Breaking the silence on obstetric violence: A case study on power/knowledge, medical discipline and the resistance of the childbearing woman

There are no relations of power without resistances; the latter are all the more real and effective because they are formed right at the point where relations of power are exercised.

– Michel Foucault

Any doula can tell you when the obstetrician-patient dialogue enters the realm of Foucault. The medical professional’s voice takes on an edge, a resonance, and he or she begins to use terms of endearment or diminutive vocabulary to describe the woman or her fetus. Medical knowledge and bureaucratic knowledge are elided, and the words “allow” and “against our policy” crop up. Time limits are mentioned obliquely. Surgery is hinted at. In the end, the vast majority of women end up “choosing” the recommended path, whether that is surgery, induction, epidural, birthing position, etc.

All this means that most babies are delivered by the methods convenient to the institution at the time – but in true Foucauldian style these practices are generally enforced from within. Many women who believed during labor, for various reasons, that a c-section had become absolutely necessary, find in their records the phrase “patient elected for c-section.” The complicated relationship between choice and compulsion means that their bodies are both the objects on which power acts, as well as acting subjects. They justify, reify and personify the power/knowledge of the medical establishment, participating in its benefits at the same time as they are manipulated by it.

Because the merged medical/bureaucratic knowledge is hidden most of the time, it is easy for women to forget that the obstetrician is the agent of the hospital, the institution that measures, observes and records them during the childbearing year, constituting and creating their identities through discipline. The modern hospital typically relies on “gentle” methods to discipline birthing women, rather than physical violence and literal imprisonment as it had in the past – although those methods are still often practiced as well. Examples of modern methods of discipline that create what Foucault called “docile bodies” include post-dates induction policies, continuous fetal monitoring, confining women to bed, required IV fluids, and widespread use of epidural anesthesia.

Women who attempt to resist this power are at a disadvantage with several forces arrayed against them: the unassailable expertise and knowledge of the doctor and institution; the de-personalization of being a hospital patient and the focus on technologies of measurement rather than human relationships; and the panopticon of observing nurses and other women who enforce discipline in lieu of the doctor. The doula can at times break this power, but more often and against her will, she becomes simply another enforcer, especially when trained according to institutional protocols.

Some women avoid engaging with this power by choosing not to enter the institution. However, those women are putting themselves in a potentially much weaker position: if their medical situation requires the technology and knowledge contained within the hospital, they will receive retaliation and punishment, according to the harshest institutional discipline, as soon as they come through the door. Because they have chosen not to enact and embody the bureaucratic-medical power, they are doubly punished if they show up to take advantage of its benefits.

In the face of these challenges, it is no surprise that so many women see no choice over whether or not to give birth in the hospital. For those who have not completely internalized their submissive/chooser role, the choices in birth revolve around the degree of resistance they are prepared to show, and around the risks of being disciplined for small acts of resistance.

Case study
The following dialogue actually took place as a woman was giving birth. It has been discussed here, and here, and can be seen on Youtube here. The Foucauldian power structures at play here are a driving force during every hospital delivery, even if they are hidden most of the time. This conversation starkly reveals those structures; but it also reveals the formation of resistance to power when the body of a woman giving birth is disciplined against her will.

Doctor: I’m going to do the episiotomy now.

Birthing Woman: What’s up, doctor?

D: I said I’m going to do the episiotomy now.

BW: What happened?

Nurse: So he said he’s going to have to do the episiotomy.

BW: Why? We haven’t even tried.

D: You are pushing, baby’s head comes out and doesn’t come out, because there is no space here to come out. Ok? Baby’s head is about that big and your vagina is only that much. Ok?

Birthing Woman’s Mother: He can’t keep playing around. The baby has to come out.

BW: Why? We haven’t even tried.

D: Try? You’re trying all the time and it doesn’t come out. And if it comes out it’s going to rip the butt hole down clean. Ok? Just try.

BWM: Yes, it is true. That is what happened to Auntie R…

N: We’re not going to feel it, remember? And you have the epidural.

N: Ok. Take a nice deep breath. And push push push. And push.

BWM: She says she wants for the baby to come out but the baby is not coming.

N: 1, 2, 3, 4, 5, 6, 7, 8, 9 Ok good job. Nice deep breath. Push HARD HARD HARD. Go, go, keep going. You’re doing it. Keep going. Go, go, go, go. You’re doing it. Ok! Again, deep breath [etc]

BW: No, don’t cut me!

BWM: Ok! He has to do his job!

D: You tell them.

BWM: Yes I told her, I’m her mother.

BW: No! Why?

D: What do you mean “why”? That’s my reason.

BW: Why can’t we try?

BWM: Doctor is the expert [la grande la cabeza]
[same time] D: I am the expert here.

BW: But why can’t I try?

D: Why can’t I do it? You can go home and do it. You go to Kentucky.

BW: Can’t we just…

BWM: No you can’t fight with the doctor. Just do it doctor, don’t worry.

N: …Sweetie you’re really small.

N: He said that it’s not…

BWM: It is difficult for him, even if he tries he doesn’t have enough space and it is starting to break.

N: But if you rip, you’ll rip more than a cut and it’s a lot more pain too.

BWM: It’s nothing. All that will shrink back again.

N: He said it’s only an inch. An inch isn’t that bad. …Do you want to see an inch again?

BW: I’m having a contraction.

N: Ok.

BWM: It’s fine do it doctor.

N: Push push push push keep pushing, [etc]

BWM: It’s fine do it doctor.

Note the progression in this exchange from verbal resistance toward silent acknowledgement. At first, the woman refuses to allow her vagina to be cut, and the doctor, nurse and mother try to make her understand that it is inevitable. The doctor’s repetition of the word “Ok?” is rhetorical, because the implied answer to that question is “Ok.”

Conversely, the woman repeats the word “Why?” in an attempt to find out what the medical reason is for the procedure. The question “why,” unlike the question “ok,” could be answered in an infinite variety of ways. Her question goes unanswered. Instead of reasons, she receives a condescending characterization of her vagina as too small to give birth to a baby – “Your vagina is only that much.”

The doctor also threatens her, not with physical violence, but with the impersonal, automated violence of knowledge/power – or rather, the consequences of declining to participate in it. His medical knowledge, as he describes it, predicts that her perineum will tear far worse if allowed to tear naturally. He uses dirty and crass language to describe the alternative to the controlled, institutional cut, saying that if she gives birth without an episiotomy, “it’s going to rip the butt hole down clean.” This is the threat of total dissolution if she does not consent to encode the power/knowledge with her body.

His later reference to Kentucky implies a similar violence, threatening her with a supposedly ignorant and backward place in opposition to the safe, technological hospital. In order to take advantage of the hospital’s life-saving expertise in case of emergency, she must submit to its disciplinary protocols.

Meanwhile, the nurse, like a prison guard, enforces discipline in encouraging the woman to allow the doctor to cut her. She uses the word “we” and calls the woman “sweetie” as a form of sympathetic identification, as if to produce in her a feminine camaraderie with the nurse, who also submits to institutional discipline. These terms of endearment are interspersed with barked orders to “PUSH! Go go go!”, measured counting and admonitions to not stop pushing until the nurse determines the contraction is over.

The mother is also a participant in the hierarchy which places the birthing woman and her individual desires at the bottom, in an alignment of family power and institutional power. The institution reproduces the configuration of the patriarchal family because discipline occurs in that configuration from an early age: “Yes I told her, I’m her mother”; “You can’t fight with the doctor.” Normally, a mother would respond to hearing her daughter plead with a man, “No, don’t cut me!” by leaping to her defense, but here, the familial configuration is defined and mirrored by the institutional configuration; her role as disciplinarian makes her deaf to her daughter’s cries.

It is not only the gentle discipline of the hospital, nor even the constant monitoring for the previous nine months, that constitutes the woman as an observed and manipulated object. From being taken to the doctor as a child, to watching older relatives undergo medical procedures and gain positive outcomes, almost as a reward for suffering inside the medical establishment, she, like most Americans, has likely spent a lifetime being told about the wonders of medical science, the value of doctors, and their ultimate goodness. That learned docility and the assumption that the establishment will use its power only to protect us is part of what leads birthing women to place ourselves in such a vulnerable position.

The initial struggle quickly gives way to silence as it is clear to everyone in the room who wields the knife. After the doctor says “I am the expert here,” neither he nor the woman says much at all. They don’t have to: their pre-determined relationship of authority and submission is confirmed and encoded by the nurse, by the woman’s mother, by the architecture of the hospital and by her vulnerable position.

The nurse continues cajoling, alternating with barked orders, and the mother continues to reinforce the doctor’s, and her own, authority, repeating the word “doctor” many times. She uses her familial power to reinforce the institutional power, and urges, “Just do it, doctor.” The doctor begins to cut without saying anything, and the woman is silent too.

But Foucault also said that there is no power without resistance. The doctor exercises his power in silence, with the knife, and the woman exercises her resistance with her refusal to consent to being cut. By asking “Why?” and refusing to verbally consent, she refuses to constitute herself solely through the knowledge/power of the institution. She constitutes herself in that moment not as a docile body, but as a resisting body.

There is no medical justification for the twelve cuts the man makes to the woman’s vagina. While the institutional power structure and the necessity for discipline provide all the justification needed, the viewer can sense the man’s frustration. He holds the knife. And at the knife’s point where he exercises power, and in the viewer’s helpless voyeurism, a potent resistance is being created.

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About investigatingbirth

My investigations of birth began in 2009 when I was trained as a doula. I helped women consider the evidence on common interventions, and helped them prepare for the physical and emotional challenge of giving birth. After some time it became clear to me that there was another type of challenge that I was unable to adequately prepare them for, the challenge of the maternity system. But it was only after my own traumatic birth in 2013 that I realized how little I had understood. I began to ask questions that few around me - doulas, nurses, midwives, doctors - were comfortable hearing. Questions like: Under what circumstances, and for what reasons, do doctors not practice informed consent? How do hospitals deal with other patient populations vulnerable to abuse? How does loss of professional autonomy, for obstetricians, and professional authority, for midwives, impact the quality of care they are capable of providing - regardless of their training? This blog will collect noteworthy information that attempts to answer these and other questions. Most of what you see here will be aggregated from other sources and analyzed. You will also see original interviews, and the occasional opinion piece or personal story, as I try to piece together a clear picture of the system in which American women give birth.
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