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Abstract
I examine writing produced in an online community of childbirth advocacy during a 2010 National Institutes of Health Conference convened to develop a consensus resolution on best practices regarding vaginal birth after cesarean (VBAC). Through an analysis of blog posts and comment threads written in response to the conference proceedings, I find that participants in the feminist counterpublic of birth advocacy utilize three primary strategies: they redefine VBAC as “just birth” rather than a medical “procedure;” they recontextualize the biomedical use of “risk” to include other factors outside of the immediate context of the hospital; and they reframe VBAC as a right rather than a preference. Together, these strategies work together to demonstrate the incommensurability of “shared doctor–patient decision making” within the current biomedical model of care. This move, toward a rights-based framework within a more highly contextualized systemic critique of health care, positions VBAC to be an issue that could link birth advocacy to a larger feminist health justice movement.
Notes
Notes
1 Mainstream news outlets regularly report on the C-section rate in response to the Centers for Disease Control and Prevention’s release of the previous year’s birth data. In addition, stories like that of Joy Szabo, an Arizona woman who traveled five hours to find a hospital willing to allow her to support her VBAC attempt, have also gained national publicity. See, for example, Cohen.
2 I recognize that not all persons who will become pregnant identify as women or mothers. The language used by participants in my case study and by the medical institutions they are critiquing consistently identified pregnant women and mothers as the people whose bodies experience pregnancy and birth. To maintain consistency throughout my argument, I retain their language use.
3 The most recent data for 2016 and 2017 show a VBAC rate of 12.4% and 12.8%, respectively (Martin et al., “Births: Final Data for 2017” 6). Because of changes to birth certificate data, national VBAC percentages before 2010 are more difficult to pinpoint, but the panel statement reports a repeat cesarean rate for women with a prior cesarean of 92% (with a VBAC rate of just 8%) in the 19 states that collected that data in 2006 (Cunningham et al. 8).
4 Some of these blogs are still in existence, others have been discontinued, and a few have changed their names and focus. I say more about the specific sites I analyzed for the case study in the Methods section.
5 In 2015, the WHO released a new statement, “WHO Statement on Cesarean Section Rates,” in which the organization reiterated that at a population rate higher than 10% there is no decrease in maternal or infant mortality. But the organization also revised its earlier position to include the conclusion that “every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate.” At the time of the NIH VBAC Conference, the recommended 10% to 15% was still the official WHO guideline.
6 The most recent Centers for Disease Control and Prevention report shows 32% for 2017.
7 The review of existing research presented in the panelists’ statement found the rate of rupture for women who attempted a trial of labor to be around 4.7 per 1,000 women, and 6% of those cases resulted in perinatal death, though the researchers indicated that more research was needed to come to a firmer conclusion about the actual risk of rupture (Cunningham et al. 17–18). By comparison, the risk for repeat C-section is the risk of maternal death, at a rate of 9.6 per 100,000 (Cunningham et al. 14).
8 See Kim Hensley Owens’s analysis of The Business of Being Born and its mixed reception; Block; Wagner; and Villarosa, “Why America’s Mothers Are in a Life-or-Death Crisis,” as examples.Villarosa is not found in works cited. Please provide this reference.
9 Gaskin, a community midwife at a communal village called The Farm in Tennessee, wrote Spiritual Midwifery in 1975. It was one of the first books in the United States to articulate the philosophy of the midwifery and home birth movement of the 1960s and 1970s. (For a compelling account of the centuries-long rhetorical history of midwifery, see Mary M. Lay, especially chapter 3.) One example of the different vocabulary Gaskin uses to describe birth includes the use of “rushes” rather than “contractions” as a way to change the perception of pain (Ina May’s Guide to Childbirth, 162–63).
10 See also Ehrenreich and English. More recent work in the social sciences includes an ethnographic account of traditional African American midwifery in Virginia (Gertrude Fraser), a history of anesthesia (Wolf), cultural analyses of specific obstetric practices like amniocentesis (Rapp) and fetal ultrasound (Taylor), and returns to earlier conceptions of power, knowledge, and medicine (Simonds et al.; Davis-Floyd and Sargent).
11 Wells’s project focuses on the work of writing and revision from the book’s inception in 1970 to the 1984 revised edition that was in circulation until 2005, when the edition most recently revised at the time of Wells’s writing appeared.
12 I do not know the racial identities of most of the participants in online birth advocacy, but the silence about issues of race in this discussion—and sexuality and class—could be a result of fairly homogenous demographic characteristics of the group.
13 Jennifer Nelson makes this point about reproductive rights organizations. See also Silliman et al. and Ross and Solinger.
14 I make a similar point about how film representation has depicted childbirth in “Technology Knows Best: Representations of Childbirth in 21st Century Film.”
15 I should note that the blogs I examine are outside of the scope of Dubriwny and Ramadurai’s analysis. They characterize their “survey of women’s discussions online” as “admittedly partial,” and their focus is on the different argumentative frames located in the two primary sites of discourse in the VBAC activist community (ICAN) and the medical community respectively (ACOG) (261). My point here is that the birth advocacy community had so well established itself as a “counterpublic” outside of the mainstream online discourse about childbirth that those perspectives did not show up in Dubriwny and Ramadurai’s survey of women’s online discussions of VBAC in places like Parenting magazine or Mamapedia.com.
16 Both of these sites are no longer published in their original format. Lamaze International has changed the name of Science and Sensibility to Connecting the Dots, and it is now geared toward “perinatal professionals.” Jill Arnold has retired the Unnecesarean blog but still maintains the Facebook page. She also created another Web site, cesareanrates.org, from the auspices of a health nonprofit, that provides more statistical information about C-sections.
17 Phillipa Spoel’s research on midwifery in Ontario suggests that “consent” may be the problematic term. She finds that “the midwifery understanding of informed choice explicitly contrasts the mainstream medical concept of informed consent: the term choice suggests the power or opportunity to choose actively among alternatives, whereas the term consent implies a more passive compliance with direction provided by a higher authority” (7).
18 A review of the extensive literature on risk is outside the scope of this article, but for an overview see especially Lupton; Hausman; Charles and Wolf; and Dubriwny’s discussion of Lupton.
19 I should note here that part of the backlash against this comment is levied at the commenter herself. Amy Tuteur is a frequent and hostile participant in discussions on birth advocacy sites, and many participants do not engage with her because they consider her a kind of “troll.” Tuteur keeps a blog called The Skeptical OB, on which she is heavily critical of midwifery, homebirth, and breastfeeding activism. Her comments often are explicitly motivated to provoke, but in some cases she offers a well-reasoned alternative position that other commenters will debate (as is the case in this comment but not in much of the rest of the discussion).
20 Marika Siegel has argued that “[l]earning how to question the experts, how and when to disengage from the system, and what one’s rights are should be routine prenatal care instructions for both pregnant women and their partners” (3), but the current manuals of pregnancy advice provide instructions with the primary aim of teaching women how to become users—not critics—of the system.