or baby can occur. Only some of these possible levels of awryness are illustrated in the stories I tell below. I selected these particular stories because they are typical: they represent the range of possible outcomes of transport and are emblematic of many other situations and possibilities I do not have room to treat here. Since I have no way of ascertaining the truth or untruth of these stories, for the purposes of this chapter I take them at face value and unpack them for what they reveal about midwives’ perceptions of, and the meanings midwives attribute to, events as they unfold.

The Stories

In this section, the stories as the midwives recounted them to me are italicized; these stories are not direct quotes but my summarized retellings (unless otherwise indicated). Contextualizing information, my analyses and interpretations, and the midwives’ additional comments, appear in regular font.

Dis-articulation

Carrie’s First Story: Unnecessary Delay

Carrie Smiley is a certified professional midwife (CPM) who has practiced in Atlanta, Georgia, for over 18 years, attending during that time over 850 births. Her practice is “unlawful” (meaning that it is punishable in the misdemeanor category). Most of the home births she attends are for white middle-class couples. She does prenatal care out of her own home, a two-story house at the edge of a small lake in an attractive Atlanta suburb. She began her birth career in the late 1960s working as a volunteer in labor and delivery, and then took training as a biomedical assistant, working in labor and delivery and for a pediatrician for several years. Starting in 1977 she began attending the home births of friends; in the early 1980s she undertook a year-and-a-half apprenticeship with another home birth midwife who later became her partner. The following episode took place in 1984, during the early years of Carrie’s home birth midwifery practice. But it should not be regarded as dated, as it typifies many transports that presently occur, especially in “illegal” states.

            Carrie and her partner are attending a mother pregnant with her first child, laboring at home and planning a home birth. After about eight hours of labor, the mother has reached ten centimeters dilation and is starting to feel the urge to push. Monitoring the baby’s heart tones, the midwives detect strong decelerations, a sign of fetal distress. Hoping to get the baby out quickly, the midwives ask the mother to push a few times to see if the baby will come down. When they realize that the mother is not going to be able to get the baby out with sufficient expediency, they get her to kneel in a knee-chest position, put her on oxygen, and call the EMTs. When ten minutes pass and the EMTs have not yet arrived, the midwives help the mother into their car, planning on driving her to the hospital themselves. Just as they are ready to go, the ambulance pulls up and blocks the driveway. Announcing, “We’re here now, we’ll take it from here,” the paramedics pull the mother out of the midwife’s car and help her into the ambulance. But they refuse to heed the midwives, who are urging that they must rush the mother to the hospital, insisting that first they have to get a history. Asking questions like “hHave you had any nausea during this pregnancy?” the EMTs are wasting precious time. Frantic at the delay, and knowing the baby might be suffering from oxygen deprivation, the midwives ask the paramedics to put the mother on oxygen. They refuse, wanting to continue with the history, so the midwives get their own oxygen tank out of the car, at which point the medics finally accede and hook the mother up to the ambulance oxygen tank. As the ambulance starts toward the hospital, the midwife riding with the mother asks her to get on her hands and knees to relieve any possible cord compression, but the paramedics get upset and turn the mother flat on her back. Knowing that this position will exacerbate cord compression and reduce blood and oxygen flow to the baby, the midwife compromises by turning the mother on her side, and continues to listen to the fetal heart tones.

            Arriving at the hospital, the midwives are told that there are several obstetricians present in the hospital, but only the one on call is allowed to treat a “walk-in” and he is not in-house and will have to be called. Increasingly frantic, the midwives insist to the nurse in the emergency room (ER) that the baby is in distress. The nurse auscultates the heart tones, records them at 130, announcing this to the midwives and the mother, and tells the midwives, “Everything is fine; we will take over from here.” She will not look at the records the midwives brought, which show the heart fluctuations, nor pay heed to their insistence that this is an emergency. The midwives are not allowed to remain with the mother in the ER or to accompany her to labor and delivery. Instead they are sent to the waiting room. Carrie says, “Every time we went outside the room, we noticed that everyone seemed to be looking at us and talking about us.”

            Terrified that they will be arrested and sent to jail, the midwives finally head home. Later they learn that it took the doctor on call one hour and 45 minutes to show up. In the meantime, the nurses caught the baby, who was stillborn. The cause of death was listed on the hospital record as “prolonged fetal distress.” The EMT records said that the mother had been antagonistic and refused oxygen, which the midwives insist is untrue. The nurses said the mother refused the electronic fetal monitor. The hospital pushes the mother to file criminal charges against the midwives, but the mother tells the hospital personnel that this death is clearly the hospital’s fault, that the midwives acted appropriately and bear no blame, and that if the hospital should try to harass the midwives in any way, she will sue the hospital, not the midwives.

In Carrie’s view, she and her partner did their best. Trained to detect fetal heart rate decelerations and to recognize which ones are dangerous, they responded appropriately to the signs of fetal distress. But in retrospect, Carrie wishes that they had taken the woman to the hospital themselves. When I asked her why they called 911 in the first place, Carrie responded, “We were really dumb—we thought that was the appropriate thing to do.”

From Carrie’s point of view, blocking the driveway and announcing, “We’ll take it from here,” demonstrated the EMTs’ arrogant and authoritative attitude, which at first glance seemed to leave no further role for the midwives to play. She feels that she and her partner demonstrated strength in their refusal to accept this dismissal. Rather, they flexibly and creatively tried to work with the EMTs to help the mother get what they felt she needed. Frustrated by their inability to convince the EMTs of the need for haste, they experienced their success in getting the mother back on oxygen as a small victory. They had good reason to believe that the baby was oxygen-deprived, so when the EMTs refused to act, the midwives resorted to the nonverbal but nonetheless eloquent strategy of getting their own oxygen tank out of the car, figuring that the EMTs would rather use their own oxygen than accept it from the midwives.

One possible reason for the baby’s lack of oxygen might have been that the cord was compressed. Cord compression is usually exacerbated when a woman lies flat on her back, so the midwives wanted to put the mother on her hands and knees in the ambulance, as this is the position most likely to take the most pressure off the cord. (In addition, the flat on the back position can cause supine hypotension ([low blood pressure]) in women because it occludes the vena cava, resulting in inadequate circulation of blood ([which carries oxygen]) to the placenta and baby.). But a woman on her hands and knees in an ambulance is a strange and unsettling sight and most likely did not match the medic’s internal maps of proper patient position or behavior, or of safety while driving. So the midwives had to give up on the most physiologic position; here again they creatively compromised, finding a position that minimizes both cord and vena cava compression while not challenging the medics’ views of how a patient should be positioned. For Carrie and her partner, these stand as examples of midwives’ ability to “think around” situations to get the system to meet the woman’s needs. Such creativity has been demonstrated to be typical of subaltern groups, who must be as aware of the features of the dominant group as of their own in order to successfully navigate inside the dominant system (Schaef 1980).

Several obstetricians present in a hospital, but only the one on call is allowed to treat “walk-ins,” and that one is not in the hospital: here Carrie’s voice dripped with sarcasm. For her, this situation evidences hospitals’ tendencies to be highly structured, category oriented, and rule-bound. Her outside gaze notes that people who have a place inside the biomedical system, having contracted with a private obstetrician, are more likely to get an immediate response than the anomalous, unplaced “walk-in.” The fact that the nurses would not look at the midwives’ records seems analogous to the medics’ refusal to heed the midwives’ insistence on haste. Instead, the EMTs wanted to take a history, which of course the midwives already had. But the information the midwives had obtained did not count for these biomedical personnel, who valued only the knowledge they themselves obtained. It seems to Carrie that reality as defined by biomedical categories (taking a history, allowing only one obstetrician to attend a walk-in, and counting only information obtained by biomedical personnel) was more salient here than reality as the midwives, the mother, and the stillborn baby experienced it.

Tragically, the mother’s refusal to be put on the electronic monitor denied the biomedical system an indicator on which it might have acted. This refusal probably stemmed from the distrust of the biomedical system and its technology that led the mother to plan a home birth in the first place. When the ER nurse announced that the heart tones were at 130, the mother took this news to mean that the problem had resolved itself and “everything was fine.” Carrie later learned that in the labor and delivery unit the fetal heart rate decelerations were noted and recorded by the nurses who were auscultating the mother, but for some reason they never told the mother that they could hear the decelerations, so she continued in the belief that the heart tones were still OK. Emphatically, Carrie stated that if the midwives been allowed to remain with the mother, they would have convinced her to allow the monitor; she said, “We would have done everything from cutting a huge episiotomy to jumping on her tummy to get that baby out. But we were sent away.”

Carrie’s sarcasm extends to the “lie” that the EMTs told on their official records, a lie she is sure they told to cover themselves in case of lawsuit. It is likely that the paramedics assumed that as biomedically trained practitioners, their word carried more authority and cultural weight than the words of the midwives and the mother, so their notes were more likely to be seen as valid. Practicing inside a hegemonic cultural space can facilitate one’s claim to truth. Practicing outside that space not only calls one’s veracity automatically into question, but also puts one at risk of legal action: Carrie and her partner feared being sent to jail since their practice is unlawful in Georgia. They have dealt with this threat through their excellent outcomes, on which they keep careful statistics; through obtaining CPM certification, which is not recognized in Georgia but at least shows that they have been tested and have demonstrated the requisite competence; and through publicity: every few years, a local paper publishes a several-page spread on Carrie and her practice, showing pictures of her and of the happy couples she has attended. She feels that this high level of visibility affords her far more protection in the form of community support than would remaining underground.

Reality is as one perceives it, and the effects of any given event depend not on the actual circumstances of that event but on how they are narrated. On both sides of this particular biomedical/midwifery//– biopower/counterpower fence, opinions were formed or reinforced by this experience. We can imagine that the story that circulated among hospital personnel about this birth was very different from the one the midwives tell: chances are it was a story about another botched home birth attended by irresponsible midwives. On the midwifery side, it was one more story about the absurdity of biomedical bureaucracies and the arrogance and narrowmindedness of biomedical personnel—nurses, physicians, and EMTs alike. And it was a story about the dedication and loyalty of the midwives’ clients: when I asked Carrie why the mother did not sue the hospital, she responded, “Because she knew that if she did, the hospital would come after us.”

Later Carrie added, “Before this experience, I always thought that if you have a problem, you call the paramedics. Now I know that if you want a problem, you call the paramedics.” She notes that this experience made her much savvier about the limitations of the biomedical system. Specifically, it taught her and her partner to always make sure they transported only to hospitals with on-call physicians in-house, and not to involve the paramedics if there was any way the midwives could transport the client on their own. And, as we will see below, it led Carrie over time to work to develop a network of relationships with individuals in the hospitals to which she now transports in order to enhance her ability to prevent this kind of disarticulation of systems, and to facilitate the kind of smooth articulation that can save lives.

Fractured Articulation

Lana’s Story: An Inaudible Voice

Lana Lane, an American direct-entry midwife, learned midwifery through a two-year apprenticeship in Fairbanks, Alaska, during which, with her mentor, she attended over 100 births. Shortly after finishing her training in 1985, she moved to Wasilla, Alaska, where she went into partnership with Susan Eakin. By then, the direct-entry midwives ofAlaska had achieved their legislation and were practicing legally. This story, told to me by Lana’s partner Susan, took place the following year.

            Arriving at the home of a woman in early labor who lived less than five minutes away from a tertiary care center in Anchorage, Lana performed a vaginal exam to check the degree of cervical effacement, dilation, and station (the position of the baby’s head), and suddenly found the umbilical cord in her hand. Susan said, “The cord was just below the baby’s head. Lana tried to slip it up away from the vaginal opening, hoping the head would block it, which can sometimes be done if too much cord doesn’t wash down. But the cord just kept slipping, so all Lana could do was keep the cord from being pinched (which would cut off the baby’s blood and oxygen supply) by splinting it between her fingers and pushing the head off it.” While the mother crouched on her knees and prayed, Lana maintained the head in place, telling her partners to administer oxygen to the mother and the father to call 911. He held the phone for Lana as she described the situation and begged them to have an operating room ready. At that point, the baby’s heart tones were fine. The ambulance arrived in two minutes. The EMTs were cooperative and did not question the midwife’s judgment. Lana straddled the stretcher below the mother, applying counterpressure to the baby’s head with one hand and with the other using the Doppler to monitor heart tones that were steadily dropping. They were inside the hospital within minutes. But upon arrival, they found that nothing had been done to prepare for the cesarean. For thirty minutes, Lana knelt on the stretcher holding the head in place and listening to the heart tones drop—50, 40, 30. She lost her voice from screaming for the hospital staff to hurry. But by the time the cesarean was finally performed, the baby had died.

A prolapsed cord is life threatening to the baby—when the cord is in front of the baby’s head, it is compressed, thereby cutting off blood and oxygen circulation to the baby. Unless the baby can be birthed immediately or a cesarean quickly performed, the baby is likely to die. In this situation, wherever it occurs, the mother must get into the knee-chest position, which takes the pressure off the cord, while the practitioner kneels behind her and applies counterpressure to the baby’s head so that the cord is not compressed between the head and the woman’s pelvis. Keeping her hand inside the mother’s vagina, the practitioner must hold up the baby’s head until the baby is removed by cesarean—a dramatic scenario to say the least, the success of which depends on how quickly the cesarean is performed.

This story resonates with pain; indeed Lana’s partner Susan, who first recounted it to me, was crying as she spoke. She did not know exactly why Lana’s pleas for speed were ignored, but she felt sure that it had something to do with the hospital staff’s disapproval of home birth. The worst-case scenario would interpret hospital personnel as deliberately ignoring this “walk-in” from outside to prioritize the women inside, to punish her for trying to give birth at home, or both. Prior and subsequent experiences have ensured that Susan holds this worst-case view. She said:

In my opinion, the reason no one came to the rescue is because it was a planned home birth gone bad. I don’t think they believed Lana knew a thing. More than once we’ve been forced to wait on circumstances they would normally be scampering to fix. I could tell you several stories in which the medical staff tried to hang us, instead of acknowledging that we transported appropriately.

In contrast, the scenario that attributes the best intentions to the hospital practitioners has to do with the logistics of hospital procedures. When a cord prolapse occurs in hospital, the practitioner who identifies it issues a crash call, the obstetrical team flies into action, and when all goes well the baby is delivered by cesarean within ten minutes. But getting everything in place for a cesarean is very expensive in terms of the personnel and equipment needed, and most hospitals have experiences of doctors, paramedics, nurses, and/or midwives telling them to prepare for a cesarean when one really isn’t needed. Setting up unnecessarily ties up rooms, obstetricians, and anesthesiologists and may keep them from being available if needed elsewhere. Thus, it is logical that a hospital would want to assess the situation before taking action, especially on the word of a person unknown to them (which might include a private physician).

This transport took place in 1986 but is far from anachronistic—similar scenarios still play out around the country, especially in states where midwives practice illegally but also in states where they are legal but not well accepted by biomedical practitioners. It illustrates the dysfunctions generated by partial, fractured articulations between the biomedical and home birth midwifery systems. The biomedical system’s first response was appropriate—the EMTs supported the midwife to continue her work and did not challenge the validity of her knowledge or approach. And on the phone the hospital promised a response. But somewhere between the promise and the mother and midwife kneeling on the stretcher in the hall, a fracture occurred in what had promised to be a system of smooth articulation, and it was the baby who fell through the crack. Both the worst-case scenario (that the hospital deliberately delayed action to punish the midwives and the mother for attempting a home birth) and the best-case scenario (that, given the expense and difficulty of preparing the Oroperating room, hospital practitioners didn’t feel they could risk taking these unknown midwives at their word) point up the importance of prior dialogue and relationship between the hospital and the midwives in order to establish mutual trust and systems of smooth articulation well in advance of this kind of emergency.

Dina’s Story: Home Birth as Child Abuse?

Dina Farraw, an American CPM from Arkansas, transported a client after a home birth for a retained placenta. The doctor did remove the placenta, but only after sternly telling the woman and her husband that it was “child abuse” to give birth at home with midwives. This insulting remark was most likely made out of sincere beliefs that midwives are ignorant and that home birth is a highly risky enterprise. The statistics on the safety of home birth in the United States are not taught in medical school, and most obstetricians are simply unaware of the good outcomes home birth midwives generally achieve (Rooks 1997:345–384). Of course, it is ironic that the doctor’s belief in the midwives’ ignorance stems from his own. The hegemony of obstetrics has forced midwives to educate themselves in its ideology and assumptions, protocols, and lexicon to enhance their chances of successfully interfacing with it and of being able to defend their actions in its terms. In contrast, the marginality of midwifery has allowed obstetricians to remain ignorant about it. Obstetricians tend to be unilingual in the language and technologies of biopraxis, while midwives tend to be multilingual. They manipulate the lexicons of both obstetrics and midwifery, as well as of various folk systems of practice and belief that inform the lifeworlds of the clients they attend (such as Latinas in theRio GrandeValley inTexas, or the Amish inPennsylvania andTennessee). Midwives thus transgress and elide professional boundaries on a daily basis, while obstetricians tend to reinforce them. Fractures in attempts at articulation (like this doctors’ insulting remarks) often result from this kind of obstetrical boundary reinforcement.

A few U.S. physicians are willing to elide and transgress professional boundaries in order to support home birth midwives. Such support can be costly: in the United States, some physicians have lost their hospital privileges, their insurance, and their ability to practice in their communities as punishment for working with home birth midwives. Of course, the more physicians supportive of home birth midwifery are marginalized within biomedicine, the less ability they have to create needed structures for smooth articulation.

Smooth Articulation

It is important to remember that for all the transports that go awry, many others go smoothly and most do not result in anyone’s death even when they are characterized by fractured articulations. Very few midwives in the United States ever lose a mother, but out of every 1,000 births, two or three babies will die no matter where they are born or who attends them. In the United States, home birth data indicate that babies whose births start out at home do not die at any higher rates than babies whose births start out in the hospital—there is no added risk to home birth (Rooks 1997; Macdorman and Singh 1998; Johnson and Daviss 2001). As I noted above, only 2 percent of transports are true emergencies; the same emergencies happen in hospitals. But clearly, transports that involve fracture or disarticulation between biomedicine and midwifery can amplify the problems already generated by the complication that motivated the transport; sometimes those disjunctures alone are enough to cause a death that would not otherwise have occurred. On the other hand, when a home birth transport is treated effectively, the chances for survival of mother and baby are greatly enhanced. This more positive scenario requires smooth articulation between the biomedical and home birth midwifery systems, which the following two stories will illustrate. They both come from Carrie Smiley, the aforementioned CPM fromAtlanta,Georgia.

A mother pregnant with her second child started bleeding during mild early labor. Although the baby’s heart tones were good, Carrie was concerned by the dark red color of the blood, which indicated that it was not from a superficial cause. She called the hospital and told the nurse-midwife that some kind of placental abruption might be occurring. Welcomed in the hospital, the mother labored for another three hours in the jacuzzi and on the birth ball. She pushed for about ten minutes, and delivered on her hands and knees while the nurse-midwife caught the baby. When Carrie and the nurse-midwife examined the placenta, they could see a five-centimeter clot on it—an indication that the placenta had partially detached in that area and had been bleeding from that place for a while. After the birth, the doctor told Carrie that she probably could have stayed at home for this one. And Carrie told him, “You have to realize that it’s important for me to transport sooner rather than later when I have the option.” And he said, “You are right—I don’t always see it from your side.”

A primary ingredient in Carrie’s willingness to transport early rather than late was the excellent relationship she has established over time with this doctor and this particular hospital. Carrie’s many positive experiences with the M.D. and the nurse-midwives who work with him illustrate how different kinds of articulations can happen in the same location as the actors come to know and develop trust in each other over time.

Brigitte Jordan’s (1993) call for the replacement of top-down, culturally inappropriate obstetrical systems with models of mutual accommodation between biomedical and indigenous systems is equally significant for postmodern home birth midwifery systems. Nurse-midwives are especially well placed to achieve such mutual accommodation, as they inherently straddle and bridge (and occasionally fall into the fissures between) biomedicine and home birth midwifery. Establishing close relationships with home birth midwives who are not legal is simultaneously a transgressive and a boundary-spanning act. The prior communication and relationship between Carrie, the nurse-midwives, and the supportive physician certainly facilitated the smooth articulation of systems that this story illustrates. In fact, the articulation between Carrie’s knowledge system and that of the hospital practitioners is so smooth that she is more than willing to transport even for situations that have nothing to do with risk:

            A mother giving birth for the first time had pulled a muscle in her back. Carrie spent hours trying to relieve her back pain with showers and warm compresses and massage. She said,

After a while we were running into brick walls as far as pain relief for the spasms, so we decided to go into the hospital where they have jacuzzis in the labor rooms. By the time we got there, she was 6 centimeters. The nurse-midwives who received us told her she was doing great. The jets did good counter-pressure on the back pain. They never started an IV and she had no pain medication. The baby’s heart tones always sounded great. I was able to catch the baby as “the grandmother” on the chart—the nurse working with us had had her babies at home, and the nurse-midwife was very supportive and felt this mom really deserved the continuity. The baby was fine and the family went home twelve hours after the birth.

As these two stories illustrate, smooth articulation between knowledge systems proceeds through points of overlap, transition, and communication that facilitate the seamless flow of information and linked, imbricated decision making in which the actions taken by one person or group build on the information supplied by another. The relationships between Carrie and the hospital-based CNMs encompass such points. When this kind of decision making takes place within the top-down biomedical system, such imbrication requires a rejection of its tendency to discount or dismiss as irrelevant other ways of knowing. Such rejections can and do take place at the level of the individual even when the system as a whole remains dismissive.

What motivates or inspires a physician to reject the top-down system and give credence to home birth midwifery knowledge? My observations are that the ingredients key to an individual MD’s predisposition to smooth articulation and mutual accommodation include (1) exposure to midwifery care, (2) exposure to midwives, and (3) attention to scientific evidence. I will briefly deal with each of these in turn.

Exposure to midwifery care. Some doctors train in hospitals where nurse-midwives practice and thus are able to observe firsthand the benefits of midwifery care, which can include birth in upright positions, without an episiotomy, and with a great deal of hands-on support. Nurturance and consideration tend to characterize the midwife’s approach to the mother; shared decision making takes place in a context of mutual respect. These trainees often become imbued with a desire to incorporate this humanistic approach into their own practices, and will be more likely to work with nurse-midwives in the future from a partnership, rather than a hierarchical, perspective.

Occasionally a brave physician will venture outside hospital bounds and observe a midwife-attended home birth—an experience that tends to be emotionally evocative and ideologically transformative (e.g., Wagner 1997). Clinicians judge other clinicians as individuals, not just as members of a class or category; individual judgments can overcome prejudices based on subcultural differences. Does a specific practitioner give good care, make good decisions, and communicate accurately? Individual practitioners decide the answers on the basis of experience. All clinical practitioners constantly gather experience and information, and react differently to a comment, order, or action from someone they trust as opposed to someone whose judgment has been faulty in the past or whom they do not know. Midwives work best with the doctors they have come to trust as a result of experience, and vice versa. But most doctors have little or no experience of working with home birth midwives, and the experiences they do have may be skewed if it they comes only during emergency transports. It’s a tautological circle: lack of experience with working together creates problems that exacerbate and perpetuate lack of experience with working together.

Exposure to midwives. It is accurate to say that in general, American home birth midwives have impressive personalities, a strong sense of commitment and dedication to serving women, a secure sense of their own self- and professional worth, and a large fund of knowledge about parturition that seamlessly permeates their conversation. Simply spending time with them can turn a hospital practitioner from an opponent to a supporter. In U.S. communities where smooth articulation characterizes transport, home and hospital midwives, and sometimes physicians, often participate in periodic potluck dinners where models of mutual accommodation begin to emerge over casseroles and drinks. Hospital midwives who develop respect for and good relationships with home birth midwives often transmit this trust to the physicians with whom they work, in a kind of spillover effect that paves the way for future smooth articulations during transport.

Attention to the scientific evidence. There is increasing emphasis these days on “evidence-based medicine” (Rooks 1999). As we have seen, midwifery tends to be more evidence based than obstetrics because midwives are generally less interventive than physicians (Frye 1995; Davis 1997; Gaskin 1990; Rooks 1997), and the scientific evidence (Rooks 1997:345–384; Macdorman and Singh 1998; Goer 1999; Enkin et al. 2001) shows that many common interventions do more damage than good. Any doctor who actually looks at the evidence instead of relying solely on what he is taught by biomedical tradition will take note of the benefits of midwifery care, and will thus be less likely to assume a blanket superiority for tradition-based obstetrics.

Cross-Cultural Perspectives on Transport

Midwives transport in hopes of resolving a situation they feel they cannot or should not handle at home, with hopes and prayers for a good reception most especially for the mother, but also for themselves. A positive reception in the hospital reinforces midwives’ sense of themselves as competent practitioners and elicits in them feelings both of pride in their good judgment and of gratitude toward the biomedical system for its efforts; a negative reception can leave the midwife (and the mother) emotionally scarred. Once burned, twice shy, they may in the future try too hard to avoid another transport, with potentially unfortunate results. Cross-cultural research provides multiple examples (e.g., Allen 2001; Barnes-Josiah, Myntti, and Augustin, 1999; Davis-Floyd 2003; Iskandar, Atom, Hull, Dharmaputra, and Aswar 1996; Graham, 1999; Kroeger, 1996). For one brief example that stands for countless others, Deborah Barnes-Josiah and her colleagues have shown that in Haiti, community midwives who have been badly treated in hospitals, or whose clients have received inadequate care after transport, try in the future to avoid transport by coping with emergencies at home as best they can, often until it is too late to seek help. If disaster befalls, the midwife is handed the blame, with no account taken of the prior experiences that generated her avoidance behavior.

The solution to the trouble with transport that the governments of developing countries have generally sought to implement usually involves the goal of eliminating home birth and traditional midwifery in favor of hospital or clinic birth attended by physicians and/or professional midwives trained in two-year, government-approved courses (Hsu 2002; Jenkins 2002; Sargent 1989). Yet for a variety of reasons (see Davis-Floyd 2000), women in many countries continue to choose their traditional attendants. Certainly, as Roger and Patricia Jeffrey pointed out in 1993, it is important not to romanticize indigenous midwifery and indigenous midwives: some indigenous customs are beneficial and some are not; some traditional midwives are competent practitioners within their own systems and some are not. Similar notes can be sounded about obstetricians: some intervene inappropriately, ignoring the evidence, while others exercise a more balanced and judicious approach. The transport stories I recount here should not be simplistically interpreted to indicate that all midwives are good and all biopowerful practitioners are bad or vice versa, but rather as ways of illuminating points of disjuncture and fracture, as well as models of smoothness, in the cross-boundary articulation of disparate knowledge systems.

Today in most developed countries, the home birth rate hovers around 1 percent. That home birth might be more widely chosen in the developed world if it were more readily available is indicated by the Netherlands, where the home birth rate has never dropped below 30 percent (Weigers 1997), and New Zealand, where in recent years it has risen to 12 percent as the result of a strong alliance between midwives and consumers that has generated active government support. These two countries stand as models of what I would name seamless articulation—their midwives practice, and their health care systems fully support, birth in all settings, creating ease of choice and continuity of care across what in most other countries can only be seen as the home/hospital divide (DeVries, van Teijlingen, Wrede, and Benoit, 2001). In Europe as in the United States, active movements seek to restore home birth as a viable option, with variable success. Meanwhile, in the developing world, home birth rates continue to decline in response to the pressures of modernization, yet millions of women still give birth at home, some because there is no other option, some out of active rejection of their region’s biomedical system, and others out of philosophical choice.

Home birth was both normal and normative for most of human history. But with the advent of biomedicine in the industrialized West, hospital birth became normative and home birth for most women ceased to exist as a viable or even thinkable option. In the developing world, this process is still unfolding; in many Third Worldcountries, it has already taken root to the extent that while home birth remains normative in rural areas, in the cities it has become an alternative and marginalized choice as it is in most of the developed world. Nevertheless, some women still make that choice, and traditional midwives continue to serve them,; only now, like American midwives, some of these urbanized traditional midwives are developing hybrid techniques that reflect the multiple systems of knowledge that intersect in their practices (Davis-Floyd 2001b, 2003). They value the knowledge systems they are creating and the sometimes lifesaving knowledge system of biomedicine; yet the biomedical system, generally speaking, values only itself. Thus for home birth midwives everywhere, biomedicine stands at once as the ultimate recourse and the ultimate enemy, often with no guarantees in any given transport as to which aspect will manifest.

The transport stories I recounted and analyzed here are fractals for thousands of others that shed light on the trouble- and stress-full interface between the worlds of biomedicine and home birth midwifery. Spiraling beyond the bounds of the specific situations they recount, they index both the myriad possibilities for tragedy inherent in one knowledge system’s closed dismissal of its marginalized competitor, and the enhanced possibilities for more positive outcomes when members of that system open its boundaries to admit the fingers of articulation extended by practitioners from the outside. When parallel fingers reach out from the inside, taking account of midwives’ information, acting on their recommendations, and encouraging them to remain with the mother to provide ongoing support, the result can be what Grossberg (1992:57) terms “active structures . . . that cut across domains and planes.” Further elaboration by medical anthropologists of such structures of smooth articulation could extend individualized links and nodes across the hospital/home divide, ending the disarticulations, and mending the fractures, that generate much of the trouble with transport.

Notes

I express my appreciation to the Wenner-Gren Foundation for Anthropological Research for its support of my midwifery research through grants #6015 and #6427.

1. Much of this chapter is adapted from Davis-Floyd (2003a).

2. Ideally, nurse-midwives’ transport experiences should be seamless but often are not. While there is are excellent data on the statistical outcomes of nurse-midwife-attended births in the U.S.United States, including home-hospital transports (Macdorman and Singh, 1998), I know of no research on American nurse-midwives’ transport experiences.

2. Medical practitioners who only see problematic home births that are transported to the hospital tend to think that all home births are “botched.” The rate of problems derives as a function of a numerator (number of cases with problems) and a denominator (total number of cases—the majority—that have good outcomes). If one only sees the numerator, it is impossible to realize that the rate of transports is actually very low compared to the number of successful home births.

3. A caveat: Tto my knowledge, most home birth midwives who transport enter the hospital and stay with their clients for as long as they are allowed to stay. But some hospital practitioners criticize home birth midwives who “dump their clients at the hospital door and take off.” Such midwives usually live in states where their practice is illegal or in places where local hospital personnel are known to be particularly negative and unreceptive. Leaving their clients at the door can be viewed as an extreme form of disarticulation stemming from midwives’ fear that any interaction with the hospital system at best will result in serious harassment and at worst will send them to jail—a powerful argument for the legalization of midwifery, which certainly facilitates the development of systems of smooth articulation.

4. In the United States, there were 23,232 home births in 1998 and 23,518 in 1999—an increase of 1.2 percent. Midwives are not the only practitioners who attend home births. Of 23,518 home births reported on U.S. birth certificates in 1999, 2,476 (10.5 percent) were attended by a physician, 12,123 (51.5 percent) by a midwife, and 8,524 (36.2 percent) by someone else. Some, but not all of the “other” attendants were probably midwives practicing without legal authority (Ventura et al. 2001).

References

Allen, D. R. (2002)  Managing Motherhood, Managing Risk: Fertility and Danger in Rural Tanzania.Ann Arbor:University ofMichigan Press.

Barnes-Josiah, D., C. Myntti, and A. Augustin. (1998). “The Three Delays as a Framework for Examining Maternal Mortality in Haiti.” Social Science and Medicine 46: 981–993.

Benoit, C., R. Davis-Floyd, E. van Teijlingen, S. Wrede, J. Sandall, and J. Miller. (2001). “Designing Midwives: A Transnational Comparison of Educational Models.” In Birth by Design: Pregnancy, Maternity Care, and Midwifery in North America and Europe, edited by R. DeVries, E. van Teijlingen, S. Wrede, and C. Benoit, 139–165.New York: Routledge.

Castro, Arachu. (1999). “Commentary: Increase in Caesarean Sections May Reflect Biomedical Control Not Women’s Choice.” British Medical Journal 319: 1401–1402. Accessed at www.bmj.com/cgi/content/full/319/7222/1397#resp2.

Davis, E. (1997). Heart and Hands: A Midwife’s Guide to Pregnancy and Birth, 3rd ed.Berkeley: Celestial Arts. (Originally published in 1983.)

Davis-Floyd, R. (1992). Birth as an American Rite of Passage.Berkeley:University ofCalifornia Press.

———. (1994). “The Technocratic Body: American Childbirth as Cultural Expression.” Social Science and Medicine 38, no. 8: 1125–1140.

———. (1998). “The Ups, Downs, and Interlinkages of Nurse- and Direct-Entry Midwifery: Status, Practice, and Education.” In Getting an Education: Paths to Becoming a Midwife, 4th ed., edited by J. Tritten and J. Southern, 67–118. Eugene, OR: Midwifery Today. Accessed at www.midwiferytoday.com.

———. (2000, March). “Global Issues in Midwifery: Mutual Accommodation or Biomedical Hegemony?” Midwifery Today, 12–17, 68–69.

———. (2001). “Las parteras de Morelos: The Strategic Negotiation of Knowledge Systems by Postmodern Midwives inMexico.” Paper presented at the annual meetings of the American Anthropological Association, November.

———. (2003). “Home Birth Emergencies in the USand Mexico: The Trouble with Transport.” In Reproduction Gone Awry (special issue), edited by Gwynne Jenkins and Marcia Inhorn. Social Science and Medicine 56(9): 1913-1931.

———. (2004). “Qualified Commodification: Consuming Midwifery Care.” In Consuming Motherhood, edited by J. Taylor, D. Wozniack, and L. Layne.New Brunswick,NJ:RutgersUniversity Press.

———. (2005). “The History, Ideology, and Politics of American Midwifery.” In Robbie Davis-Floyd and Christina Johnson, Mainstreaming Midwives: The Politics of Change.New York: Routledge, in press.

Davis-Floyd, R., S. Cosminsky, and S. L. Pigg, eds. (2001). Daughters of Time: The Shifting Identities of Contemporary Midwives. Medical Anthropology 20, no. 2-3/4 (special triple issue).

Davis-Floyd, R., and E. Davis. (1997). “Intuition as Authoritative Knowledge in Midwifery and Home Birth.” In Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives, edited by R. Davis-Floyd and C. Sargent, 315–349.Berkeley:University ofCalifornia Press.

Davis-Floyd, R., and C. Johnson, eds. (2005). Mainstreaming Midwives: The Politics of Change.New York: Routledge, in press.

DeVries, R., E. van Teijlingen, S. Wrede, and C. Benoit, eds. (2001). Birth by Design: Pregnancy, Maternity Care and Midwifery in North America and Europe.New York: Routledge.

Enkin, M., M. J. N. C. Kierse, J. Neilson, C. Crowther, L. Duley, E. Hodnett, and J. Hofmeyr. (2000). A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. New York: Oxford University Press.

Foucault, M. (1978). The History of Sexuality: An Introduction, vol. 1. Translated by Robert Hurley.New York: Random House.

Frye, A. (1995). Holistic Midwifery: A Comprehensive Textbook for Midwives in Home Birth Practice, vol. I: Care during Pregnancy. Portland, Oregon: Labyrs Press.

Fullterton, J., ed. (2000). “Skilled Attendance at Delivery: A Review of the Evidence.” Family Care International,New York.New York: Family Care International.

Gaskin, I.M. (1990). Spiritual Midwifery, 3rd ed.Summertown,TN: Book Publishing Company.

Goer, H. (1999). The Thinking Woman’s Guide to a Better Birth.New York: Penguin Putnam/Perigree.

Grossberg, Lawrence. (1992). We Gotta Get outa This Place: Popular Conservatism and Postmodern Culture.New York: Routledge.

Graham, S. (1999). “Traditional Birth Attendants inKaramoja,Uganda.” Ph.D. diss.,SouthBankUniversity,London.

Hsu, C. (2002). “Making Midwives: The Logics of Midwifery Training in St. Lucia.” In Daughters of Time: The Shifting Identities of Contemporary Midwives (special issue), edited by R. Davis-Floyd, S. Cosminsky, and S. L. Pigg. Medical Anthropology 20, nos. 2-3/4: 313–344.

Iskandar, M., B. Atom, T. Hull, N. Dharmaputra, and Y. Azwar. (1996). Unraveling the Mysteries of Maternal Death in West Java: Reexamining the Witnesses. Depok: Center for Health Research, Research InstituteUniversity ofIndonesia.

Jenkins, G. (2002). “Modernization and Postmodernization in the Changing Roles and Identities of Midwives in Rural Costa Rica.” In Daughters of Time: The Shifting Identities of Contemporary Midwives (special issue), edited by R. Davis-Floyd, S. Cosminsky, and S. L. Pigg. Medical Anthropology 20, nos. 2-3/4: 409–444.

Johnson, Kenneth C., and Betty Anne Daviss. (2001, October). “Results of the CPM Statistics Project 2000: A prospective study of births by Certified Professional Midwives In North America (Abstract).” American Public Health Association Annual Meeting,Atlanta.

Jordan, B. (1993). Birth in Four Cultures. Revised and updated by R. Davis-Floyd.Prospect Heights,IL: Waveland Press.

Jordan, B. (1997). Authoritative knowledge and its construction. In R. Davis-Floyd & C. Sargent (Eds.), Childbirth and authoritative knowledge: Cross-cultural perspectives (pp. 55-79).Berkeley:University ofCalifornia Press.

Kolenda, P. (1998). “Fewer Deaths, Fewer Births.” Manushi 105: 5–13.

Kroeger, M. (1996). Final Consultant Report. CHN III Project.Indonesia: Provincial Department of HealthCentral Java.

MacDorman, M., and G. Singh. (1998). “Midwifery Care, Social and Biomedical Risk Factors, and Birth Outcomes in the USA.” Journal of Epidemiology and Community Health 52: 310–317.

Rooks, J. P. (1997). Midwifery and Childbirth in America.Philadelphia:TempleUniversity Press.

———. (1999). “Evidence-Based Practice and Its Applications to Childbirth Care for Low-Risk Women.” Journal of Nurse-Midwifery 44, no. 4: 355–369.

Rothman, B. K. (1982). In Labor: Women and Power in the Birthplace.New York: W. W. Norton.

Sargent, C. (1989). Maternity, Medicine, and Power: Reproductive Decisions in Urban Benin. Berkeley: University of California Press.

Ventura, S. J., J. A. Martin, S. C. Curtin, R. Menacker, and B. E. Hamilton. (2001). “Births: Final Data for 1999.” National Vital Statistics Reports 49:1.Hyattsville,MD:NationalCenter for Health Statistics.

Wagner, M. (1997). “Confessions of a Dissident.” In Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives, edited by R. Davis-Floyd and C. Sargent, 366–396.Berkeley:University ofCalifornia Press.

Weigers, T. (1997). Home or Hospital Birth: A Prospective Study of Midwifery Care in the Netherlands. Ph.D. thesis,LeidenUniversity, NIVEL,Utrecht.

ORAL HISTORIES FROM THE PIONEERS OF

AMERICA‘S SPACE PROGRAM

An Oral History Project conducted in conjunction with

the Houston Chapter of the AIAA and Honeywell Corporation

Interviewers:

Dr. Robbie Davis-Floyd, Research Fellow, Dept. of Anthropology, University of Texas at Austin

Dr. Kenneth J. Cox, NASA Johnson Space Center

Interviewees:

Guy Thibodaux, Maxime Faget, Paul Purser, Clotaire  Wood, Josephine Dibella, Adelbert Tischler, Harry Finger, Chris Kraft, Eilene Galloway, Paul Dembling,

Ed Cortright, Walt Dankhoff

Copyright Robbie Davis-Floyd and Kenneth J. Cox, 1998.

All Rights Reserved.

            Official histories often make it appear that nations make big decisions based on thorough research and understanding. But when the individuals intimately involved in those big decisions are given voice, a very different story emerges–one of hops and skips, personality clashes and chats between friends, and bootlegged designs that lead to billion-dollar programs. With funding from the American Institute of Aeronautics and Astronautics, Houston Chapter, and from the Honeywell Corporation, Robbie Davis-Floyd and Kenneth J. Cox have embarked on the project of collecting oral histories from a number of  individuals who were intimately involved in the events leading to the formation of NASA and the early development of its space program. Our focus is not on the well-publicized astronauts, but on the inside stories of the engineers and administrators who worked behind the scenes.

INTERVIEWS 1 AND 2: THE SPACE CADETS

(Thibodaux, Faget, Purser)

Our first interview was with Guy Thibodaux, the engineer and rocket propulsion scientist responsible for the propulsion work on Mercury and many other space projects, at his home near Johnson Space Center in Houston/Clear Lake, on Sept. 9, 1996. The following day we met again at his home, this time to conduct a joint interview with Thibodaux and his colleagues Maxime Faget, who was instrumental in the design of the Mercury, Apollo, and Gemini spacecrafts and the early shuttle, and is widely considered the father of spacecraft design, and Paul Purser, engineer and manager at Langley Research Center in the Pilotless Aircraft Research Division, which formed the early nucleus of the space program. Brief biographies of these three space pioneers follow below.

BIOGRAPHIC INFORMATION

Joseph Guy Thibodaux Jr.

tibido@ghg.net

Guy Thibodaux graduated fromLouisianaStateUniversitywith a B.S. in Chemical Engineering in January 1943. He immediately reported for Active duty as 2nd Lt. in the U.S. Army Corps of  Engineers and was assigned as a training officer at Ft. Leonard Wood,Mo.He was transferred to the China Burma India Theater and assigned to the 45th Engineering Regiment, and built advanced fighter strips in the Burmese Jungle and worked on the construction of a road fromLedo,IndiatoKunming,China.

After returning home he was employed by the Langley Memorial Aeronautical Laboratory’s Pilotless Aircraft Research Division (PARD) inVirginia, where in a period of three years he became head of all propulsion and pyrotechnic activities atLangleyand its launching range atWallops Island,Virginia. He pioneered the redesign and modification of surplus military rockets to enhance the quality and types of aerodynamic data from free-flying supersonic rocket models and wind tunnels. He was responsible for the development of high temperature ceramic heated jets, electric arc heated tunnels, hypervelocity impact research, high vacuum technology, thermo-physics research, electron beam radiation, and oxidation resistant coating and thermal protection technology using ground and hypersonic reentry vehicles. He designed and operated an experimental solid rocket manufacturing plant and produced some of the highest mass fraction design spherical rockets from his own patented ideas, and developed novel manufacturing techniques. He conducted research on many solid fuel rocket operational problems which only occur in free flight. In 1958 he was a charter member of a committee which eventually planned the transition from the NACA to NASA and its first years’ programs. He was instrumental in starting the Scout,America’s only all solid propellant launch vehicle, and the first one ever developed by NASA; he managed development of all propulsion and pyrotechnic systems on that vehicle.

In 1964 he became Chief of theJohnsonSpaceCenter’s Propulsion and Power Division and was responsible for all propulsion, pyrotechnic, and cryogenic storage and supply systems, power generation and storage systems and hydraulic systems on all ofAmerica’s Manned Spacecraft. He was responsible for the operation of large test facilities at JSC and White Sands,New Mexico, needed for the development, testing, and evaluation of these systems.

He retired in 1980 after completion of work on the Space Shuttle and was a consultant to various industry and government organizations on such topics as solid and liquid rockets, free flight techniques, safety and hazards, and H-bomb simulation facilities.

BIOGRAPHIC INFORMATION

Maxime Faget

Max Faget graduated fromLouisianaStateUniversitywith a B.S. degree in Mechanical Engineering (aeronautics option) in June 1943. He immediately joined the Navy as a Naval Reserve Officer assigned to submarine service. He then became employed  at the Langley Laboratory of the National Advisory Committee for Aeronautics (NACA) in August 1946. He was assigned to the newly created Pilotless Aircraft Research Division (PARD), a division that was to fly rocket-powered models of aircraft and missiles at transonic and higher velocities to obtain aerodynamic data. During this period he did pioneering work on supersonic inlets and ramjets. He designed a compact (6-1/2″dia.) ramjet engine and a supersonic flight test vehicle which was powered by two of these ramjets. During a flight test in 1950 this vehicle accelerated under ramjet power in a climbing flight achieving  an altitude of 65,000 feet and a velocity of  M=3.2, setting unofficial speed and altitude records for vehicles powered by air-breathing engines.

While atLangley, he was appointed to the four man team that prepared the conceptual design and performance analysis of a research aircraft that could fly twice as fast and much higher than currently possible. The NACA then approached the Air Force to contract with industry to complete the design process and manufacture such an aircraft. This became the start of  the X-15 program. Faget was also appointed the NACA member of the Polaris Missile Steering Task Group where he proposed the aerodynamic shape that was employed for the reentry warhead. During the winter of 1957-58 he conceived the design and started development of the one-man spacecraft subsequently used in Project Mercury. Both the Gemini and Apollo spacecraft are derivations of the Mercury concept. When NACA was notified that it was chosen as the cadre from which a new civilian space agency would be formed, Faget was appointed a member of the transition team.

After NASA was formed, Faget was assigned to the Space Task Group (STG) organized to manage Project Mercury. Although Mercury was the main task at STG, there was great interest in follow-on programs. Consequently he devoted a large part of his time to heading a design and analysis team exploring manned flight to the vicinity and the surface of the moon. Because of this and other NASA studies, President Kennedy was able to commit theUSAto a lunar landing by the end of the decade. With the advent of Apollo, STG became the Manned Spacecraft Center (MSC). Faget was appointed Chief Engineer at MSC, responsible for the design, development and proof-of-performance of manned spacecraft and their systems. This responsibility included specifying the function and design of numerous engineering laboratories to be constructed as part of MSC. In April 1969, shortly before the first lunar landing, he organized a special preliminary design team to do an intensive feasibility study of a reusable manned spacecraft. This effort achieved program status whenJohnsonSpaceCenter(nee MSC) was given formal authority to develop the Space Shuttle. Subsequently, Faget gave prime emphasis in his personal activities and those of the organization toward solving the manifold problems in the development of the Shuttle. He retired from NASA after the Shuttle successfully completed its second test flight in 1981.

In 1982 Faget and severalHoustonbusinessmen founded Space Industries Inc. (SII). SII designed the Industrial Space Facility (ISF). The ISF was to be a manned-tended orbiting facility to be used for experiments in a high-quality micro-gravity environment with special emphasis on material processing. Westinghouse became a partner with SII in a joint venture for financing, construction and operation. Significant backing was obtained for an initial deployment in 1992. However, the aerospace industry, Congress and NASA feared it would curtail the Space Station program and consequently the ISF was never deployed. SII then manufactured a wide range of experiment support equipment that was flown on numerous Shuttle missions. The most significant was the Wakeshield built for theUniversityofHouston. This free-flyer was successfully deployed on two missions, providing the experimenters with an ultra-high vacuum environment for material processing.

BIOGRAPHIC INFORMATION

 PAUL E. PURSER

Paul E. Purser was born and raised inSoutheast Louisiana. He graduated fromLouisianaStateUniversityin 1939 with a B.S. in Aeronautical Engineering. He took the Civil Service Exam that spring in anticipation of a major growth in NACA (National Advisory Committee for Aeronautics) during the pre-World War II period, and worked briefly as a Junior Inspector at Glenn L. Martin, Co.Baltimoreon a twin-engine attack bomber being built for the French armed forces. In mid-October he received his NACA appointment and immediately departed for Langley Field.

During the prewar and WWII period, Purser carried out wind-tunnel research and evaluation work on practically every aircraft proposed for, or used in, WWII. At the end of WWII, he joined the Pilotless Aircraft Research Division (PARD) which was then being formed atLangley. There he and his colleagues carried out aerodynamic and structural research in flight using rocket-propelled models at Mach Numbers up to 15. Additionally, Purser headed up the development of various high-temperature ground facilities for research on materials, structures, and missile nose cones. During the major portion of the period between October 1957 and October 1958, he was a member of the small (12-man) team that conceived and “sold” the U.S. Manned Space Program and as part of the larger (75-man) team that planned and implemented the conversion of NACA to NASA.

From October 1958 to April 1970, Purser was Special Assistant to the Director of Project Mercury, which  developed into theMannedSpacecraftCenter(nowJohnsonSpaceCenter). During that same period he continued his membership in the American Institute of Aeronautics and Astronautics  (AIAA). In the early 1960s, he became a charter member of the American Society for Oceanography and a Member of the Marine Technology Society when the MTS and ASO merged. Also during the 1960s he was registered as a Professional Engineer inLouisianaandTexas. Purser was also invited to (and did) join 3 National Honor Societies Tau Beta Pi (Engineering), ODK (Leadership), and Sigma Gamma Tau (Aerospace Engineering.). During the 1968-69 academic year he was on loan to theUniversityofHoustonwhere, as Special Assistant to the President, he guided the development of theUH-ClearLakeGraduateCenter.

Upon his retirement from NASA in April 1970, he began consulting in various fields trying to apply what he had learned in NACA and NASA. In addition to various consulting tasks in the oil & gas industry, this led to a 10-year stint as Staff Consultant to the NAE/NRC Marine Board, overlaid with a 5-year stint as consultant to the Stanford School of Medicine Cardiology Division, about 5 years as a part-time Systems Engineer with the Gulf Universities Research Consortium (GUBC), and a 25+-Year association with CAPT W.F. Searle (USN-Ret.) on various tasks in the oceans industry. During this time he prepared and presented several technical papers at the Offshore Technology Conferences and the MTS Oceans Conferences.

INTERVIEW #1

Interviewee: Guy Thibodaux, NACA/NASA engineer and rocket propulsion expert, former Chief

                      of  the Propulsion and Power Division at the Johnson Space Center, Houston, TX.

Interviewers: Robbie E. Davis-Floyd and Kenneth J. Cox

Interview Dates: Sept. 9-10, 1996

This seven-hour long taped interview has been edited by both interviewers and by Guy Thibodaux himself for clarity, organization, and flow. Thibodaux (aka Tibby) has also added in extensive supplementary commentaries and additional information, all of which appear in italics or parentheses. [Editorial comments from Robbie Davis-Floyd or Ken Cox appear in brackets.]

Guy Thibodaux: It’s been a long time and the story hasn’t been told about how the space program and NASA really got started.  There are quite a few people still alive who are responsible for getting them going. I have a list of those that I know who are still alive with their addresses and phone numbers that you can use to contact them regarding further interviews.

I’ve never seen any references to the fact that some of us spent a lot of time up in Washington, going through the Pentagon like we owned it, coming up with what became the space program. It’s not documented, you see. I think the history, from the time the Space Task Group came down to JohnsonSpaceCenteris pretty well documented (even if it is wrong).  What I am really interested in is covering that gap, the transition between the NACA and the events leading up to that, up to the early years of the Space Task Group.

Robbie Davis-Floyd:  That’s what we’d like to focus on too.

Guy: I talked to Paul Purser and Max Faget and they’ll be down here tomorrow.

Robbie:  Good! Ken Cox said that you yourself have some great stories.

Guy:  Well, these are fairly interesting stories because  most of what went on is undocumented.  We never kept minutes at meetings.  Most of it was in verbal reports to our leaders and the results which were achieved speak for themselves.

Personal History: World War II, Model Airplanes, and LSU

Robbie: Tibby, before we get into the space program, tell us a little bit about yourself. Where were you born?

Guy: I was born in theLouisiana swamps.

Robbie: Where in theLouisiana swamps?

Guy: I was born at the F.B. Williams Lumber Camp in theAtchafalaya swamp on the west side ofLake Verret.  It is certainly a swamp. It was a big cypress logging organization. My father worked there. My birthplace was registered asNapoleonville,Louisiana which is twelve miles north ofThibodaux,Louisiana on Louisiana Highway 1 which parallels Bayou Lafourche.

Robbie:  Is that town named after your family?

Guy:  Yes.

Robbie:  Did you grow up there and go to school there?

Guy:  No, we left there and moved toNew Orleans when I was about five and I went to high school inNew Orleans and later on I went toLouisianaStateUniversity. The interesting part of it is that Paul Purser, Max Faget, and I were all LSU graduates. Max and I were college roommates. We ( Max and I)  had a pact that at the end of the war, if we both survived, we’d get together and go look for a job together.

Robbie:  What was your role in the war?

Guy:  I was an officer in the Corps of Engineers and I served in the China-Burma-India Theater building a road fromIndia intoChina and some advanced fighter strips. I was a white officer in a segregated Negro organization. I’m doing a lot of historical work on that right now, as a matter of fact.

Robbie:  So, when you went to LSU, did you go all the way through and get your degree in engineering from LSU?

Guy: I had that before I went into the service.

Robbie:  What was it in?

Guy:  Chemical Engineering.

Robbie:  What did you do when you came home from the war?

Guy:  Well, then I came back and I was sitting at home one day and Max called me and said, “Hey, my dad said I could borrow his car. Let’s go look for a job.” His dad had a little ’41 Chevrolet business coupe and it had airplane tires on it because you couldn’t get tires during the war for cars. We went back to the university and we went to our various departments and told the department heads we wanted to go look for a job, and asked who we might talk to about getting a job.

Robbie: In chemical engineering?

Guy: Whatever, I thought chemical engineering.

Robbie: What was Max’s degree in?

Guy: His degree was in Mechanical Engineering with an Aeronautical Engineering minor. Paul was the same way as Max–they were both in aero-engineering, mechanical engineering. Paul graduated about two years before, two or three years before we did.

I know Max as well as I know anyone and I knew him longer than anyone. When I met Max, he was a transfer fromSan FranciscoJunior College. He was already a sophomore, but he was a freshman in Military science. I was his platoon sergeant, and I thought he had two left feet! That’s how I first met him. Later on we got to know each other fairly well. I’m not sure why, we were both about the same size, and we’re both fromLouisianabut he’s not a Cajun. I am. I had to work to earn some of my school expenses and it took me four and a half years plus a summer school session  to finish because there was one required course I had to have that I could not schedule because of my work. During the summer school session,  Max and I roomed together. Then I had another semester that I had to finish so we roomed together again.

Comment: I think I first got to know Max because of Hank Bourgeois. Hank was a childhood friend who lived around the corner from me in New Orleans. He was a talented model airplane builder . I used to help him fly models in the huge Agricultural Auditorium building at LSU. Max was also an avid model builder and there were a few other cadets who shared the same hobby. Hank went on to become  a Marine Pilot and was Pappy Boyington’s wing man in the Black Sheep Squadron of  WWII. Hank stayed in the Service and still built models, this time radio-controlled models. He retired, worked in the Aviation Electronics Industry and became mayor of some town in New Jersey.

Ken Cox:  OK, so you roomed together.  That’s where you really got to know Max.

Guy:  We roomed together for two semesters and we used to wrestle and play handball, work out, and do all sorts of things together. I use to go up to the leper colony with him and spend weekends with him up there because they had a golf course, tennis courts, and a swimming pool for all the public health officers. It was only about thirty miles south ofBaton Rouge. Max’s father discovered the cure for leprosy. He served in the Public Health Service and was moved around the States to various Marine Hospitals. He (Max’s dad) had been assigned to head up a leper colony inCarville,Louisiana. Max went to high school inNorfolk, which is right across from Langley Field. And he began college when his dad was inSan Francisco. Max was very familiar with theNorfolk area. He used to build model airplanes and used to go over to Langley Field for model airplane contests with a friend, Woody Blanchard, back when they were high school kids.

There is an interesting story there, about how Caldwell Johnson [a technician who worked closely with Faget on spacecraft design for many years] got hired. The way they hired people atLangleywas they went to these model airplane meets because they knew that the kids who built the best model airplanes were the best craftsmen. WhenLangleywas hiring craftsmen, what they would do was go and check up on these kids who were winning all these model airplane meets. They would find out the kids who were building the best models and those were the ones they would try to convince that they ought to apply for a job to work in the shops out atLangley.

So, they convinceCaldwellhe ought to apply for this job. Ray Sharp is the guy who hired him–he was the head administrative honcho back atLangley. In order forCaldwellto meet the requirements for the job, he couldn’t be color-blind. SoCaldwellwas rejected by the doctor and he went in with his rejection slip, whatever it was the doctor gave him, and talked to Mr. Sharp with his tail hanging down between his legs and his chin down and said, “Mr. Sharp, I don’t qualify for a job. You can’t hire me.” Sharp said, ‘What the hell’s the matter, son? He said, “I’m color blind.” Sharp looks at the map on the wall and points over to thePacific Oceanand says, “Son, what color is that?”Caldwelltold me that everybody knows the ocean is blue, so he said, “Blue.” He said Sharp pointed to another ocean and said, “What color is that, son?”  “Blue.” He said, “Hell, you ain’t color blind, son. That doctor doesn’t know what the hell he’s talking about. You passed!” And he scratches it out the rejection and said, “You’re hired!”

Something like that you never could do today.Caldwelldidn’t even finish college, in fact. Here he is, this designer of American spacecraft, but he never finished college. He went a couple  of years, maybe. He went through the apprentice school and became–back then the top trades were engineering draftsmen and metal model maker and instrument maker. He was one of the top students in the class, so he became an engineering draftsman. Then he headed the section that designed all the little models we used to fly out onWallopsIsland.

Ken:  I didn’t realize it, but apparently model building, in those days, early maybe mid-50s or right after World War II, was really an area where a lot of people became craftsmen.

Guy:  Yes,  but during the 30s, 40s and  50s, they knew how to design airplanes. Model airplanes had to fly. Then you knew what had to be, and you knew about wing sections, and you knew about  stability and dihedral and all that other stuff.

There is a story about Max that is priceless.  When we first went up toLangley, Max was still a big model airplane builder. His friend Woody Blanchard eventually became the one of the top model airplane builders in theUnited Statesfor a number of years. We’d all go to meets together. I was what they called the gopher. You see, in order to win prizes you had to fly in a lot of different events. When you launch the airplane, it was up in the air for a long period of time. If you waited and ran and chased it down and came back–you had to fly it three times, then you’d have get to other events. The gopher was the guy who goes for it and gets it to bring it back while the other guy is entering some other event.

Anyway we were going up early in the morning to a meet, the New York Daily Mirror Flying Meet.  It was held at the Grumman Airfield inBethpage,Long Island. We were riding up toNew York, and we got up real early in the morning. The back of the car was filled with model airplanes. Max and I and Woody went to eat breakfast on the main street inNewport News,Virginia. At that time in the morning the street was totally empty. This car is a Chevrolet Coupe and it’s canary yellow, just as bright as can be. We walked over and had breakfast. Woody and I reached into our pockets and said, “I got the exact change, Max. You don’t have any change, do you?” He said no. And we said, “Well, we’ll leave it and you pay for the bill. We are going to go back to the car. Meet us there.” The car was parked right across the street.

Woody and I went and sat in the car. No Max, No Max. No Max. No Max. (laughter)  Pretty soon we look around and here comes Max walking right past the car. Woody starts to holler, but I said “Shhhh!” Max walked right past this canary yellow car. He walked all the way to the other end of town and came back. Then, when he came back and it had gotten a little bit lighter, he looked at us with this big grin and said, “Where you guys been?”

He just had his head in the clouds. He was thinking about the meet or something. He was that way about a lot of things. When we went to Langley, it was almost six months before he could find his way out to work. I used to have to tell him how to get to work every morning. (laughter) We roomed together and he’d get up in the morning and he’d go in the bathroom  and he’d blink in the mirror a few times. Next thing I know, he’s back in the sack!

Ken: What was it that attracted you early to a friendship with Max?

Guy:  I don’t know. We got along. We didn’t have too many common interests. We did share interests in sports. Max had been a quarter-miler–I wasn’t very athletic. I was kind of small. I couldn’t play with the big boys, but I did intramural pretty well. I shot on a varsity rifle team, I ran cross country, I played softball. Max and I used to wrestle a lot and play handball, one of the things that we liked. I love handball because you have to be ambidextrous. You have to develop coordination on both sides of your body. We played a lot of handball together. We were both very similar students. We didn’t take our college work that seriously. (laughs) We were pretty damn independent. No one told us what we had to do. The professors couldn’t manage us very well.

If we got a lousy grade (C) it was usually because the professor didn’t like us and he couldn’t manage us or that we just weren’t interested in the subject. That didn’t bother us. My whole attitude was I was there to learn something, not there to get a fancy grade. I found a lot of people who got fancy grades but who didn’t know a damn thing except they memorized stuff by rote and they could answer the test questions.

Oddly enough, I think with our school records, even though we had reasonable records, they’d have never hired Max and me today. We couldn’t even qualify to be hired over here [at JSC] today. That’s a fact.  No one would look at us if they looked at our college transcripts and resumes–neither one of us were honor society types or anything else. We flunked out more roommates than anyone I know because we never studied. When it was time for final exams we used to always go to the pool hall and shoot snooker all during the week while everyone else was boning up. I never took notes in college. I’d come home at night and I’d try to remember what I had heard and I’d do all my note taking at night. If I couldn’t remember it, it obviously wasn’t very important.

Ken:  You must have a pretty good memory.

Guy:  I had a pretty fair memory. Somewhere along the way I understood what I was good at and what I wasn’t good at. I was fortunate enough that the profession I took up was one which I was very happy I chose. The teaching methods they used in my department were better, far better than anything else I’ve seen. We were taught to think. The problems we had to solve were thinking problems, not multiplication and addition and stuff like that. We also taught team work. All of our labs were done by teams of people. We rotated the leadership and somebody had to figure out how to adjust all the valves so the thing would flow in the right direction. Somebody had to collect the samples. Somebody had to weigh them. We had to give assignments.

Guy [comment]: I had always thought I wanted to be a chemist, but at a career counseling session my senior year in high school, the Dean of Engineering at Tulane University convinced me that Chemical Engineering was a much better way to go. Like Paul, I couldn’t afford the tuition at Tulane. I also needed help to earn some money to help pay for my education. My dad knew some politicians who helped me get a NYA Scholarship at LSU which paid me 30 cents an hour. That paid for all my food, and I earned some extra money during summer vacations.

I never regretted the decision. The professors in the Chemical Engineering Department were outstanding. Most had industrial as well as academic experience. As one never knew what kind of industry he would work in, the curriculum had to be very basic. Paul Horton, Jesse Coats and Arthur Keller were my principal teachers. We were taught to think. Methodology was much more important than getting the arithmetic right. In Chemical Engineering Lab, we, with a few professionals, operated an experimental sugar mill for the Louisiana Cane Growers Association and got valuable experience. And with grants from the local petrochemical Industry, we did experiments using the type of equipment used in that field.

The cost of doing business was paramount and almost every project involved what is now known as “cost engineering.” While each student was required to write his own reports of the experiments we did, we were taught teamwork. Each assignment had a leader who was required to assign tasks to the other students on the team. I learned that to solve a problem, you didn’t start at the beginning, you started with the end result that you desired and worked backwards from that. The professors required enough from each student that merely to pass was an accomplishment. Less than 20 percent of those who wanted to be chemical engineers in their freshman year graduated in that field.

Guy: We had a lot of real problems. Nothing imaginary. The old department head just made us think. While we did our work as a team, we each had to write our own individual reports and submit them. They all had to be typed. He was a real great teacher, very demanding. He didn’t put up with any bull crap. He, I could tolerate, because I knew what he was up to. The other guys who told me I had to keep this notebook and I had to be neat and look this way–I didn’t pay much attention. (laughs) Max and I are really not that great for neatness.

Robbie (laughing): What did your dorm room look like?

Guy:  When I was a cadet it looked great because I would have been walking drill tours if it wasn’t. It was spit and polished and shined and the bed you could bounce quarters off of and the whole bit. But after I got out I got out of that–well, it was sanitary. It was a hall, that’s what it was. We lived in a stadium. They have  cheapest rooms on the inside of the stadium. They didn’t even have windows to the outside.  So it was kind of dark and dank and mildewy. There were three of us–Bobby Dreher, I guess it was. Billy Drake was another one. Billy is dead. He was a Grumman test pilot that got killed out at Edwards Air Force Base flying a new  Grumman airplane.  Bobby works up at Langley. They had trouble trying to keep up with us because they couldn’t shoot snooker during final exam week. They had to study. I could never do anything like boning up. If I didn’t know it before I went in there,  I wasn’t going absorb it in a two or three night period. I’ve been that way all my life. I was fortunate that I was born with two great assets. I was born lazy and with no ambition. (laughs)

Robbie:  You sure went a long way for somebody who is lazy and with no ambition!

Guy:  Those are two of my greatest assets. Because I was lazy, I became, I think, an outstanding supervisor because I didn’t mind letting other people do the work. I didn’t have to do the work, or try to be smarter than the sum of the guys in my division. But I knew enough to guide them. And because I had no ambition I was never a threat to any boss I had. I never walked over any of them. I walked around quite a few of them, but I never walked over any of them. And I never worried who got credit for the work.  I think I parlayed those two things other people think are not too hot into a pretty good career. And I had an awful lot of fun doing it. I don’t think anybody could have worked in anything more exciting than Max and I and Paul did. We were right in the forefront of everything.  We always had the best tools. We had tremendous support in everything we did.  You just couldn’t ask for a better deal.

Ken:  Paul went to LSU also. Did you know him there?

Guy:  I didn’t know Paul that well. I knew of him at school, but I didn’t know him. He graduated two  or three years ahead of us. Because he was working atLangley, he had an exemption from going into the service because he was working on defense related research. So, Paul didn’t go into the service. By the time we had gotten toLangley, Paul had been working there for six years and had kind of gone up the ladder. Gilruth had brought him in–Paul had headed up the small wind tunnel there at one time. He also headed up the fiscal office, the payroll office atLangley one time. We got Paul’s name from the head guy who taught Max aero-engineering.

The guy who headed up the aeronautical department at LSU was an old German from World War I, Ernst (Fritz) Maser. He designed some real fancy airplanes back in the ’30s. The fastest airplanes in the world had been designed by this guy. He came over to theUnited Statesand became a professor at LSU. He had a very small organization. He never had any more than ten or twelve students. He handpicked all of his students, so he knew they were all topnotch people before he accepted them. He knew they would get through.

Fritz designed racing planes on the side for Harry Williams and Jimmy Wedell  during the 1930s. These usually won the Cleveland Air Races and were piloted by Wedell. They were built inPatterson,Louisianaon Bayou Teche at a site which is now the Louisiana State Air andSpaceMuseum.  Harry is the son of Frank Williams who owned the logging operation where I was born.

Robbie:  And he was your professor?

Guy:  No, he wasn’t mine. He was Max’s. I knew him and I worked with him. I got to know him fairly well back in the early ’40s. Fritz was head of a Navy and Air Corp Cadet training program at LSU. As I already had my commission, but had not been called to active duty because I was being allowed to complete my education, I was hired at the enormous salary of $5.00 an hour to give these cadets military training. That’s really how and when I got to know Fritz.

Robbie:  And he taught Max aeronautics?

Guy:  He taught Max aeronautical engineering, as well as Purser. So he gave us Paul Purser’s name and I got a few leads in some sugar companies and various industries from the head of my department. It turns out that we were on our way to visit our other roommate who was a pilot on the Franklin D. Roosevelt, a new aircraft carrier just commissioned. Billy was still in the Navy as a Naval pilot.  He was atQuonset Point,Rhode Island. (Billy later became a Grumman test pilot and was killed in an airplane accident at Edwards Air Force base.)  We took off in this little car and we headed off to Quonset Point. On the way there we stopped inNorfolk,Virginia and Langley Field,Virginia

Robbie:  Paul was already atLangley?

Guy:  Paul had been there for about three years before the war. He was there all through the war and had been there three years prior to the war. Max and I spent almost three or four years during the war in the Army and the Navy during WWII. Paul didn’t go because he had an important civilian job. He got a deferment and didn’t have to go into the service. They may have inducted him as a private or something but never sent him.

Robbie:  So you drive up there in Max’s father’s car, and say “Hey Paul, we’re here?”

Guy:  No, he didn’t know we were coming up. We got there and the first person we met was Adeline. She was a pretty little thing. She was the receptionist in this fancy building. There was a rotunda and it had paintings of the history of flight on the large hemispherical dome. There was this big circular table and she sat there where you went in. She took one look at us and kind of turned her nose up for some reason–I guess because we looked like two bums. We were wearing very loud Hawaiian sport shirts and either kakhi or navy gray work pants . We had opened-toed sandals with no socks on. I think we slept in our clothes. We weren’t anything special looking. (Later on, she must have changed her mind because she asked us to give her a ride home after work.)

But they didn’t give a hoot–they didn’t care about that. They were totally informal. The whole operation was informal. Paul never wore a tie, in fact. He suffered with the heat so always in the hot summer he had a big towel wrapped around his neck. Whenever we had any distinguished visitors, he used to keep a old seersucker coat hanging on a tree in his office. This office was just one big office with everybody in there. Paul had a desk at the head of the room. He’d go grab some kid who had a tie and say “Hey, I want to use your tie” and take the tie off him and put it on and go to the meeting if he thought he had to be dressed up. (laughter)

Robbie: So when Paul saw you guys what did he say?

Guy: He was enthused because here are two young fellows who had engineering degrees looking for a job. They had hardly hired anybody with degrees. Most of the people had gone off to war. It wasn’t that easy to get good people. He made us an offer right on the spot. He said, “Sure, we’ll hire you” and we said, “We’ll let you know in July,” and we went up to visit Billy up in Quonset Point. We spent a little time up inNew York City and did a few other things. After we went back home, we decided one day, “Well, we didn’t get any better offers,” so we called up in July and said, “Hey, we’ll report the first of August.” That’s how we got to work up there.

Robbie:  What did he offer you?

Guy: A job working in the Pilotless Aircraft Research Division—PARD—under Bob Gilruth. He said he needed someone–both of us worked in propulsion for a time. This was the first place where they had offered us a real job that sounded interesting. They hired me to work on rockets and they hired Max to work on a type of propulsion called ram jet. Paul said to me, “You are a chemical engineer. We need someone who can work on things called liquid rockets.” Well, once I got up there, I found out that liquid rockets were not what we were supposed to use–solid rockets were so much easier and cheaper, and we could handle those  so much better.

Robbie:  Is that what got you interested in propulsion?

Guy:  Yes, I got interested. I taught myself with a bunch of books from the library. I set up test facilities and later on, I built myself an experimental solid rocket plant so I could try out some of my own ideas on high performance solid rockets that I had patents on. They had a bunch of surplus military rockets we were working with–little teeny things between two and five inches in diameter. I got interested in them and a lot of other things. I was part of a service organization–I provided a service to all the people there. I was not in the forefront like the other people. I kind of worked in the background.

Design and Experimentation at Langley/PARD

Guy: I found out a lot of things–that if they would let me make changes in the rocket designs, fix the rockets up and do things a little bit differently, I could help enhance quite a lot of the aerodynamic data we got. So I got in the business of cutting rockets in half, building bigger ones, gluing two of them together, putting them in a lathe and cutting them down, doing all sorts of things to change their performance characteristics, which would help the engineers get better information. We developed a bunch of little techniques.

One of Bob Gilruth’s real strong points was that he believed in absolute simplicity. He believed in using your head rather than the machine to do things. He would say, “Use your head!” I learned a very important lesson which I began to put together from him–that passive systems are much more difficult to design than active systems. Passive systems are where you press the button and everything happens according to the laws of physics and chemistry without any intrusion of anything–a valve that you have to adjust, something that has to turn something else off or on–he was real great for that. He never let you use a lot of complicated devices.

Robbie:  Why? Because there would be more stuff to break?

Guy:  Yes. They cost money and they can go wrong. They can fail. So what you do is use the laws of physics and chemistry and put those to work for you so that everything happens the way it’s supposed to happen on the way up. With the basic design, you design that into the system so that nothing active had to come in and intrude on it. It’s done–when you press the button, everything is preordained that is going to happen, you see?

I caught onto that real quick and that’s why Gilruth and I got along real well. One time he had us study the dynamic qualities of an airplane to make the airplane stable. If you pulled back on the stick and then you release it then your airplane goes through oscillations, and those oscillations tell you how stable your airplane is. He didn’t want anything to go bad so I said, “I can fix you up. I can put little rockets about so big–about a half inch in diameter and four inches long–that fire at right angles to the model, and that’s going to knock the nose down and make the thing oscillate. I can set those so they go off in one second intervals using delay fuses. I’ll put eight or ten of those and I’ll fire them all from the ground and they’ll all go off at different intervals, so as the airplane is slowing down, you get the  entire speed range from supersonic through subsonic.”  We started doing things like that.

There were a lot of other little things that people wanted. One of the guys said there was an aerodynamic quality they wanted to measure called damping in roll. He came and talked to me about it. He said, “I have to have something to make the airplane spin but I can’t use the rudder to make it spin.” He said, “If I had something to spin it—”  and I said, “Then I’ll design you a rocket to spin it, and I can tell you how much force the rocket’s using to spin it–will that help?” and he said “Sure.” So I designed those things–a lot of little things like that.

One of the guys in the wind tunnel called me one day and said, “Hey, we’d like to study something in the spin tunnel, but we can’t. There are a lot of things we can’t do.” The spin tunnel is a vertical tunnel –the air goes up. You throw a model in there and then you put it into a spin and you blow the air on it, enough so it keeps it floating there, you take pictures of it as it floats around as it spins. He said “Well, you really can’t tell very much about the aerodynamic forces on there or the other forces, because they are all  in the wash.  It spins around, it’s nothing but the air that is displaced that it’s spinning back into.  I can’t tell what  forces and what direction you need to apply to cause the airplane to recover from a spin—” But he said, “If I had a way that I knew what the forces are that cause the recovery, I might understand what I have to redesign in the airplane to make it recover from a spin.” And I said, “Well I’ll design you a little rocket that can provide a known force and moment you can put in there.”  And I built little rockets that fire a couple of seconds. They could fire those at all the various axes and cause it to de-spin. Then they could study the spinning characteristics, the forces and the inertia that it  went through in the tunnel. That was a big help.

Robbie:  You built rockets that were tiny?

Guy: They about a half inch in diameter and an inch long and produced three ounces of thrust for two seconds. They were mounted on a little model airplane in the tunnel and what they would have inside was a little switch. The tunnel had a large solenoid coil in its throat. When you energize that magnetic coil, you close this little switch to fire those little rockets without any external wires into it. There was a small battery and initiator inside the model.

We did all sorts of things. It was a kind of free-swinging outfit. When we tested airplanes in the wind tunnel you had these turbojets hanging on there, but there was no exhaust coming out. With no exhaust coming out, it doesn’t give you true conditions. The exhaust acts like a big solid body. It’s like trying to stick your finger into a hose. The jet exhaust pushes the free stream back out. John Stack asked my advice on installing something to simulate turbojet exhausts, so I suggested a hydrogen peroxide mono-propellant system which would give about the same exhaust characteristics as a turbojet. I helped John Swihart and Jack Runkel, both of them in the 16-foot wind tunnel, get this started.

I’ll tell you a little story about my rocket plant. That’s a good one. You see, Lewis was the propulsion research center andLangleywas supposed to be in aerodynamics.

Robbie:  What were you doing atLangley instead of Lewis if you were in propulsion?

Guy:  I was supportingWallopsIsland andWallopsIsland used rockets all the time.  I wanted to build this rocket plant. I had some ideas about a brand new spherical rocket that I thought would have some advantages. I wanted to be able to build one to prove it. So I needed to build a rocket plant.  Headquarters would absolutely not approve of building a rocket plant atLangley field.  They said, Oh no, only Lewis could have a rocket plant.

Bob Gilruth came to me and said, “My signature authority is worth $999.99.  If it’s over $1000, you’ll have to go to headquarters for approval. Can you buy every piece of equipment you need for that rocket plant for under $1000 per piece?” I said “I think I can.” He said, “Don’t worry about the building. We’ll call that a model assembly shop or something. We’ll build you the building.  That’s no problem.” I had to take some of the low bidders for equipment I needed. But, I built me a rocket plant. I bootlegged it! The next year, because of what I did with that plant, headquarters decided to give $225, 000 to build me a good one, a bigger one.

Robbie:  So in other words, you bootlegged it and then once you were doing it, then they gave you money for it!  What did you do with that rocket plant?

Guy:  I built these nice rockets.

Robbie:  The round ones?

Guy:  The round ones.

Robbie:  What did they do, how did they perform?

Guy:  They were the highest mass fraction rockets ever built in the country at that time. I could build them in any size. I built a lot of them for research–for studying meteors coming to the earth at extremely high speeds. They were very unique little things. Then they were used as retro rockets and the Japanese copied them. I got to go toJapan to give a paper. They started copying all the ideas that I had and a lot of other people got into the act. I designed and built another non-circular, non-spherical rocket that had some rather unique qualities to take advantage of filament wound rocket cases.

Robbie:  Are those designs still used or have they evolved into new designs?

Guy:  They’ve evolved.

Development of the American Space Program: Early History

GT written commentary:

To understand the space program you have to go back to a number of events during World War II and the ensuing years. Rockets have always been an interesting subject, but other than some crude early designs by Congreve and Goddard, they had little practical application other than for holiday pyrotechnic displays.  In America our use of rockets during World War II was restricted to small solid propellant rockets like the Bazooka (an anti tank weapon), barrage rockets, some air to ground weapons and a few applications in naval warfare. The Germans, under the leadership of Walter Dornberger and Wehrner von Braun, developed a long range liquid rocket bombardment system. This story is told in Dornburger’s book, which is entitled V-2.  At the end of the war, Operation Paperclip brought many of the German scientists from Penemunde to America to continue their work on rocket-powered weapons, first in El Paso, Texas, then in Huntsville, Alabama.

At the end of WWII, Robert Rowe (Bob) Gilruth began to use free flying rocket powered models to conduct aeronautical research at transonic and supersonic speeds at a remote location off the eastern shore of Virginia named Wallops Island. This started in 1945 with a small group of engineers at the National Advisory Committee for Aeronautics (NACA) Langley Research Center (LaRC) called the Auxiliary Flight Research Section. The work expanded and grew into the Pilotless Aircraft Research Division (PARD) in 1946.

In the ensuing years numerous things happened.  In the interests of obtaining higher and higher speeds, PARD developed a number of simple multi-staged solid propellant rocket vehicles which had  hundreds of successful launches with few failures. The International Geophysical Year brought together a number of scientists interested in the upper atmosphere. These simple launch vehicles were an ideal way to obtain the extremely high altitude this group was looking for. Bill O’Sullivan was PARD’s representative on this International Geophysical Year Committee. Some others were  James Van Allen of the University of Iowa, I.M. Levitt  of the Fels Planetarium, and I believe S. Fred Singer of the University of Maryland.  PARD engineers worked with these scientists to customize various systems including rockets launched  shipboard and from high altitudes on helium-filled balloons (Rockoons). This work led to the discovery of the Van Allen Radiation Belts, Standard Tables of Properties of the Atmosphere, etc.

With the Cold War heating up in the early and mid1950s, the emphasis shifted to Intercontinental Ballistic Missiles (ICBMs). The multi-staged research vehicles that we were launching were capable of achieving the speeds and altitudes near those reached by ICBMs and thus were ideal research tools to study aerodynamic heating and heat resistant materials needed to protect the warheads during atmospheric reentry at high speeds. Max Faget was on a Fleet Ballistic Missile (Polaris ) committee and Paul Hill was on a similar committee for the Army’s Pershing Missile.

The models were getting larger and more expensive. Paul Purser was given the task by Bob Gilruth to look into development of ground facilities to do more detailed studies of high temperature structures and reentry thermal protection systems and materials.  This led to the development of high temperature ceramic heated air jets, electric arc heated air jets and chemical jets (rocket exhausts). 

Further work resulted in facilities led by Bob Jewell which prepared oxidation resistant coatings such as borides, carbides, nitrides, oxides and silicides using a vapor deposition technique by bubbling hydrogen through metal halides and passing them over induction heated carbon models.

Later on we became involved in electron radiation in space using high voltage cascade rectifiers to accelerate the electron beams, micro-meteoroid damage using light gas guns developed by Alex Charters of Aberdeen Proving Grounds, high vacuum technology, and thermo-physics.

All of these technologies were at the forefront of those needed to understand what was required in order to send things and people safely into space. Every bit of this was conceived and executed by a small handful of people in NACA’s Pilotless Aircraft Research Division at Langley Research Center, and the supporting effort of everyone at the Center. This led management to recognize the expertise of this group in technologies which were precursors to going into space. The effort supported our country’s ICBM program and had a great influence on the shift from all liquid propellant launch systems to all solid propellant launch systems, along with the knowledge as to what the real size and weight of the hydrogen bomb was.

Guy: The space program  really got started back in 1957 with NACA, the National Advisory Committee for Aeronautics. I worked for the NACA in PARD, and what we did was aeronautical research using free-flying rocket-powered models, and that research had a great influence on the ballistic missile program, including the shift from big liquids to all solid.

With these small launch vehicles, we were getting up into the ionosphere, and at the same time getting a velocity that was short of orbital velocity, but pretty well up there. Just about the time Sputnik flew, in October of 1957, the Air Force had a program which was eventually called Dynasoar. Dynasoar was  either a winged bomber or a winged orbiting space surveillance aircraft. There were two versions of it  –one with a semi-global range–it could fly halfway around the world. Then they discovered that with available propulsion technology you could  actually go into orbit and fly it all the way around. The Air Force wanted to develop this winged space bomber to be able to fly and bomb anywhere in the world.

That program was the outgrowth of something happening in Germanyin World War II.  The Germans had developed the V2s, and were looking at the very large V2 they called A4 (or A10). Its purpose was to be able to  bomb New Yorkfrom Berlin. The way Dynasoar came into being was that the Army had gotten all the German scientists at the end of World War II. It had gotten von Braun because the Air Force did not exist at that time–it was still the Army Air Corps. The Air Force, once it did exist, was kind of miffed because the Army had gotten the group who were in the business of developing rockets which could bomb cities in direct competition with bomber airplanes.

Since the Army had von Braun, the Air Force decided on a little one-upsmanship. So they imported von Braun’s boss. That boss was one of the German generals in Hitler’s high command. His name was Walter Dornberger. He’s the one who wrote the book called V2, about how the V2 developed inGermany. He had a PhD in engineering and oddly enough was a very delightful person. He had a very nice quiet personality–not what one would expect of Hitler’s generals. The Air Force set him up at Bell Aircraft Systems inBuffalo,New York.

Robbie:  What year was this?

Guy:  This must have been in the early 50s.  He was Chief of Research, Chief Scientist at Bell Aircraft. The Air Force had some studies which were conducted under the code names Robo and Brass Bell.  They were top secret studies. They were basically on glide bombers, not like Dynasoar.  These studies eventually grew into a proposal to build some of these things.

In October 1957, the NACA was asked by the Air Force to convene a group of people and to take a look at this program they later called Dynasoar and to advise them of the feasibility of doing this program, possibly as a continuation of the high speed flight research program past the X-15. People from throughout the agency were invited to the NACA’sAmesResearchCenteratMoffett Field,Californiato sit in on these discussions. It was the week when Sputnik was launched. TheU.S.had its own satellite launching program—Vanguard–which was the responsibility of the Naval Research Laboratory.

That grew out of a program called Viking, which was a relatively large liquid-fueled sounding rocket that could probe the upper atmosphere and gather all the properties of the atmosphere–density, temperature, radiation and various other things that scientists were interested in measuring. This program wasn’t doing that well at the time. It was having many failures and was way behind schedule.

Anyhow, we got out toCalifornia–I don’t know the names of all the people who were present there, but the senior guy fromLangleywas a fellow named Floyd Thompson. He later became Director of Langley. He was a very, very interesting person in a lot of ways. He had a lot of talent, and then he had some shortcomings later on, I discovered. His shortcomings were that he didn’t know how to choose people to run the various organizations that were part ofLangleyafter people to began to leave and branch out. (To be fair, his problem there could well have been that almost all of the really innovative people who were capable of leading the Center into the Space Age had been assigned by Bob Gilruth to the Space Task Group.) Other than that, he was a real great guy.

And, there was myself, Paul Purser, Max Faget, Adolph Busemann, a scientist who we imported fromGermanywho  was a  supersonic and hypersonic  aerodynamics  specialist. I don’t remember everybody fromLangley. Dr. Dryden, who was head of the NACA, was there. There was Milton Ames who was head of the aeronautics programs for the NACA, and Clotaire Wood who was Dr. Dryden’s special assistant. He was a young fellow who took care of a lot of Dr. Dryden’s agenda.

There were many, many people fromAmesResearchCenter. There was Harvey Allen who later became Director of Ames, and Al Eggers. These were the two who were responsible for the blunt body ballistic missile nose cone re-entry development.There was Walt Williams ( Paul Purser’s classmate from LSU) who  at the time was Director of the High Speed Flight Research Station at Edwards Air Force Base, California, and later became NASA’s Chief Engineer and Deputy Director of the Manned Spacecraft Center for a while. I think his assistant De Beeler was also there.

I don’t remember all the other people, but since it was out atAmesthere were quite a fewAmesparticipants. There was a young X-15 test pilot named Neil Armstrong who was there too. We all flew out toCaliforniato Ames Research Laboratory nearMountain View. It’s in theSan Franciscoarea. We sat around for about three or four days and had a number of technical discussions about what the Dynasoar should do and what it should look like.

Another fellow named Hartley Soule fromLangleywas also there. Hartley was the guy who started the Flight Research Program at Edwards Air Force Base. The last big one they had was the X-15 Mach 6 research airplane. And Bob Piland was another young fellow who worked with us. ( I can pinpoint the date because Piland had his 30th birthday while we were there. It was also the 30th anniversary of Hartley Soule’s working for the NACA.)

We looked at Dynasoar and saw that there were a tremendous number of obstacles, but none of them were insurmountable. They were strictly engineering problems that somehow or another, if you worked hard enough and you did enough research in some specific areas, could be overcome. Nothing seemed to violate any laws of science as we understood them.

Ultimately we have proven that–the shuttle is nothing but a very large Dynasoar.  [Note: Max Faget disagrees with this assessment.] When you really look at it, the Dynasoar had a similiar shape. We didn’t have very large launch vehicles at the time. And the shuttle basically had wings just about like the Dynasoar.  It glides back in just like the Dynasoar was supposed  to do. You see, the Dynasoar was feasible, it’s just that there’s a lot of what I call collateral technology that has to be developed. You want to do things, but in order to do them something else has to happen to allow you to do those things. You have to develop the materials and understand the aerodynamic forces, heating, propulsion, structures, materials and guidance and control. And all those things you need have to be small and lightweight, and have to use little power and last a long time unattended .

Well, from 1957-1970, when we were working the space program on Mercury, Gemini, and Apollo we were developing all that technology which would allow Dynasoar to happen [i.e. the shuttle].

We had a few things we were interested in doing. I was interested in building an all solid-propellant launch vehicle. You see, most of the launch vehicles are liquid-propellant except that suddenly they shifted over from liquids into solids for the ballistic missile launch vehicles, for a lot of very good reasons. Many of the reasons were the results we got from launching these multi-stage solid- propellant rocket vehicles atWallopsIsland. We demonstrated a very high degree of reliability and very simple operation. Their simplicity, lack of much ground support equipment and instant readiness makes them much easier to do than the big liquid system.

Max had gotten interested in putting a man in space as a result of discussions with Al Eggers and  in addition to looking at Dynasoar. And it looked much easier to do than Dynasoar. The easy way looked  a lot like this ballistic missile nose cone technology. We would build a little blunt nose cone and it didn’t have to have all the controls or everything on it. It was going to be a very, very simple thing to do compared with doing a great big thing like Dynasoar and really a way to get man into space in a hurry.

So out there at Ames, Max and I cornered Dr. Dryden in the lobby and we were doing a little bit of lobbying ourselves, telling him that we were not going anywhere fast and if he would just give us a chance, we could develop this little launch vehicle–which later on became a four stage solid propellant rocket satellite launch vehicle called Scout. (The Scout had a very successful history. It’s no longer flown but it was flown up to about two years ago before the program  was cancelled.  During its lifetime it had the most reliable launch record of any launch vehicle.) And Max said we could put a man in orbit if we were given the authorization to do so.

GT commentary: I picked the Scout concept up in July of 1957 after coming back from a big rocket conference in Denver. I saw that the Navy was developing something called the Jupiter Jr. Jupiter was a big liquid rocket that was being developed by the Army in Huntsville. The Jupiter Jr. was going to be something the Navy would put in the water and that would float like a buoy with the nozzle down, and  be launched like a plumb bob flying right out of the water. Another option was to launch it from the deck of an aircraft carrier.  It was about the largest solid-propellant rocket that had been developed in the country at that time. The program was supplanted by the Polaris later that year.

I had looked at that and I looked at some other rockets that were available, things that were being developed for the upper stages of the Vanguard, which was going to be the first satellite put into space in the Navy program. And then there was another program called Hermes which had another large solid rocket. And taking a look at the size of these things I could see that when you put a third stage  in the stack, they all  come up almost to a perfect match where each upper stage was compatible with the total stages under it without relying on a monster size booster first stage. So you have three of them already being built and you don’t have to spend any  money to develop them and repeat a lot of mistakes–you only have to develop the fourth stage. (The third stage in this case. ) I looked at the propellants available, and at the case manufacturing technology and other possible improvements, and did a few calculations to show that four properly designed stages would put a lot more into orbit than the Vanguard.

And Dryden said well, Eisenhower had told him that the Naval Research Laboratory was the only one that was going to put a satellite into orbit. (Later it turned out that he had to recant, because the Navy got so far behind that von Braun launched the first little satellite with the Redstone and two stages of solid propellant rockets.) And then Max talked to Dryden about putting a man in space–he wanted to get a manned space program going. Dryden didn’t take too kindly to that. I think his comments were, “Shooting a man into space is like shooting a girl out of a cannon”–or something like that! And frankly, Al Shepard’s flight was about like that. I think when you really get honest about it, it was more about PR than anything else.

So Dryden said NO we are not going to do any of that. So we got back toLangleyand talked to Bob Gilruth and Bob said, “Well, you guys go ahead and work on it.” He said, “We won’t tell anybody.” Most of the greatest work we ever did is what we called “bootlegged.”  We got it started before we ever had authorization to do it. We would develop the concept, prove that it worked, and after we proved that it worked by bootlegging it, why then they’d give us authorization to do it. We always did think like that back in the old NACA days.

The NACA

Guy: The NACA was a very unique organization. We probably had somewhere around 7 to 8 thousand people in the organization–scientists, administrative people, and crafts people. We had a lot of very skilled people who could make anything you wanted. The machine shops–they could make anything that anybody could conceive of. We had instrument machine shops that could make instruments. We were completely self-sufficient, our organization, pretty much. We did not have to do a lot of outside contracting except for maybe the large construction. To manage that organization of 7000, the total headquarters/professional staff was 58 people inWashington! The proportions are quite a bit different these days. But the NACA was not a political organization. It wasn’t big enough that anyone would want to grab it. It really didn’t have to be defended, and there were a lot of people who supported it because it did nice work.

I wrote a Foreword to the commemorative album for the NACA’s fifth reunion. It will describe what the organization was really like and what made it great and why.

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NACA 1915-1958

Reunion V

Galveston Texas

October 19-20, 1991

Foreword, by Guy Thibodaux

            In the winter of 1915, Congress passed an Act attached as a rider to the Navy Appropriations Bill creating a new organization known as the National Advisory Committee for Aeronautics (NACA). The initial annual budget was $5000. This organization was to become the finest ever created by the U. S. Government. Its charter was “to supervise and direct the scientific study of the problems of flight with a view to their practical solution, and to direct and conduct experiments in aerodynamics.” The Act provided that the governing body be composed of those acquainted with the needs of aeronautical science, either civilian or military, or skilled in aeronautical engineering or its allied sciences. Vannevar Bush described the NACA as “unique among Federal Agencies in that its controlling body served without salary and had been composed of men of such high character and distinction as to render it completely free of political influence.”

            The committee was limited to fifteen members. As the work of the Committee grew, it added working groups also known as Committees to advise in those major subdivisions of the science of flight such as Propulsion, Stability and Control, etc. These were further divided into subcommittees depending on the degree of specialization. The members of the Committees usually served as subcommittee chairmen. They were served by an Executive Secretary who was a member of the Washington Office Technical Staff. All members were cautioned that they had been chosen for their personal reputation and expertise and were to represent their opinions and convictions rather than those of the organization that employed them.

            The product of these groups were the Resolutions, suggesting that specific areas of research should be increased or added. The minutes of these meetings were circulated to the Field Centers. It was left to the organizations and individuals what course of action to pursue and what resources would be allocated in support of these resolutions. Two documents were necessary to apply the resources of the various organizations, the Research Authorization (RA) and the Job Order (JO). This lack of unnecessary paperwork and bureaucracy left the individual researchers free to pursue the major goals of the agency without encumbrance. The absence of a body of documents and procedures regulating all of the Agency’s operations allowed the leaders to make the tough decisions based on what they felt was good for the Agency. Often their interpretations of the rules could be construed by others to violate other existing Government regulations. Individuals were recognized for their skill or expertise rather than the positions that they held. The engineer, scientist, administrator, designer, craftsman, or technician were all equal members of the teams that sprang up in response to the Agency’s goal.

            Henry Reid once said that a great error was made when his title was changed from Engineer-in-Charge to Director. He remarked that it was impossible to direct those bright, talented individuals who had attained national and international reputations in their fields and the accolades of their peers. Leadership and respect in the NACA was not conferred. It was earned.

            The change in world events leading up to World War II resulted in a major expansion of NACA’s facilities at Langley Field, Virginia. The center of the aircraft industry was moving from the east coast to the west coast. A new research center called Ames Aeronautical Laboratory was opened at Moffett Field near San Francisco in California. Another, called the Lewis Flight Propulsion Laboratory, was opened at Hopkins Airport in Cleveland, Ohio. The Langley Memorial Aeronautical Laboratory furnished the nucleus of people to supervise the design, construction, and staffing of these new centers. Further expansion in the postwar era resulted in the establishment of the High Speed Flight Research Station at Muroc, California and the Wallops Research Station on Wallops Island, Virginia. In this expansion, the NACA grew from one research center and a Washington office staff of 5 in 1939 to three Field Centers and two Field Stations numbering almost 7000 with a total headquarters staff of 135 by 1945. The agency had but one attorney on its staff, a General Counsel.

            The greatness of the Agency resulted from many factors. It had outstanding leaders who were men of vision and integrity. It did not compete with its major customers and in the same vein, it had no real competition from its customers. The NACA never designed a commercial or military airplane. The large, complex research facilities were too expensive for any one company to afford. The NACA operated as a self-sufficient organization reporting to the Independent Appropriations Office of the House of Representatives. It justified its own budget, allocated its own resources, designed and contracted for the construction of its facilities, developed its own research equipment and techniques, and scrupulously followed the rules of competitive acquisition of goods and services.

            The pay wasn’t that great, but the working conditions were outstanding. During the lifetime of the Agency, not one member of the leadership ever left seeking higher pay or a more satisfying work environment. At Reunion II, Bob Gilruth said that he would have been willing to work for room and board because it was such an honor to be accepted to work for the NACA after graduation. The “cream rises to the top” was true at the NACA. Everyone likes a winner. Those individuals who possessed the imagination and ingenuity to suggest practical ways to carry out the NACA’s mission had little trouble gaining support for their projects. They found an eager group of equally talented people from all support areas to assist them. The Agency never gave out trivial pieces of paper or hardware for individual achievement. The rewards were more responsibility, the ability to work on the most exciting projects, and the respect of their peers. It was said that one had to be superior just to work for the NACA. While these same bright, talented people were highly individualistic and had egos, these egos were suppressed for the good of the Agency. Everyone who had thoughts or ideas to contribute could be heard. There was little turnover of the most talented people. Long-term professional and personal friendships were developed that exist to this day. These are some of the reasons why after 33 years large groups of us gather to renew these friendships and pay tribute to the organization which all of us are proud to have served.

            Dr. Dryden expressed great concern that the environment that made the NACA what it was would be radically changed in the ensuing years under NASA. He feared that much of the spirit that was the NACA would be lost. The legacy of the NACA was passed on to the next generation under NASA with the talents and integrity of those who were the NACA’s leaders. Most of us participated in the transition from the NACA to NASA. The NACA spirit was carried into the Space Age by people who were NACA-trained, educated, and developed. The second generation is now retiring, and it remains to be seen how many of Dr. Dryden’s concerns are realized.

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Guy: The NACA was a funny outfit. I worked there for 17 years and I don’t know anybody who ever got an award from the organization, as I explained in my Foreword. The way you were awarded is you got to work on the best jobs. You got ideas heard, you got promoted. They didn’t give you a piece of paper or a plaque. Everybody knew who was doing the job and what would happen. Then, if you did something good, everybody in the organization who was good wanted to work with you on your team or on your ideas. It was “the cream rose to the top.” That’s the way the organization worked and everybody understood that. No one had to worry about anybody patting them on the back because they knew what they did and everybody else knew what was done. Occasionally somebody got a big award from some place outside the agency.  A modern parallel to the way the NACA operated is what happened in the computer industry inSilicon Valley in its early years.

Caldwell Johnson was another one of the wonderful people in the outfit. He designed spacecraft. He said his neighbor always asked him, “Well, I see all these military people getting all these outstanding ratings and superior performance awards–how come I never see any of you guys ever get one?” Johnson said, “Hell, you got to be superior just to work for the NACA!”

Somehow or another back in March of 1958, someone in the Eisenhower administration apparently decided they wanted a space agency. The troops in the trenches didn’t really know that much about it. But I think the NACA headquarters was told that they were going to become the nucleus of the space program. Most of that is a result of the work that we had done atWallopsIslandwith Bob Gilruth and his Pilotless Aircraft Research Division–that’s why we became a space program–the aeronautics part of course was fairly well established throughout the rest of the agency.

Formation of the NACA Space Committee

Guy: Gus Crowley, who was the deputy under Dryden, formed a little committee in the middle of March, 1958. Its job was to take a look at the NACA’s role in space.  [Shows a two-page piece of paper] That’s the committee that was formed–it’s a little innocuous-looking memo.

R (reading the memo): It says that the people appointed to the committee were Bruce Lunden from Lewis, Walter Olsen from Lewis, W.J. O’Sullivan, Jr., Paul E. Purser, Joe A. Shortal, Guy Thibodaux, Floyd L. Thompson. J. W. Crowley from NACA headquarters, Ray L. Zavasky, secretary, Clinton E. Brown, Ed C. Buckley, Robert Crane from Ames, and Max Faget and R. L. Krieger. What’s his first name?

Guy:  Bob Krieger.  Bob’s dead and Bob Crane’s dead.  Quite a few people have died. It was a long time ago. We got together–

Robbie:  Where did you meet?

Guy:  I think we met the first time atLangley. It’s been 50 years, I don’t remember exactly. There were many, many meetings that came on after that. This grew into almost a permanent type of affair. And not all the people from the original group stayed with the group. There were various reasons why a lot of them didn’t continue and various reasons why there were substitutions.

Robbie:  And what was the name of this group?

Guy:  It was a group to prepare a NASA space technology program for budget purposes.

Robbie:  Was this the Space Task Group?

Guy:  No, this was a year before the Task group. This was just a group of people mostly from Lewis and Langley who they thought were leaders in their fields who could come up with the program, and with enough convincing arguments, be able to get funding for it. It turns out, Lunden went to this one meeting. Ted Olsen was not a permanent member of the group. Bill O’Sullivan stayed with us. Paul Purser stayed with us. Joe Shortal was not a member–he didn’t stay with us. Joe was our Division Chief at the time. He had to run the Division. Floyd Thompson was an Acting Center Director at the time so he didn’t stay with us. Gus Crowley stayed with us. He was up in headquarters and we reported to him and Dr. Dryden. Zavasky stayed with us. He was a kind of top administrative assistant. He’d pull budgets together and he did a lot of other things.  Clint Brown stayed with us.

Here are the addresses of all the people who are still alive and their phone numbers. Josephine Dibella was Dryden’s secretary, either Dryden orCrowley’s secretary. She’s still alive. The secretaries usually know more than anyone else about what goes on.

Robbie:  That’s for sure!

Guy: Clotaire Wood was Dryden’s special assistant and it was me, Max, Paul. Zavasky was the top administrative guy. The two guys from Lewis, Ted Olsen might have come up once or twice with us.  Abe Silverstein, who was the Director of Lewis, realized something big was going on, and appointed himself in place of these two guys in this group. He was the acknowledged leader of the group at that time. Thompson appointed Bob Gilruth in his place and Bob was the Number Two guy in the organization at the time.

The other fellow who was added on there was Adelbert O. Tischler. [Robbie: We have subsequently conducted interviews with Clotaire  Wood, Josephine Dibella, and Tischler]. He was my counterpart from theLewisResearchCenter. There was Edgar Cortwright. He was another real bright guy. He was an outstanding speaker and was on this committee. He became some kind of Associate Administrator inWashington. Then they appointed him Director of theLangleyResearchCenter for a while.

Ed  Buckley was Chief of the Instrument Research Division and he elected not to go. He sent his deputy, Mort Stoller, which was a super choice, although Ed would have been a great choice himself. Solid guy. Both of them later became Associate Administrators in headquarters at one time. Mort  was very super guy. I didn’t really know him (Mort) that well. The few times we talked I felt he was very astute in almost every facet of what we discussed.

Bob Crane fromAmescontinued on but because he was so far out inCaliforniaand he didn’t have a lot of money to travel, he didn’t attend an awful lot of meetings.  Later on, he became Assistant Director for Space at theAmesResearchCenter. Al Eggers was the guy who worked withHarveythat developed this blunt body re-entry nose cone theory. Al Eggers came up only once or twice. Krieger didn’t participate. Krieger was runningWallopsIsland, although he did participate in some other activities relating to this group–on occasions we had special assignments.

The other guy who came up there, Charlie Zimmermann, was added to this group. He didn’t take anybody’s place–I don’t know whether he was Chief of Staff or what but he was the guy who found out everything going on in the Pentagon and let us know about it, as far as I remember. He had a little petty cash fund we could throw chits in and take out cash for taxi fares and things like that. I really don’t know everything that everybody did. They all somehow  did something they were supposed to do!

There was an area called  Stability and Control where Zimmermann was assigned to work. He had several new ideas. One of them was an airplane with a circular wing . Another was riding a thrust vector.  If you had a controllable thrust vector passing through your center of gravity and it exceeded your weight, you could just take off and fly anywhere you wanted.Bellmade a jet pack which accomplished it (best known as Captain Keds Rocket Belt) and people rode on top of rotating propellers which had lift in excess of a man’s weight.

Max Faget was very active on this committee and I don’t know if Paul was that active or not. Paul was kind of Gilruth’s Chief Executive Officer. He did everything Gilruth didn’t know how to do or didn’t want to do. Gilruth had some things that he was super at that he loved to do, but like all of us, we can’t do everything and he knew who to choose to do all those things that needed to be done that he wasn’t going to mess with. Paul was that type of person–in addition to being very good in his own field as a scientist, he was good at all kinds of planning and administrative stuff.

In addition, Bill  O’Sullivan was our resident egghead.  They call them nerds these days.  He was a kind of science type.  He’s the one who came up with this great big balloon, this hundred foot diameter balloon we launched in space called Echo. I don’t know if you have ever heard of that. You could see it from everywhere.  It was a real bright star and we had two of them up at once.

Robbie:  What did they do, monitor?

Guy:  Well, you could monitor radar signals, radio signals actually, sort of like a passive communication satellite except satellites now act so you can  send the signals to them, amplify them and retransmit them.  It was fundamentally something that everyone could see in space. It was a lot of good PR as well as for measuring the density of the atmosphere because the number of molecules up there is what slows the thing down so much. It was measuring the de