Tuesday, July 6, 2010

Knowledge Systems and Coercion

This article: Anthropology and Birth Activism: What Do We Know? by Robbie Davis-Floyd was linked over at theUnnecesarean this morning, and it's gotten me thinking. It's a really great article, and short and very accessible, so you should go read it.

I particularly like the way Davis-Floyd deals with the issue of choice and coercion:
What is choice and privilege in one setting becomes an almost invisible coercion in another.
And this concern can apply equally to both the influence of the medical community on birthing moms and the influence of birth activists. It remains true, after all, that no matter how noble your cause is, using coercive methods to get people to do what you want them to do is profoundly problematic. Especially from a feminist perspective.

But what if you dig below the surface of the persuasive machinery both camps utilize and look at the underlying knowledge systems themselves? The assumption seems to be that knowledge systems are morally neutral and deserve equal amounts of respect within their cultural contexts. But I'm not convinced of this. It seems to me that a knowledge system will be coercive to the extent that the context it evolved in is informed by political and economic interests. And if the knowledge systems in question are inherently coercive, then even if the persuasive methodology is acceptable, you still have a problem.

Let me give you an example of what I'm talking about. In the area of birth activism, the conflicting knowledge systems in play are generally the biomedical knowledge system versus what I'll call the "indigenous midwives" knowledge system. One area of conflict between the two is the practice of clamping and cutting the umbilical cord immediately, which is called for in the biomedical system, versus delaying clamping until the blood has finished pulsing through the cord. While I was pregnant I read that traditional midwifery (in my culture) calls for waiting to cut the cord until the blood had finished pulsing, which take 7-10 minutes. On a visit to relatives that same summer I mentioned this to my great-aunt (one of thirteen children born to my great-grandmother at home), and she told me that this was the practice of midwives in their community, as it was thought to produce "more robust" babies. I later read that research on this practice showed that babies who had received all the cord blood were far less likely to become anemic during their first six months. So the midwives were right about this, although they didn't understand the causal mechanism at play.

Based on this research I specified in my birth plan that I didn't want the umbilical cord clamped and cut right away. This invoked a lot of eye-rolling and dismissive tongue-clicking in the birthing room, and was ultimately disregarded under the guise of getting my daughter checked out immediately because she was born early, even though she was clearly breathing well and wasn't in distress in any way. During the discharge process I was asked by a nurse to rate my experience at the hospital. I cited this as one way in which they completely disregarded my birth plan. She said "honestly, we don't even know why this old wives tale is still around, or what waiting to clamp the cord is supposed to do." I referenced a couple of large studies at respectable research institutions concerning iron levels and cord clamping, and she looked at me with a totally blank look and said, "but formula has lots of iron in it, honey."

Clearly she had never heard of the studies, which isn't surprising given the fact that our medical practices are not evidence-based to begin with. Notice also that the default assumption is that all babies will be fed at least some formula, so even if medical professionals were aware of the iron issue, they would assume it was irrelevant. Further, notice the phrase "old wives tales" which is used to delegitimize and belittle any kind of knowledge outside of the medical industry. When I went back for my 6-week checkup, I asked the OB who wrote my birth control prescription about the cord-clamping issue, just out of curiosity, and she said they don't condone waiting for the cord blood because it doesn't provide any benefit. She also had never heard of the studies I cited, and acted skeptical even as she acknowledged that they had been done at conventionally-recognized institutions.

So here you have a case where the knowledge system most Americans are going to base their decisions on appears to contain some deliberate misinformation. The facts about cord blood and iron levels have been confirmed by their own research institutions, after all, and yet the standard of care still involves immediate clamping and cutting of the cord. And most medical professionals are going to look you in the eye and tell you that this is the best practice for you and your baby. And they'll probably sincerely believe it. It seems clear to me that this information has been intentionally withheld or modified because delaying cord cutting doesn't mesh well with institutional schedules. And the same applies to placing limitations on labor time lines. Allowing these things to progress at their own rate within a hospital environment is inefficient and no doubt frustrating from the administrative end. But basically that means that the knowledge system on which most Americans will base their birthing decisions has adapted itself to a value system in which scheduling and staffing take precedence over maximizing healthy outcomes. And the same can be said for the lack of accurate information given to expectant mothers when it comes to the use of epidurals, pitocin, fetal monitoring, episiotomies, c-sections, etc. In other words, you can utilize non-coercive methods of informing expectant mothers and laying out the choices available to them, but if your knowledge system itself has evolved in such a way that it suits your purposes and misleads them into "choosing" the option you prefer, then the process is still profoundly coercive.

Now obviously there's no such thing as a value-neutral knowledge system. Knowledge systems are the product of human activity, which is always and everywhere informed by political, economic, religious, personal, social, etc. interests. Nobody is agenda-free, right? But it seems to me that you can at least attempt to minimize the misinformation and potentially misleading, selectively chosen information built into your system. And it seems to me that a knowledge system like the biomedical birthing one is more likely to be coercive because it has a "top-down" kind of quality (as opposed to a more dynamic, grass-roots, indigenous one) and is so thoroughly infused with economic motives. This isn't to say that indigenous knowledge systems don't incorporate all kinds of agenda-driven information. But it seems less likely due to the input of multiple voices and the lack of explicit formalizing structures (like the ACOG or the AAP).

So I'm not sure we do have to give competing knowledge systems equal respect and deference. For one thing, they evolve rather differently, and incorporate information that is arrived upon through very different processes and motivations. Davis-Floyd says
As both an anthropologist and a birth activist, I am trained to honor and respect women’s choices and the knowledge systems on which they base those choices, but also to deeply question the cultural conditioning underlying all “choice.”
But how do you separate the knowledge system from that cultural conditioning in a culture like ours? We're socialized to respect doctors and believe what they say. We're taught that people who question the medical establishment are wacko conspiracy-theorist types. And most importantly, we're taught that the only important outcome of childbirth is a healthy baby (mom's experience be damned), and the only way to ensure a healthy baby is complete compliance with medical institutions. And so, once again I think this issue of "choice" is much more complex than we take it to be, and shouldn't be used as a conversation-stopping trump card the way it often is in feminist discussions.


  1. momofthree7/06/2010

    This hits on an uneasy feeling I've often had that nurses and doctors were telling me things that they had been taught in med school or nursing school that were pretty clearly outdated or had been disproven. But since they learned it in med school it was unquestionable, even if you had read something contradictory from a very reputabl source, and they weren't even willing to entertain the idea. I've had the luxury of switching to a new care provider when this has happened in the past, but not everybodys insurance allows for that.

  2. Anonymous7/06/2010

    But I choooose my choice!

    Seriously, I do think this is a huge issue of concern for feminists, but I think our language for choice and agency and autonomy are a very big part of the problem. I think the words we use make it seem like a cut-and-dried thing when it's really way more complex, as you keep saying.

    Thanks for saying it.

  3. dirtyhippie7/06/2010

    A lot to mull over, here. I think you're right to suspect both the body of knowledge and the persuasive methodology. But if there are no value-neutral knowledge systems, then avoiding coercion seems impossible, right?

  4. Can I just say that I loved this article and that I really like your blog? Thanks for expounding on this issue, you gave me a lot to think about.

  5. And I think your point about the complexity of "choice" and it's relationship to power structures and cultural conditioning is really relevant to feminist discussions of porn and sex work as well. I don't think raising very good questions about these things has to equate to being dismissive of a woman's knowledge or agency. I agree that at times it can, but that doesn't mean we have to drop all talk of this important stuff in order to "honor women's choices."

  6. Anonymous, I do think language has a lot to do with our confusion. Language is such a repository for outdated concepts and attitudes, and they're often so subtle that we don't even notice them.

    dirtyhippie, I think we can try to be aware of the attitudes and biases built into our knowledge systems and try to minimize them. But this is really just a part of being human, after all.

    Thanks Rebekah!

    And Seely, I totally agree. As you probably already know!

  7. Michelle7/11/2010

    I think it's the sincere advice that you know is based on bad info that's so very hard to deal with. When someone honestly thinks they're helping you, what can you do? It's one thing to fight off unecessary interventions that are being pushed on you simply to move the process along and adhere to scheduling timetables for the sake of staff convenience. That's easy enough. But when the person honestly thinks they're helping you and really doesn't (can't) know any better because of their training...that's hard.