Oh my goodness. Doula training was amazing. Just amazing. 50 women, every one so passionate about birth, together for four intensive, wonderful days of education and training. There was just so much energy and joy in the room.
I'm going to compromise my anonymity here, because I think it could be valuable to others for me to say what class I took. So, it was at the Simkin Center at Bastyr University near Seattle, and one of the instructors was the legendary Penny Simkin. I know, how lucky am I, to live in this area and have that opportunity?
Demographics-wise, I was expecting the class to be fairly small - say, 20ish people; and I was expecting to be perhaps the only woman without children. I had the impression that many women get interested in birthwork after having a birth experience, so I expected it to be a crowd of mothers.
Instead, the class was a full 50 women! An unusually large group, I've since heard. The vast majority of the class was under the age of 35; there was even at least one high schooler, which I thought was neat. Slightly over half of the women did not have children. There were actually quite a lot of the early-to-mid-20s, childless women, like myself. I found that very reassuring. In a way, I'm glad that we had such a big class, because there was such a diversity of experiences. We had college students, we had a few ladies in their 50s, mothers and non-mothers; women who wanted to be doulas, women who were already doulas, women who wanted to be midwives; nurses, lactation consultants... oh, and quite a few pregnant ladies, too!
As far as the course material, it was quite comprehensive. There were some basic overviews of pregnancy, the stages of labor, complications, etc. - stuff that we were expected to know, but it was reviewed. Probably the most useful thing was our discussions and practice on how to be active listeners. That made me realize that I very rarely practice active listening. My main goal in a conversation is just to keep it going; I often want to hear information from the other person, but I want to give information from them, too. Sometimes I just want to hear or tell an entertaining story. The give and take is important. But in doula work, the doula's role as a conversation partner is much more as a listener, and much less as a teller, than in an everyday conversation.
Overall, I found the training to be incredibly inspiring and encouraging, as well as very informative and educational. It was a very supportive environment that gave me a lot of confidence that this is work that I can do. I am very lucky to be starting out in a region where doulas are very supportive and collaborative, not isolated and competitive as they can be in some other places.
Friday, July 29, 2011
Friday, July 8, 2011
Pre-Modern Death in Childbirth
More than once, I've seen homebirth advocates remark that homebirth is good and safe because it's natural: before there were hospitals, every woman gave birth at home, and most of them came through it just fine!
And just as many times, I've seen homebirth opponents reply: Yeah, umm, a lot of those women died. Giving birth at home is like giving birth in the middle ages, when mothers were dying left and right! (The Middle Ages gets mentioned a lot in this sort of argument. I guess we're to picture homebirth as if it were taking place in the most exceptionally ignorant, disease-ridden situation we can imagine.)
Of course, both arguments are wrong. The evidence of the past doesn't support or preclude homebirth. Things were very different then. Looking at the past, those of us in developed countries should be very glad that birth is so much safer now (for us, in our countries). In wealthy countries, our comparative good health and ease of access to information and skilled birth attendants makes birth remarkably safe, regardless of where we do it.
What, I ask myself, were the biggest killers of women back in the day? My suspicion is (1) infection, the deadly "childbed fever," and (2) postpartum hemorrhage. If I'm right that those were the major killers, well, that really speaks for the safety of homebirth today! Modern understanding of hygiene helps to prevent infections; antibiotics can (for now) take care of any infection that does occur. As for hemorrhage, it's scary, but any good midwife should see it happening and get the woman to the hospital in time, where the mother will most likely be saved. The literature for the LifeWrap notes that a woman can bleed to death in less than two hours. That's very bad news if you're hours away from a hospital, but it's kind of encouraging for women giving birth in developed countries who can get to a hospital in just a few minutes.
Anyway, I'm trying to do some research to see if my ideas here are correct. Here's what I have so far.
This website has a graph midway down the page of leading causes of modern maternal mortality. This is worldwide, not just U.S. Ignoring the many deaths from unsafe abortion, pregnant and birthing women are most likely to die of:
Maternal mortality is going to be dominated by places where we could characterize medical care as "pre-modern": places where women have poor pre-natal care, little or no access to trained and skilled birth attendants, and long distances or no access to hospitals. According to the WHO, "99% of all maternal deaths occur in developing countries, where 85% of the population lives." Thus, we can take worldwide causes of death in childbirth as representative of "pre-medical" birth.
The most deadly countries for mothers have maternal mortality rates of 1,000 maternal deaths for every 100,000 live births. That's about a 1% chance of dying each birth. (Well, probably greater, when you consider that some women are going to die after a stillbirth, or from an obstructed labor with no live birth.) In the countries with the worst maternal mortality, 1 in 6 childbearing women die from pregnancy-related complications in that country. That's in Afghanistan and Sierra Leone. It's 1 in 7 in Niger. (For comparison, in Europe, it's 1 out of 30,000 women. The worldwide average is 1 in 74 women. Source - Lancet article.)
That Lancet article, "Maternal mortality: who, when, where, and why," backs up the above-cited article and says that postpartum hemorrhage is the leading cause of maternal mortality worldwide.
That same article also notes the disparities in maternal deaths between rural and urban areas. On average, worldwide, a woman giving birth in a rural area is half again as likely to die during birth as an urban woman. (About 640 deaths per 100,000 in rural areas, 447 per 100,000 in urban areas.)
Okay, so, that's modern statistics that may be somewhat representative of past conditions for women. How about actual past conditions? That's not so easy because people weren't exactly doing big medical studies in the 1500s, but there is some evidence, of course!
Here's a cool article available as a PDF online that anyone can access. Published in 1982, it's called "An Attempt to Estimate the True Rate of Maternal Mortality, Sixteenth to Eighteenth Centuries." (Found via this article, which contains a fascinating account of childbirth in ancient Rome!) I will spend the rest of this section discussing that paper.
The article notes first that, of course, the evidence is flawed and incomplete; any estimate of maternal mortality from the 16th to 18th centuries cannot be any better than a very rough, error-riddled estimate. That said, here's what they found. In one parish in England, church registers counted 23.5 maternal deaths per thousand baptisms (so, per thousand births, assuming each birth results in a baptism). The London Bills of Mortality count an average of 15.9 maternal deaths per thousand baptisms from 1666 to 1758, not counting plague years. That's a maternal mortality rate comparable to that in modern Afghanistan. The paper notes that these are "certainly underestimates." For example, deaths from ectopic pregnancies or early miscarriage complications might not have been counted if they couldn't be recognized.
Continuing on, death rates in the mid-1800s were apparently lower, on the order of 5 maternal deaths per 1000 live births. That's a bit higher than Bangladesh's rates today. Odds of the mother dying were much higher when the baby was stillborn, ranging from 57 to 137 maternal deaths per 1000 stillbirths. That's as many as 13% of women dying while giving birth to a still baby. Sort of an intuitive result: unknown pregnancy complications, on which we can only speculate, mean a much higher chance of both maternal and fetal death.
Overall, the paper estimates about 25 deaths per 1000 live births from the 16th to 18th centuries. That's a 2.5% chance of death per birth, or 2500 in 100,000 live births. That's quite a bit higher than the rate in Afghanistan today, which is 1800 maternal days per 100,000 births.
As far as causes of death: a male midwife who lived 1596-1768 described postpartum hemorrhage as one of the leading causes of death in his patients. He also noted that women who delivered on their own had infections less often. Infection was nonetheless a great danger. The paper notes that "even in normal cases, the vagina was repeatedly smeared with materials such as butter, goose grease, capon's or hen's fat, or whole egg. Operative procedures almost inevitably meant infection." Not so hygienic, back in the day.
Now, this was just one paper, so take it with a grain of salt. However, from it, we can glean that pre-modern childbirth was more dangerous than it is in the most dangerous-to-birth-in countries today. Some evidence from New England suggests an average maternal mortality rate of 2.5%. That is, for every 1000 births, there would be 25 women who died. In countries with the maternal mortality closest to that, 1 in 6 childbearing woman will die from complications of childbearing; we can expect that the rate was similar in pre-modern times.
What's my take home message here?
And just as many times, I've seen homebirth opponents reply: Yeah, umm, a lot of those women died. Giving birth at home is like giving birth in the middle ages, when mothers were dying left and right! (The Middle Ages gets mentioned a lot in this sort of argument. I guess we're to picture homebirth as if it were taking place in the most exceptionally ignorant, disease-ridden situation we can imagine.)
Of course, both arguments are wrong. The evidence of the past doesn't support or preclude homebirth. Things were very different then. Looking at the past, those of us in developed countries should be very glad that birth is so much safer now (for us, in our countries). In wealthy countries, our comparative good health and ease of access to information and skilled birth attendants makes birth remarkably safe, regardless of where we do it.
What, I ask myself, were the biggest killers of women back in the day? My suspicion is (1) infection, the deadly "childbed fever," and (2) postpartum hemorrhage. If I'm right that those were the major killers, well, that really speaks for the safety of homebirth today! Modern understanding of hygiene helps to prevent infections; antibiotics can (for now) take care of any infection that does occur. As for hemorrhage, it's scary, but any good midwife should see it happening and get the woman to the hospital in time, where the mother will most likely be saved. The literature for the LifeWrap notes that a woman can bleed to death in less than two hours. That's very bad news if you're hours away from a hospital, but it's kind of encouraging for women giving birth in developed countries who can get to a hospital in just a few minutes.
Anyway, I'm trying to do some research to see if my ideas here are correct. Here's what I have so far.
This website has a graph midway down the page of leading causes of modern maternal mortality. This is worldwide, not just U.S. Ignoring the many deaths from unsafe abortion, pregnant and birthing women are most likely to die of:
- Hemorrhage.
- Sepsis (infection).
- Obstructed labor.
- Eclampsia.
Maternal mortality is going to be dominated by places where we could characterize medical care as "pre-modern": places where women have poor pre-natal care, little or no access to trained and skilled birth attendants, and long distances or no access to hospitals. According to the WHO, "99% of all maternal deaths occur in developing countries, where 85% of the population lives." Thus, we can take worldwide causes of death in childbirth as representative of "pre-medical" birth.
The most deadly countries for mothers have maternal mortality rates of 1,000 maternal deaths for every 100,000 live births. That's about a 1% chance of dying each birth. (Well, probably greater, when you consider that some women are going to die after a stillbirth, or from an obstructed labor with no live birth.) In the countries with the worst maternal mortality, 1 in 6 childbearing women die from pregnancy-related complications in that country. That's in Afghanistan and Sierra Leone. It's 1 in 7 in Niger. (For comparison, in Europe, it's 1 out of 30,000 women. The worldwide average is 1 in 74 women. Source - Lancet article.)
That Lancet article, "Maternal mortality: who, when, where, and why," backs up the above-cited article and says that postpartum hemorrhage is the leading cause of maternal mortality worldwide.
That same article also notes the disparities in maternal deaths between rural and urban areas. On average, worldwide, a woman giving birth in a rural area is half again as likely to die during birth as an urban woman. (About 640 deaths per 100,000 in rural areas, 447 per 100,000 in urban areas.)
-----------------------
Okay, so, that's modern statistics that may be somewhat representative of past conditions for women. How about actual past conditions? That's not so easy because people weren't exactly doing big medical studies in the 1500s, but there is some evidence, of course!
Here's a cool article available as a PDF online that anyone can access. Published in 1982, it's called "An Attempt to Estimate the True Rate of Maternal Mortality, Sixteenth to Eighteenth Centuries." (Found via this article, which contains a fascinating account of childbirth in ancient Rome!) I will spend the rest of this section discussing that paper.
The article notes first that, of course, the evidence is flawed and incomplete; any estimate of maternal mortality from the 16th to 18th centuries cannot be any better than a very rough, error-riddled estimate. That said, here's what they found. In one parish in England, church registers counted 23.5 maternal deaths per thousand baptisms (so, per thousand births, assuming each birth results in a baptism). The London Bills of Mortality count an average of 15.9 maternal deaths per thousand baptisms from 1666 to 1758, not counting plague years. That's a maternal mortality rate comparable to that in modern Afghanistan. The paper notes that these are "certainly underestimates." For example, deaths from ectopic pregnancies or early miscarriage complications might not have been counted if they couldn't be recognized.
Continuing on, death rates in the mid-1800s were apparently lower, on the order of 5 maternal deaths per 1000 live births. That's a bit higher than Bangladesh's rates today. Odds of the mother dying were much higher when the baby was stillborn, ranging from 57 to 137 maternal deaths per 1000 stillbirths. That's as many as 13% of women dying while giving birth to a still baby. Sort of an intuitive result: unknown pregnancy complications, on which we can only speculate, mean a much higher chance of both maternal and fetal death.
Overall, the paper estimates about 25 deaths per 1000 live births from the 16th to 18th centuries. That's a 2.5% chance of death per birth, or 2500 in 100,000 live births. That's quite a bit higher than the rate in Afghanistan today, which is 1800 maternal days per 100,000 births.
As far as causes of death: a male midwife who lived 1596-1768 described postpartum hemorrhage as one of the leading causes of death in his patients. He also noted that women who delivered on their own had infections less often. Infection was nonetheless a great danger. The paper notes that "even in normal cases, the vagina was repeatedly smeared with materials such as butter, goose grease, capon's or hen's fat, or whole egg. Operative procedures almost inevitably meant infection." Not so hygienic, back in the day.
Now, this was just one paper, so take it with a grain of salt. However, from it, we can glean that pre-modern childbirth was more dangerous than it is in the most dangerous-to-birth-in countries today. Some evidence from New England suggests an average maternal mortality rate of 2.5%. That is, for every 1000 births, there would be 25 women who died. In countries with the maternal mortality closest to that, 1 in 6 childbearing woman will die from complications of childbearing; we can expect that the rate was similar in pre-modern times.
-----------------------
What's my take home message here?
- Birth in the past was very dangerous.
- In developed countries, birth is very safe: we're generally healthy and well-nourished, making complications less likely. When complications arise, we can generally treat them quickly, effectively, and safely.
- In many countries of the world, birth today is nearly as dangerous as it was hundreds of years ago. In far more countries, maternal mortality rates are 10 to 15 times as high as the rate that appalls us here in the States. We are right to care about having a rising mortality rate in the U.S., but it is also right to care about the staggering maternal mortality in the countries we don't think about very often.
Thursday, June 16, 2011
Big steps
I signed up for a doula training course.
On one hand, it's not much. Just training. I'm not quittin' my day job and I'm not committed to anything more.
On the other hand, it feels huge.
On one hand, it's not much. Just training. I'm not quittin' my day job and I'm not committed to anything more.
On the other hand, it feels huge.
Sunday, June 12, 2011
What does it mean to be a midwife?
Most of the midwives the U.S. are certified nurse-midwives (CNMs). The CNM - by definition as far as I know - is an RN with a Master's degree. However, most of the midwives that attend births at home are direct-entry midwives (DEMs), often certified professional midwives (CPMs). DEMs train for three years of coursework and apprenticeship, but they have no nurse training. Some DEM programs, like Bastyr University's, require a Bachelor's degree as a prereq, but most programs do not require a college degree.
To give you the numbers, about 8% of births in the U.S. are attended by midwives, but only 1% of all births are home births (Source: Pushed). Taking those numbers, I think we can say that roughly 1 in 8 US midwives are DEMs, and they are the ones who attend homebirths.
One of the criticisms leveled at home birth in the U.S. is that its attendants are underqualified, and that home birth in all other developed countries are attended by CNM-equivalents. (See here for an example of such an assertion.) I wonder: Is that true?
So, I'm going to do a series on midwifery education in other countries. Look for them under the tag "educationseries"!
Also, if anyone would like to contribute a guest post on midwifery education in their country, I would love that! Between the languages that I myself speak and online translators, I figure I can get a decent amount of coverage, but obviously it will be difficult for me to cover countries whose languages I don't speak. Basically I've got German, French, and Spanish covered (and English, of course!). If your country speaks a different language, please e-mail me. You can find my e-mail address in my profile. Just make sure to delete the "DELETETHIS" that I stuck in there to try to prevent robo-spam. :)
To give you the numbers, about 8% of births in the U.S. are attended by midwives, but only 1% of all births are home births (Source: Pushed). Taking those numbers, I think we can say that roughly 1 in 8 US midwives are DEMs, and they are the ones who attend homebirths.
One of the criticisms leveled at home birth in the U.S. is that its attendants are underqualified, and that home birth in all other developed countries are attended by CNM-equivalents. (See here for an example of such an assertion.) I wonder: Is that true?
So, I'm going to do a series on midwifery education in other countries. Look for them under the tag "educationseries"!
Also, if anyone would like to contribute a guest post on midwifery education in their country, I would love that! Between the languages that I myself speak and online translators, I figure I can get a decent amount of coverage, but obviously it will be difficult for me to cover countries whose languages I don't speak. Basically I've got German, French, and Spanish covered (and English, of course!). If your country speaks a different language, please e-mail me. You can find my e-mail address in my profile. Just make sure to delete the "DELETETHIS" that I stuck in there to try to prevent robo-spam. :)
Saturday, June 11, 2011
Viewpoints
Recently, on The Unnecesarean, there was a post about how 94% of US births had "complicating conditions" in 2008.
Now, as some astute commenters pointed out, complicating conditions does not mean exactly the same thing as complications. Complicating conditions does include things like hemorrhage, episiotomy, etc. - things going wrong and injuries - but it also includes things like the patient being of "advanced maternal age," very minor first degree tears that don't need repair, etc. Basically, any deviation from "mother in her 20s, hasn't had too many kids, spontaneous physiological delivery over intact perineum" gets put into the "complicating conditions" box.
Now that that's clarified, I'd like to look at the two major opposing viewpoints in the comments.
(1). A lot of these aren't real "complications." I mean, a woman over 35 who otherwise has a perfect birth gets put in the "complicated" box just because of her age. Many, many of these "complicating conditions" are either nothing but the hospital's definitions, or they are caused by the hospital. How ridiculous is it that the hospital treats 95% of births as complicated, when birth left to its own devices might be uncomplicated, if not 95% of the time, probably at least a good 80% of the time! (That is a totally made up but vaguely-ballpark stat.)
versus:
(2). Look how complicated and dangerous birth is! How ridiculous it is to "trust birth" when something goes wrong 94% of the time. This is proof of how inherently unsafe birth is, and of how much would be going wrong if most births didn't take place in hospitals with modern medicine.
Neither of those are direct quotes, and #2 is certainly exaggerated beyond what that commenter would probably actually say, but I think that both of these little "summaries" describe pretty accurately how the extreme camps feel.
I just think this is an interesting example of how two people can look at the same fact and draw wildly different conclusions about it. One group looks at "94% rate of complicating conditions" and concludes that hospitals make normal birth scarier than it has to be to justify their control of it. The other group looks at that 94% and says, look how scary birth is, hospitals need to be in control of it!
Now, as some astute commenters pointed out, complicating conditions does not mean exactly the same thing as complications. Complicating conditions does include things like hemorrhage, episiotomy, etc. - things going wrong and injuries - but it also includes things like the patient being of "advanced maternal age," very minor first degree tears that don't need repair, etc. Basically, any deviation from "mother in her 20s, hasn't had too many kids, spontaneous physiological delivery over intact perineum" gets put into the "complicating conditions" box.
Now that that's clarified, I'd like to look at the two major opposing viewpoints in the comments.
(1). A lot of these aren't real "complications." I mean, a woman over 35 who otherwise has a perfect birth gets put in the "complicated" box just because of her age. Many, many of these "complicating conditions" are either nothing but the hospital's definitions, or they are caused by the hospital. How ridiculous is it that the hospital treats 95% of births as complicated, when birth left to its own devices might be uncomplicated, if not 95% of the time, probably at least a good 80% of the time! (That is a totally made up but vaguely-ballpark stat.)
versus:
(2). Look how complicated and dangerous birth is! How ridiculous it is to "trust birth" when something goes wrong 94% of the time. This is proof of how inherently unsafe birth is, and of how much would be going wrong if most births didn't take place in hospitals with modern medicine.
Neither of those are direct quotes, and #2 is certainly exaggerated beyond what that commenter would probably actually say, but I think that both of these little "summaries" describe pretty accurately how the extreme camps feel.
I just think this is an interesting example of how two people can look at the same fact and draw wildly different conclusions about it. One group looks at "94% rate of complicating conditions" and concludes that hospitals make normal birth scarier than it has to be to justify their control of it. The other group looks at that 94% and says, look how scary birth is, hospitals need to be in control of it!
Thursday, June 9, 2011
Quickie: Another thought on insiders & outsiders
One of my favorite anecdotes in Henci Goer's The Thinking Woman's Guide to a Better Birth was this:
Someone once asked her what her credentials were. What gave her the authority to write books about medical research?
Her answer: "I can read."
I love this. So empowering! How fantastic is it, that she is communicating that anyone who can read has the right and the ability to understand and critique medical research? It totally goes against the idea sometimes espoused by OBs that only doctors can understand medical research, and so only doctors can make decisions about medical care. (Like: a woman who asks questions or tells her OB about some research she heard about it, and getting asked with a sneer, "And where did you get your medical degree?" Most OBs are nicer than this, thank goodness, but this has happened to plenty of women nonetheless!)
Not everyone who can read can be a doctor. But pretty much anyone who has the cognitive abilities to read can educate themselves enough to be active participants in their medical care, not just passive recipients of care.
Someone once asked her what her credentials were. What gave her the authority to write books about medical research?
Her answer: "I can read."
I love this. So empowering! How fantastic is it, that she is communicating that anyone who can read has the right and the ability to understand and critique medical research? It totally goes against the idea sometimes espoused by OBs that only doctors can understand medical research, and so only doctors can make decisions about medical care. (Like: a woman who asks questions or tells her OB about some research she heard about it, and getting asked with a sneer, "And where did you get your medical degree?" Most OBs are nicer than this, thank goodness, but this has happened to plenty of women nonetheless!)
Not everyone who can read can be a doctor. But pretty much anyone who has the cognitive abilities to read can educate themselves enough to be active participants in their medical care, not just passive recipients of care.
Another thought on Spritual Midwifery
Why do I keep breaking these things into two posts lately? Mainly because I forget to include some point, and I write such long posts as it is that it seems like a bad idea to just make the previous post even longer, I suppose.
Anyway, one thing I forgot to write about is the way that Spiritual Midwifery tries very hard to be as accessible as possible in the medical/technical chapters. It does this mainly by trying to avoid medical jargon as much as possible. So, she writes pee-hole instead of urethra, butthole instead of anus, taint instead of perineum, etc.
Personally, I found this quite off-putting. I'm a scientist. I like technical language. I prefer it. I'd much rather talk about urethras than pee-holes. And I've been a birth nerd for long enough to know very well what a perineum is.
But I just started reading Robbie Davis-Floyd's Birth as an American Rite of Passage, and she makes the point in Chapter 1 that "technical jargon... shouts 'off-limits to the unitiated" (p. 30). She also notes that one way that men historically created power over women was by creating "spheres of authoritative knowledge" to which they then denied women access. To put it more simply, using technical language can be way of asserting "I'm the expert, and you're not, so just listen to me." Technical language in writing can be a way of signalling to a reader, "If you're not comfortable with this language, you probably shouldn't be reading this. You don't have a right to this knowledge if you don't understand this vocabulary."
By using language that is very common, sometimes vulgar but always comprehensible, Gaskin is asserting that the knowledge she puts down in her book is for everyone. It's knowledge that is available to someone who doesn't know the difference between a urethra and a ureter. Gaskin is saying that it doesn't matter if you know what a urethra is; you don't need fancy vocabulary to understand your body. You know where your pee comes out, and that's what you need to know to understand your body!
So, although it may not be my preferred language, I acknowledge that Gaskin may be doing a great service to the average woman by using such plain and easy-to-understand language.
I also find it interesting to think about what sort of language I should use with clients, someday, when I'm a midwife. In my ideal of midwifery, the midwife should not be an authority figure who has power over the birthing woman. She should be a source of knowledge and skills who offers up that knowledge in service, and works with the woman to communicate that knowledge and assist the woman in making her own choices. In my mind, I imagined that this would include educating the woman on technical terms for anatomy, but now I wonder, how important is very technical language? Does it not in some ways go against the ideals of midwifery to use technical language that functions to set up the midwife as the expert, the authority figure, the guardian and sole holder of knowledge? We know that many doctors use knowledge to give themselves control: some doctors say that their great knowledge gives them the right to command and control the birthing woman. If a midwife uses technical language that sets up her client as an outsider, unitiated, does it set up the expectation in the woman that she ought to be obedient and is not the one in control?
Anyway, one thing I forgot to write about is the way that Spiritual Midwifery tries very hard to be as accessible as possible in the medical/technical chapters. It does this mainly by trying to avoid medical jargon as much as possible. So, she writes pee-hole instead of urethra, butthole instead of anus, taint instead of perineum, etc.
Personally, I found this quite off-putting. I'm a scientist. I like technical language. I prefer it. I'd much rather talk about urethras than pee-holes. And I've been a birth nerd for long enough to know very well what a perineum is.
But I just started reading Robbie Davis-Floyd's Birth as an American Rite of Passage, and she makes the point in Chapter 1 that "technical jargon... shouts 'off-limits to the unitiated" (p. 30). She also notes that one way that men historically created power over women was by creating "spheres of authoritative knowledge" to which they then denied women access. To put it more simply, using technical language can be way of asserting "I'm the expert, and you're not, so just listen to me." Technical language in writing can be a way of signalling to a reader, "If you're not comfortable with this language, you probably shouldn't be reading this. You don't have a right to this knowledge if you don't understand this vocabulary."
By using language that is very common, sometimes vulgar but always comprehensible, Gaskin is asserting that the knowledge she puts down in her book is for everyone. It's knowledge that is available to someone who doesn't know the difference between a urethra and a ureter. Gaskin is saying that it doesn't matter if you know what a urethra is; you don't need fancy vocabulary to understand your body. You know where your pee comes out, and that's what you need to know to understand your body!
So, although it may not be my preferred language, I acknowledge that Gaskin may be doing a great service to the average woman by using such plain and easy-to-understand language.
I also find it interesting to think about what sort of language I should use with clients, someday, when I'm a midwife. In my ideal of midwifery, the midwife should not be an authority figure who has power over the birthing woman. She should be a source of knowledge and skills who offers up that knowledge in service, and works with the woman to communicate that knowledge and assist the woman in making her own choices. In my mind, I imagined that this would include educating the woman on technical terms for anatomy, but now I wonder, how important is very technical language? Does it not in some ways go against the ideals of midwifery to use technical language that functions to set up the midwife as the expert, the authority figure, the guardian and sole holder of knowledge? We know that many doctors use knowledge to give themselves control: some doctors say that their great knowledge gives them the right to command and control the birthing woman. If a midwife uses technical language that sets up her client as an outsider, unitiated, does it set up the expectation in the woman that she ought to be obedient and is not the one in control?
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