Birthing Expectation, Attitudes and Education: Are we Traumatized by the Politics of Expertise?

Maternity practitioners believe that birth outcomes are better when women “learn” what they need to know and therefore they provide “education” about birth. I believe that birth outcomes also improve when practitioners don't assume that women giving birth are stupid and when they begin education by asking women about their expectations. From Helen Murphy and Joanna Strong's research we learn that trauma occurs when women experience difficult births and when there is a mismatch between expectations and intrapartum care. Presumably women who have not previously experienced birth talk with women who have had experience and they learn from them as well as from practitioners about what to expect. The authors analyzed narratives of women's birthing experiences to reveal that difficult births resulting in trauma are those that don't seem as ideal as what they have come to expect. One expectation of women giving birth is that they be heard and that their wishes be considered, but women claimed in their narratives that when there is a crisis in the delivery room, they are treated as if disembodied.

Practitioners want to convey confidence, but they might not realize when teaching that their education is value laden and that values may not be universal. Two research articles are presented about episiotomy. Read each carefully so as not to misconstrue the results. Whether episiotomy should be performed, is controversial among both feminists and practitioners. I imagine the controversy will remain as politics abound in the scientific world of expertise. Episiotomy concerns may be polarized for political reasons rather than scientific ones. I believe that when one attempts to teach patients what they need to know about a procedure, one should inform women that controversy exists.

Christophe Clesse and colleagues make a substantive and methodological contribution to international women's health literature as they analyze static and dynamic statistics concerning episiotomy rates. Performing secondary analysis using data gleaned from studies published by others, they report rates of episiotomy are declining globally, but it is only in the most industrialized countries where reliable longitudinal data exist. It is from the more current static data or less extensive longitudinal data that the rates are highest in less industrialized countries, particularly those on the Asian continent. The authors do not suggest whether the global decline in episiotomy is always in the best interest of women, yet I inferred this from the article.

Gebuza et.al., collected data in Poland where they learned when episiotomy rates drop, rates of perineal tear increase. They provide evidence that falling episiotomy rates is not necessarily good due to the tears, although they also provide data that most perineal tears are inconsequential in the long run. The authors don't argue however that all women need to have episiotomies, and it would be a misuse of their findings to make such an argument. Rather I inferred from their work that severe perineal tears are consequential to the delivery of large birth-weight babies and that episiotomies may indeed be needed in such instances.

In the last two articles authors consider circumstances contributing to preference of mothers to be for either caesarean or vaginal births. The articles are published together because in both researchers conclude that education programs are needed to change women's attitudes toward one or the other mode of baby delivery. Bagherian-Afrakoti et.al suggest that preference for caesarian births differs by social class with wealthier women preferring Caesarian births. In their semi-experimental study, they demonstrate educating women about vaginal births helps to change their minds. Implicit in the study is the authors’ belief that too many caesarian births occur and thus education is necessary to inform women that vaginal births are safer for them. In contrast, Bola Lukman Solanke, argues that in Southern Nigeria, education is also needed, but they argue in favor changing women's preference for vaginal births so that those whose medical condition suggests a caesarian birth would be advantageous do not reject the option out of ignorance. The research in each article is sound, yet I want readers to consider why practitioners often see their role as helping to change women's minds. Is it not possible to be an expert without dehumanizing those we wish to educate and without assuming that if women hear the controversy they will make bad choices?

As always, I am interested in facilitating discussion about the issues raised by research published in our journal. What are readers thinking?

Eleanor Krassen Covan, PhD, Editor-in-Chief May 23, 2018