Diane Mint Lynch-Macduff

Anthropology of Health & Healing

December 2007

Inspired by the readings from Rayna Rapp's Testing Women, Testing the Fetus I set out to do my

research on pre-natal testing in different cultures. When looking for articles on pre-natal testing from a

medical anthropology perspective I came across the phrase "ways of knowing about birth". When I started

searching for more on this I repeatedly came across references to a Brigitte Jordan and her definition of

authoritative knowledge especially as it relates to medicine and birth. I decided to trace Jordan's concept of

authoritative knowledge in birthing practices over time in Medical Anthropology Quarterly. Jordan's most

quoted work is her book Ways of Knowing about Birth in Four Cultures. As a full book exceeds the scope of

this assignment I located one of her earliest articles on the subject of authoritative knowledge (AK),

"Knowledge, Practice, and Power: Court-Ordered Cesarean Sections" co-authored with Susan Irwin. Next I

found an entire issue of the journal from 1996 focusing on the theme of "The Social Production of

Authoritative Knowledge in Pregnancy and Childbirth." There was a great deal of fascinating research in the

whole issue but I ended up narrowing my focus to the introduction and "Ways of Knowing about Birth in

Three Cultures" by Carolyn Sargent and Grace Bascope as their article was the most direct follow up to

Jordan's work. Finally, the most recent article I could find in Medical Anthropology Quarterly on the subject,

"Preparing for Motherhood: Authoritative Knowledge and the Undercurrents of Shared Experience in Two

Chilldbirth Education Courses in Cagliari, Italy" by Suzanne Ketler seeks to further explore some

unanswered questions about AK, challenge some of Jordan's claims and offers some suggestions for

improving childcare courses in the future. I will summarize the main arguments of the three articles and

discuss my conclusions about the importance of shared or "horizontal" knowledge systems in birthing.

    There are many ways of knowing about birth. First, there is a woman's personal knowledge of her own
body (examples of this knowledge are the knowledge that "something feels wrong", "I feel fine", or "this

baby is ready to be born"). Next, this knowledge can be enhanced with experience - knowledge owned by

women who have given birth before. This experiential knowledge can be shared - with peers in a birthing

class, friends and neighbors, or passed down from generation to generation.

There is the knowledge of "specialists" which ranges from lay midwives who engage with the experiential

knowledge of women to biomedically trained midwives, various other medical staff, and doctors. The

knowledge produced by technology may also almost be seen as a separate way of knowing about birth

because it usually goes unchallenged in biomedical settings even though it requires the knowledge of

"specialists" to interpret it. (Jordan 329) Jordan explains that in areas such as birthing where multiple ways of

knowing exist, "one kind of knowledge gains ascendance and legitimacy." She calls this knowledge

"authoritative" and follows up by saying "a consequence of the legitimization of one kind of knowing as

authoritative is the devaluation, often the dismissal, of all other kinds of knowing." As a result those who try

to utilize alternate ways of knowing are either ignored or seen as causing trouble. Furthermore Jordan

clarifies that there is not necessarily any correlation between the accuracy of a knowledge system and its

authoritativeness: "The power of authoritative knowledge is not that it is correct but that it counts...."

(____cite this (intro plus ces plus others? or?) plus earlier in para_____)

Following up on her original work on AK, Jordan and Irwin's article about court-ordered cesarean sections

shows how people with AK who control technology can use their position to justify invasive actions against

women subscribing to alternative ways of knowing. The authors describe nine cases from the late 1970s

through the mid-1980s in which women refused cesarean surgery for various reasons (including prior

birthing experience or religious faith) and medical staff obtained court-orders requiring them to submit to the

surgery. In at least two of the cases, cesarean was deemed necessary based on highly questionable

interpretations of ultrasound scans. One theme brought up by the article is that in societies where

biomedicine is the predominantly accepted way of knowing women are socialized both from birth and from
pre-natal classes to be "prepared" for a medicalized birth.  Women who have not been thus socialized such as

immigrants or those who have not participated in official pre-natal care are seen by medical staff as

troublesome or "difficult" patients. (JI 327)

In the United States and elsewhere biomedicine is seen as the ruling knowledge and to question it is a radical

act. The doctors and hospital staff control the technology, the knowledge and the entire birth. When what a

woman has to say about her own birth is ignored not just philosophically but legally the birth is taken out of

her control and given to the doctors.

Court-ordered cesareans both squash radical acts, alternative thinking, knowing and strengthen and confirm

medical authority. These court-orders put on record that in the U.S. there is one recognized "right way" of

knowing about birth - and that is the biomedical way.

In reaction to her research Jordan takes an applied approach when she calls for a shift from the top-down

authoritative knowledge distribution that is most common in "technologized" nations to a "horizontal"

distribution of knowledge in which womens' knowledge about their own pregnancy and birth is given equal

weight to the knowledge provided by technology and "specialists". (____in introduction___)

Second article: In their article "Ways of Knowing about Birth in Three Cultures", Carolyn Sargent and Grace

Bascope place three more birthing studies, In Mexico, the U.S., and Jamaica,  in the context of Jordan's

concept of AK. The authors both support and reinterpret Jordan's argument. Sargent and Bascope question

Jordan's emphasis on technology by using low-technology examples in which status plays a higher role than

access to specialized tools or methods in birthing. The study of Spanish-speaking women in Texas who did

not know why cesarean sections had been performed on them reinforced Jordan's original claims about

techno-medical hierarchy. However, the studies on home birth in Mexico and "hospital birth" in Jamaica shift

the focus of AK away from technology. Sargent and Bascope discuss home birth in rural Yaxuna, Mexico
(216). The most respected of only 2 midwives in the town, Dona Lila,  comes from a respected family. Her

father-in-law was a high status shaman. With over 35-years experience in attending births her way of birthing

has come to be considered the "right way" in Yaxuna, with people only resorting to use of the other midwife

in emergencies. What qualified Dona Lila as a birth "specialist" was her high status, her experience, her

umbilical-cord cutting skills, and later her access to drugs. The distribution of AK in Yaxuna was both

hierarchical and shared. First-time mothers were expected to do whatever Dona Lila, and their older relatives

tell them. Experienced mothers, however had a great control over their birthing experience, with Dona Lila

only there to assist as needed. (SB 219-221) Yaxuna's midwives had both received government biomedical

obstetrics training but chose not to incorporate this knowledge into their practices. However, Dona Lila

began taking advantage of access to painkilling and labor-speeding drugs after she broke her wrist and no

longer had the strength required to manually pull on the cervix. The women of Yaxuna would rather accept

the introduction of minor biomedical intervention (the drugs) than use another midwife. This example shows

how AK can be owned by "specialists" even without the use of technology, and also how collaborative

elements taking the woman's birthing experience into equal consideration can be implemented.

The last study Sargent and Bascope discuss is on "hospital births" in Kingston, Jamaica. I place "hospital

births" in quotations because I am not sure if continuing to call a place that used to function as a hospital

makes it continue to be one. In Jamaica the imperialist government systematically eliminated the practice of

lay-midwifery while funding biomedical programs featuring "hospital-based government nurse-midwives"

(SB 226). The hospitals later lost most of their funding and therefor most of their staff. This lead to a

situation in which women were giving birth alone in dirty hospital rooms. In fact in 1987 around 65 percent

of women who gave birth in Jubilee hospital in Kingston did so all by themselves. This led to an increased

mortality rate from "avoidable" causes. Even if a mother-to-be wished to bring a relative or friend into the

delivery room she was not permitted to do so. Even with the high chance of facing an unattended delivery,

and no more access to technology women still placed faith in the AK of the nurse-midwives and the hospital

system feeling that it was safer than giving birth at home. S and B then juxtapose a story of a nana, the local
midwives who no longer practice in most of Jamaica with a woman who had to give birth at home in an

emergency. The nana would stay with a new mother for nine days after the birth. She would pass on her

knowledge to the mother and help her transition into her new role. The mother would also take this

knowledge with her for future births. Taking us back to present day (as of the writing of the article) S and B

tell the story of a young woman who could not make it to the hospital in time. She and her family panicked

and didn't have any idea what to do. They called for a nurse who made it to the house in time to cut the

umbilical cord. Afterwards the family and their neighbors came to the conclusion that "no one today knows

how to manage a delivery." (SB 230)

The studies discussed by Sargent and Bascope may shift the focus of AK away from technology somewhat

but they ultimately enhance Jordan's original research by giving further examples of what can happen when

one way of knowing about birth becomes so predominant that all others are denied and then lost.

The third and final article I wish to discuss is "Preparing for Motherhood:Authoritative Knowledge

and the Undercurrents of Shared Experience in Two Childbirth Education Courses in Cagliari, Italy" by

Suzanne Ketler. This article is another direct response to Jordan's work over ten years later. The works of

Sargent and Bascope as well as others are incorporated. This article deals with the transfer of AK in two

birthing classes in Italy. It seeks to answer questions the authors feel are raised by Jordan's work but still not

fully answered. First, they seek to show how socially some knowledge gains acceptance while other

knowledge gets pushed to the side until it is no longer considered valid. Specifically they they illustrate this

process in the context of birthing classes. They then ask if and how shared AK is important. Does women's

knowledge matter? They also take an applied approach by suggesting that this research can and should be

used to improve future childbirth classes.

Ketler discusses two different kinds of pre-natal classes. In one of the classes biomedical knowledge is

simply passed down from the top up in a classroom setting, socializing it's participants to be passive

participants in medical birth. In the other class the format is more open and women are encouraged to talk to

each other and ask questions. Women who took this second class often come back with their new babies and
share their birthing knowledge with the class. The teachers of this class sometimes answered questions not

just with their biomedical textbook knowledge but with stories about the births of their own children.

In discussing the value of one type of course setting over the other, Ketler leads into an interesting question.

6She says "many feminist and anthropological analyses suggest that a re-valuation of women's experiential

knowledge about maternity is an important objective. However, few of these studies indicate why this should

be so...". Should this be a goal? Why?

To answer her own question Ketler provides examples of women from the more open course who felt that the

friendships ans shared knowledge they gained with the other women in the course helped them on a practical

level to transition into being new mothers better than the biomedical knowledge did (Ketler, 141). She quotes

one woman directly: "I was agitated and scared, and I didn't remember anything... At the moment of birth,

you don't have your wits about you to think about what they told you during the course...but the course did

allow me to meet new, different people with whom...I have continued to have friendships".

The friendships became support systems for new mothers thereby lending a value to the shared AK course

over the hierarchical one. I also believe that despite what Ketler says the prior studies she built her work on

did provide many examples as to the harm that can come when birthing women are deprived of a second

opinion (including their own!)

    Throughout time and across multiple cultures women have shared or passed down birthing knowledge.

There are now increasingly hierarchical birthing systems in both biomedical settings and others in which this

knowledge has been lost or taken away. It is important for women's knowledge about birth to continue to be

shared,passed down, and given valid consideration in  decision-making situations. This importance is

illustrated by Jordan and Irwin's example of U.S. women who were denied control of their own deliveries

even in situations where the doctor's decision was later deemed questionable, by Sargent and Bascope's

example of women in Jamaica who no longer have access to biomedical technology or assistance but have

lost the knowledge needed to feel safe giving birth at home, and finally by Ketler's study of a childbirth class

in Italy where women's shared knowledge helped them transition into motherhood. Having their own
knowledge enables women to question readings from technology that is fallible or recommendations from

doctors/"specialists" who have been known on occasion to make mistakes themselves.