Discrimination Against Women in the Western Medical System
By Leann Moore - 2000 (Written for a medical anthropology class)

The Western medical system relies on several culturally accepted norms.  First, it relies on using the most technologically advanced mechanical and electrical machines to monitor and control the conditions of illness and to speed up natural processes.  Secondly it relies on the institutionalization of health practices, as seen in the categorical lumping together of symptoms to put names on illnesses and then the assembly line style treatment of patients with unique needs.  People in general are losing the connections they once had with nature and their own bodies, while the patterns of patriarchal society are much imbedded into how the medical system allows for the treatment of patients and practitioners alike. 

The last point is most important for it is the basis of sex discrimination within the medical system that keeps women oppressed throughout society, and “because only women have babies, the way a society treats pregnancy and childbirth reveals a great deal about the way that society treats women”. (Davis-Floyd 1997)  I want to explore how the culturally accepted norms of sexism have been used by medical science to keep women oppressed while scientific medicine has changed the process of birth itself.

Once upon a time

The reality of birth is that it’s a natural process that a women’s body is completely capable of on its own.  Midwifery was never institutionalized, but offered assistance to a personal and private event centered around a woman’s individual needs.

Kim Dominguez (2000) recalled the story her grandmother, a midwife, told of helping a young Native American woman:

… how beautiful and strong the woman seemed, how she had prepared her birthing spot ahead of time... As the moment approached, the woman squatted over the hole, supported by my grandmother and another female relative and gave birth to her child. My mother recalled the birth as being very peaceful, a few women, alone, under the protective canopy of the forest, connected on a spiritual level with their ancestors, with one another, and with nature.”

Compared to modern births in the hospital, it hard to believe it is even the same physiological process.  No matter how long or short, how easy or hard their labors, the vast majority of American women are hooked up to an electronic fetal monitor and an IV.  There is an epidural (or pain reliever) rate of 80 percent, and 90 percent of first-time births receive episiotomies (a surgical incision in the vagina to widen the birth outlet in order to prevent tearing).  Most women also receive a synthetic hormone pitocin to speed their labors, they give birth flat on their backs (in the position used for surgeries), and they are separated from their babies shortly after.  Nearly one quarter of babies are delivered by Cesarean section. (Davis-Floyd)

How did this change come about?  It is clear from stories like the one above that less technological ways of giving birth exist and always have.  In spite of tremendous advances in equality for women, the United States is still a patriarchy and ninety-nine percent of American women give birth in hospitals (Davis-Floyd), where only physicians who are mostly male, have final authority over the birthing process.

There are two interacting social paradigms, which I feel contribute to the current discrimination against women in the modern medical system: How the perception and treatment of women has changed over time, and how the medical system has changed through time.

Harris and Ross (1987) make the connection between environmental pressures and scarcity, which generated considerable male antagonism toward women and lead to accusations of witchcraft in Europe.  Western Europe experienced dramatic population losses due to plague in the fourteenth and fifteenth centuries, which in turn drove political leaders to encourage population growth.  But some time toward the sixteenth century there was a “turbulent transitional era in Europe between late feudalism and the capitalist epoch”, when rural populations in particular were subjected to severe economic and social pressures.  From the late fifteenth century onwards, people seem to have become more receptive to the idea of witchcraft (Harris and Ross; Russell 1972) and in almost every district of Europe, the victims of witchcraft accusations were disproportionately women.  Because leaders were still encouraging population growth while the commoners were trying to limit it, a notable group among the victims of witchcraft accusations, were the midwives who often doubled as abortionists. (Harris and Ross; McLaren 1984) 

Robbie Davis-Floyd uses “the technocratic model”, developed in the 1600s to explain western thought and how it has shaped other aspects of our society, such as the medical system.  It states that western thought assumes that the universe follows predictable laws that the enlightened can discover through science and manipulate through technology, in order to decrease their dependence on nature. 

The dominant religious belief systems of Western Europe at that time also held the belief that all things are part of an oppositional dichotomy.  It enhanced the technocratic model above, by putting men and women in opposition so that women were inferior to men because they were closer to nature and feebler both in body and intellect.  The male body became the standard; the female body was regarded as abnormal, inherently defective and dangerously under the influence of nature. 

One other premise in scientific medicine, is that the mind and body are separate aspects of human beings (Joralemon 1999) therefore giving doctors the right to dominate over one (the physical body) without concern for the other (psycho-emotional needs).  Although in its original context, Joralemon is referring to organ transplantation, the mentality underlying the principle serves to explain how the modern obstetrician can routinely separate a mother from biological processes she can surely accomplish on her own.

Women in the Medical System

According to a biography on Elizabeth Blackwell, the first female medical doctor of the modern era, (url: womenshistory.about.com/), she began searching for a medical school that would admit her for a full course of study in 1847.  She was rejected by all the leading schools to which she applied until her application arrived at Geneva Medical College at Geneva, New York, where the administration asked the students to decide whether to admit her or not. The students, reportedly believing it to be only a practical joke, endorsed her admission.  At first, she was even kept from classroom medical demonstrations, as “inappropriate for a woman”.  She graduated first in her class in January 1849, becoming the first woman to graduate from medical school, however hospitals and dispensaries uniformly refused her association in 1851.  Her lectures, and personal example, inspired several women to take up medicine as a profession.

As late as the 1840’s, about 70% of all male physicians in the U.S. had no formal training.  Medical institutions continued to impose tougher entry standards on women than on men until the 1970s, when such actions became illegal.  The American Medical Association admitted women to full membership only in 1951, 104 years after it was founded.  This leads me to point out that if western society and its medical system were not shrouded in sexual discrimination in the first place, the first female doctor would have emerged with the advent of medical schools, not generations later, under the presumption her application was a practical joke. 

Obstetrics was traditionally practiced by women, midwifes in particular, but once the trained medical profession began to focus on surgeries and it became more lucrative, midwifery itself became a competitive entity.  As U.S. medical schools began trying to compete with the more advanced Germany in the early 1900s, the surgeon needed experience, which is exactly what the midwife was keeping from him (Gibson).

"Whether because midwives provided more skilled care or because obstetricians were too eager to interfere in labor and birth, obstetric mortality rates often rose as ... midwife practice declined." (Gibson; DeVitt, MD 1975) 

Many articles were published by physicians in professional journals discussing the "The Midwife Problem".  Because the rates of mother and child mortality increased around the time surgical obstetrics gained footing, the physicians blamed midwifery, saying it providing dangerously inadequate care.  The historical account Gibson writes comes primarily from documents published in professional journals between 1900 and 1930.  This archival material records the historical blueprint of an official campaign to do away with the independent practice of midwives.  Also in these journals was the efficacy of care by midwives of the era, the history of the excellent statistics of the school for midwives in New York City, and the increase in maternal and infant mortality that occurred as midwives were progressively eliminated from practice.  These documents, written at a time when women did not have the right to vote, were intended for "professional eyes only". (Gibson)

Men continue to hold higher proportions of the high-status roles in health-care and women face gender discrimination and sexual harassment during training.  One very interesting point made by Sapiro (1999) is that today, “in hospitals staffed by women doctors, there are fewer operative deliveries of babies and lower maternal mortality rates.”  

Midwifery in the U.S.

In contrast to women struggling to work within the institutions of medicine, midwifes have a longer history and acceptance.  According to an article on the “midwifery problem” by D. Wier (1996), midwifery in colonial America was established from the beginning.  It was noted that Brigit Lee Fuller attended three births on the Mayflower.  Midwives filled a clear, important role in the colonies and it was seen as a respectable profession.  Women actively sought these skilled practitioners and training was predominantly through apprenticeship.

Wier goes on to show how the attitude toward medical professionals and midwives changed over the next few hundred years.  Midwifery practice generally remained on an informal level, while knowledge of sophisticated medical advances did not filter into the midwifery profession. The homeopathic remedies and traditions practiced by generations of midwives began to appear in stark contrast to more "modern" remedies suggested by physicians.

Obstetricians identified a difference in the neonatal/maternal outcomes of the two professionals.  Available statistics regarding maternal deaths and neonatal deaths showed that midwifery attended births often had poorer statistical outcomes than physician attended deliveries. This discrepancy may have been influenced by other factors such as money. For example midwives often took immigrant patients or those with less money and the poor nutrition and sanitation that often accompany it (Wier).

World War I (1914-1918) also influenced women’s health care.  As more individuals became members of the armed services, the abundance of domestic help decreased, and women began to seek alternatives for support after delivery.  They discovered the care given in the hospital for childbirth included food and housing.  However, hospitals were not owned by midwives, nor were midwives allowed to conduct births in hospitals.  (Wier)  In fact the Massachusetts Supreme Court (Hanna Porn v. Commonwealth) declared midwifery to be an illegal practice of medicine in 1907.  (Gibson; Woodbury 1926)

Dr. Neal DeVitt, MD (in Gibson), a contemporary scholar who extensively researched this topic, proposed in 1975 "that the slow decline in infant mortality would have been greatly accelerated had not the campaign to eliminate midwives been undertaken." The Committee on Maternal Welfare of the Philadelphia County Medical Society (1934, in Gibson) expressed concern because the rate of deaths for infants from birth injuries increased 62% from 1920 to 1929. This was simultaneous with the decline of midwife-attended birth and the increase in routine obstetrical interventions, due in part to the influence of operative deliveries.

Two major solutions were posed to the midwifery problem. One solution was to educate midwives in order to raise the level of practice to the accepted mainstream. European midwifery practice was used as an example.  The second proposed solution of the midwifery problem was to abolish midwives for the sake of the health of the country.  Midwifery was almost eradicated in the United States in less than three decades by restrictive legislation and effective public campaigns. Midwifery in the United States, became practiced in only a few areas by less and less midwives and became exclusively associated with care of the foreign born or the nonwhite. In 1915 midwives attended 40% of all births. However, by 1935, that number had decreased to 10.7%, of whom 54% were nonwhite. (Wier)

As traditional midwifery decreased in popularity a new type developed which became known as nurse-midwifery.  Mary Breckinridge is known for truly bringing the concept of nurse-midwifery to the U.S.  She attended nurses' "training" and was then educated as a midwife in Britain.  Then she returned to the United States and formally founded the Frontier Nursing Service (FNS) in Hyden Kentucky in 1925.  The number of nurse-midwifes continued to grow. 

Today there are more than 5,000 Certified Nurse-Midwives in the United States who attend approximately 150,000 births annually, primarily in hospitals. They work in a variety of practices, but all nurse-midwives have a relationship with an obstetrician in case of complication.

Other Changes in Society

Since before the origin of nurse-midwifery, many societal changes have taken place, which have changed the way we live.  And since the way we live reflects a mental attitude which permeates all aspects of life, it is necessary to include some non-medically based changes in society which may have led to changes in medical practices.  First was the advent of the industrial assembly line (especially useful in times of war).  This essentially gave way to an assembly-line mentality in all aspects of life, from animal husbandry to childbirth, where a woman's reproductive tract came to be treated like a birthing machine by skilled technicians working under semi-flexible timetables to meet production and quality control demands.  In fact, one obstetrician in Davis-Floyd’s research commented they were "trained to produce...the perfect body.  The quality of the mother's experience-we rarely thought about that." 

The assembly line allowed “producers” (in this case the doctor) to turn out more “products” (in this case babies) in a shorter amount of time by treating all their patients in a highly routinized way to minimize costs. 

            In the late 19^th Century, something else happened surrounding women, particularly in the working class.  Anthony Comstock, as Secretary and Special Agent for the Society for the Suppression of Vice in 1873; also U. S. Post Office Inspector since the same year, recorded that he destroyed 160 tons of literature and brought 3,760 "criminals" to "justice" during these years.  What were called the "Comstock laws" were passed in 1873, and prohibited the sending of any matter through the mails which, in the opinion of Anthony Comstock, the Postal Authorities choose to call "obscene."  Most of this obscene literature was medical texts and pamphlets, which discussed birth control as a woman’s right to pursue knowledge and control whether and when she had children.  (Sanger 1915)  One can infer that midwifery practices, which have been associated with abortion and birth control before men were ever involved in obstetrics, would have also been victims of this ethical warfare.

Before World War II, women in general were starting to be portrayed in a new light.  The early waves of the women’s liberation movement had allowed for more than just a few women to become professionals in fields previously dominated by men.  Movies and magazines from this era portrayed women doing anything they wanted, like graduating college and then becoming a pilot, before making decisions about marriage and children.  Instead of the Victorian image of a woman who only went to college to study liberal art or homemaking in order to attract a husband, these women were actively seeking their own purposes. 

During the war, women also gained independence because they had access to jobs previously held by the men who were now overseas.  When the war ended, however, women were displaced and encouraged by propaganda and advertising, and sometimes by getting demoted or fired, to go back to the home and try to find a part of themselves, which was now missing. 

In her book, “The Feminine Mystique”, Betty Friedan (1983) shows how the 1950’s were characterized by the loss of support from female relatives and the isolation of the suburban housewife ideal.  Women were manipulated to feel helpless and were encouraged to seek fulfillment in housekeeping and motherhood as opposed to careers.  At the same time, the incidents of mental disorder, depression, anxiety, suicide, drug abuse, child abuse, and "neurosis" skyrocketed among these women who then sought the expert advice of Freudian doctors, who were still accustomed to diagnosing a woman’s problem as sexual. 

Advertisements were purposely geared toward offering salvation from the emptiness women felt, through state of the art, high tech cleaning and cooking products.  They were taught that everything had to be kept sanitized and that they needed technology to help them do things they're mother's and grandmother's had always done by hand because it promised a better life and the fulfillment they weren't getting elsewhere.  These seem to be the same things that lured women into the hospital after any kind of medical progress had been made, and after traditional midwifery had been excluded from the professional medical system.
            After publishing the Feminine Mystique, Friedan became a prominent figure among feminists everywhere and she established the National Organization for Women (NOW).  This and several other organizations, combined with the strength of the Women’s movement at the time, helped to sway society’s image of women and childbirth in a new direction.

When the Natural Childbirth movement became popular in the 1960s, it sought to empower women to educate themselves about pregnancy and birth, to reject total domination by physicians, to give birth consciously, awake and aware, with their husbands present.  These were radical ideas at the time, but today’s idea of “natural childbirth” has been distorted into plants on the IV pole, designer sheets on the birthing bed, or Jacuzzis for labor that look wonderful in ads but are seldom used.  In other words, that heretical energy has been re-directed by those in power, and applied to making technocratic birth more humanistic, more appealing and palatable to the increasing numbers of women who choose it.  (Davis-Floyd 1996; Morris Berman 1989) 

I also think Davis-Floyd’s symbolic analysis of routine obstetrics deserved some attention.  She states that upon entering the hospital many women are seated in a wheelchair, sending their bodies the symbolic message that they are disabled.  They are put to bed as if they are sick with an IV attached to their arms or hands, which is symbolically an umbilical cord to the hospital.  By making her dependent on the institution for her life, it symbolizes how we are all dependent on these institutions for our lives.  “But she is the real giver of life.  Society and its institutions cannot exist unless women give birth, yet the birthing mother in the hospital is shown, not that she gives life, but rather that the institution does.”

In the 1970s, within hospitals, episiotomies were recommended for all first time pregnancies and any woman who'd had a previous episiotomy, birth took place in the lithotomy position (for surgical procedures), babies were routinely kept in nurseries, breast feeding was scheduled hourly for restricted lengths of time according to the age of the baby, and breastfed babies were bottle fed by staff without the mother's knowledge or consent. (Taylor 2000)

This treatment stemmed from the fact that western medicine attempts to be preventive.  If the doctor can prevent complications, he thinks he is doing his job.  However, these preventive measures implemented on all women, no matter their risk and which aren’t always needed, have become a normal routine.  This is in sharp contrast to traditional or even modern midwifery practices, which include providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support, as well as minimizing technological interventions. (url: www.mana.org/) What was once an exception has now become the rule. 

Obstetric nursing is cheaper than midwifery.  Treating all patients with the same “symptoms” in the same ritualized way, plus making procedures like caesarean section routine, are more cost effective for the doctor than waiting for a woman's physiology to accomplish the task in its own time. (Taylor)

The Surgical Revolution

Nearly one quarter of babies are delivered by caesarean section.  This brings me to several ongoing controversies.  One is whether a woman without any risks should be allowed to choose a caesarian section.  Second is whether the obstetrician has grounds for encouraging women with little or no risk to have a caesarian section.  Lastly, and most significantly, there is the question of whether the number of caesarians will continue to rise thereby making vaginal birth in a hospital obsolete (and thereby taking a woman’s role in birth away from her and rendering her powerless once again).

I asked several women about their own experiences with caesarean section and found that there are situations in which surgical procedure is necessary to save the baby (if his heart rate drops to zero), or more convenient for the mother (if she needs to have a different surgery in the same area around the same time anyways they “might as well take the baby while their there”. 

Nationally, the rate of Caesarean sections, among low-risk and high-risk women combined, more than doubled from 10.4 percent in 1975 to 22.7 percent in 1985.  (Lewis 1997) Women are almost three times more likely to have a caesarean birth now than they were twenty years ago (McAleese 2000; Francome et al, 1993).  This rise is attributable to many factors, including the vastly improved safety of the operation itself and of anesthetic techniques.  Relative indications for surgery include “fetal distress” and “failure to progress” in labor (both loosely defined conditions), multiple births, particularly large and particularly small babies, breech babies and women who have had a previous caesarean (McAleese; Francome et al, 1993). Non-physical indications are less well documented but may include fear of vaginal delivery, fear of pelvic floor damage or previous bad experience of vaginal delivery (McAleese; Ryding, 1991).

One of the stories from the women I interviewed pointed out how the she didn’t even get a choice.  She was two days past her due date on her first pregnancy and the doctors told her that because of her small build, the baby would be too big for her and they needed to do a caesarean.  The fact is that the doctor gets more money from the insurance company if they perform surgery than if they deliver a vaginal birth and there are too many women who are not given a chance to at least try it on their own first. 

Social policy over the last few years has started to once again embrace women's right to be at the center of decisions about their maternity care.  It is on these grounds the notion that it is every woman's right to demand a caesarean section became accepted.  Once again the patriarchy steals the motto for freedom, that woman be at the center of maternity care decision, and sells it back under the guise that it is their right to demand a surgical procedure instead of vaginal birth.  However, it can be argued that if women choose caesarean over vaginal delivery, obstetricians and midwives may not be giving them enough information about maternal and neonatal morbidity and mortality following surgical delivery (McAleese; Viccars, 1997).

Conversely, caesarean delivery, despite being major surgery involving severe pain and permanent scarring, is sometimes seen as the easy way to give birth.  Oakley and Richards (1990) discuss how the operation is now conceptualized very differently that other forms of surgery, euphemistically called a “section” rather than an “operation” and how it is not expected to carry any of the physical and psychological morbidity associated with surgery (despite evidence to the contrary).

Savage (1992) has stated that: "as the developed world becomes more and more dependent on technology, there is a danger that people will cease to believe that women can give birth naturally," and comments that she believes that a reduction in the caesarean section rate can only be achieved by making midwives independent practitioners, mostly based outside hospitals, and allowing them to become the guardians of normal birth again.

The study of women and health is highly controversial.  Professional medicine has managed to save many women’s and their baby’s lives.  On the other hand, many of the routine and high-tech procedures, which are used by obstetricians, convey a message to women that their bodies are defective machines incapable of giving birth without the assistance of more efficient machines.  (Brettell and Sargent 1997)  However, the health care system has changed in recent decades and is considerably more focused on the unique needs of women just as in all aspects of society.  We can hope that this continues until women are in control of birth once more.

References:

Brettell, Caroline B. and Sargent, Carolyn F. 1997.  Gender in Cross-Cultural Perspective. Prentice Hall.  New Jersey.

Davis-Floyd, Robbie E. 1996. “The Technocratic Body and the Organic Body:  Hegemony and Heresy in Women’s Birth Choices”. In Sargent, Carolyn F. and Brettell, Caroline B.  Gender and Health, and International Perspective.  Prentice Hall.  New Jersey.

Davis-Floyd, Robbie E. 1997.  “Gender and Ritual: Giving Birth the American Way.” In Brettell, Caroline B. and Sargent, Carolyn F. Gender in Cross-Cultural Perspective. Prentice Hall.  New Jersey.

Friedan, Betty. 1983. The Feminine Mystique. Dell Publishing.  New York, NY.

Harris, Marvin and Ross, Eric B.  1987. Death, Sex, and Fertility: Population Regulation in Preindustrial and Developing Societies. Columbia University Press.  New York.

Joralemon, Donald. 1999.  Exploring Medical Anthropology. Allyn & Bacon. Needham Heights, MA

Oakley, A and Richards, M. 1990. “Women's experiences of Caesarean delivery”. In The Politics of Maternity Care. Clarendon Press, Oxford.

Sapiro, Virginia. 1999. Women in American Society, An Introduction to Women’s Studies. Mayfield Publishing Company.  Mountain View, California.

Savage, W. 1992. “The rise in caesarean section - anxiety or science?” In Obstetrics in the 1990s: Current Controversies. Blackwell Scientific Publications Ltd, Oxford.

Internet Sources:

Dominguez, Kim. 2000. “Images of Birth”. Midwifery Matters. Issue 84, Spring. http://www.radmid.demon.co.uk/midwives1.htm

Gibson, Faith C.P.M. “The Official Plan to Eliminate the Midwife: 1900 – 1930” http://www.goodnewsnet.org/weekly/rosenbt1.htm

TAMAR LEWIN. 1997.  “Report on the Research of Dr. Roger Rosenblatt, MD
University of Washington, Department of Family Medicine”. The New York Times http://www.goodnewsnet.org/weekly/nyt.htm

McAleese, Sara. 2000. “Caesarean Section for Maternal Choice?” Midwifery Matters.  Issue 84, Spring   http://www.radmid.demon.co.uk/midwives1.htm

North American Registry of Midwives. FAQ: What is a Midwife?
http://www.mana.org/htbapp.html

Taylor, Meg. 2000. “Is Midwifery Dying?” Midwifery Matters. Issue 84, Spring. http://www.radmid.demon.co.uk/midwives1.htm

Sanger, Margaret. 1915. "Comstockery In America". International Socialist Review, pp. 46-49 http://www.nyu.edu/projects/sanger/comstock.htm

Wier, D. 2000, “History of Midwifery in the US” © Parkland Memorial Hospital
http://www3.utsouthwestern.edu/parkland/midwifery/txt/mdwfhsustxt.html