Preparing and Breathing

I am readying myself for another journey.
A year later and somehow no less complicated.
Last year in Uganda the goal was to work on a maternity ward at a government hospital serving mostly refugees of the war.
The trauma was deep (go back to the June 07 archives of this blog to read about the experience) and it manifested not only in the care that women received, but in the culture surrounding birth and intrinsically, death.

My partner and I worked in a hospital with no running water and unreliable electricity, and perhaps it was that our goals were not clear enough or that there really is a fine line between helping and hurting, or that we put ourselves in a traumatizing situation from which we had the privilege to walk away from, but ultimately we never managed to escape the dynamic of insider/outsider. I believe that both of us had radically different experiences of our time and of the ward itself.

I returned from that trip with post traumatic stress disorder. I began to have panic attacks and had to slowly peel back the layers of hurt and anger that I had pushed through in order to survive, in order to work, in order to be a healer to the best of my ability in that environment. Many things have come up in this process of reflection that have brought me to an innate trust that both personally and globally, change begins within. So how does a person, a group, an organization effect sustainable change in a space that so desperately needs help?

The Earth-Birth project has been a long time collaborative vision between myself and my co-midwife Olivia. Over the last year much has happened to turn vision into reality and without going into a long list, I will say that the turning point for me was when I realized I needed to stop pushing up against a system that isn't working. The question of why 'western' medicine is problematic in under-resourced areas is a subject of much fascination to me- and is the heartbeat of my work in academia, narrative medicine and midwifery. Right now it's all questions- but the main goal is to create sustainable birthing centers that allow women access to important maternal and child care while at the same time offering opportunities for emotional health, healing and empowerment.

So how do I enter into this?
Midwives say its all in how you breath.
Find the center of it, go deeper, allow it to fill all the little spaces and then release. Expansion and contraction.

I am feeling the contraction after expansion. Perhaps it is the necessary tightening before opening wider. I wonder how a person stays open despite the past.

Turning Vision Into Reality

I am happy to announce the initial launch of the home site for The Earth Birth Global Women's Health Collective: http://www.earth-birth.com/
We are officially virtual.

Thank you to everyone who has supported our project. If I have not been able to send you a personal thank you it is because things have been blossoming quickly.
If you have not had the time to see how you can get involved and support this enormous effort, check out the website!

The site is a work in progress. Please check back for updates, podcasts, interviews and more.

Midwives reach out

This is a great little PSA for a better trained international community of midwives.
The problem, as I see it, is that we tend to train from one model (a western model) of care which fails to take into account the cultural needs and resources of a community. I think hand in hand with the medical training of midwives, we must do training's in critical risk assessment based on a community of cultural competent midwives. We have to start thinking about how culture effects medicine and inversely, how western medicine effects culture, if we want to have truly integrated approaches to treating women.

Abnormal agency

Twenty-four women sit cross-legged on straw mats that are laid out strategically to cover the dirt between two huts in Unyama, a camp for internally displaced persons in Northern Uganda. A plate of boiled yams is passed around and water is poured from a large gourd into tin cups. One of the women towards the back raises her hand and begins to speak. I cannot tell if she is young or old. Her voice is soft and we all lean in to hear her. She pauses between sentences so that the translator can speak into the recorder.
A woman came to me in the night. She was feeling strong labor pains. I stayed with her into the morning. Finally, she began to push. I leaned in close to her, placed my hands to catch, but instead of a baby… she pauses and glances around the circle, we are all silent in anticipation, imagining what could have come out in place of a baby…instead of a baby, a swarm of one thousand black flies flew out of her vagina into the hut in a thick cloud. Almost like smoke from a fire. After this there was no sign of a pregnancy. Nothing at all. Her belly became small and tight very quickly. We took her to a hospital and the ultrasound revealed nothing. It was as if it never happened. An American doctor for World Vision suggested we were crazy but I know what I saw. Tell me sisters. Tell me. Was this the Devil? Most women begin to nod their heads in agreement and one woman calls out “yes, yes, this is the work of the devil, I have seen something similar…”
Suddenly there is a rush to speak. Women begin rapidly telling tales of abnormal or ‘devil influenced’ births they have attended: a woman who gave birth to a large hairy eyeball, a child born with her foot attached to her head, and a baby born with a full set of teeth. Sitting in this circle I find myself wondering how narratives about the body and birth work to both create and heal the traumatized female body.

This particular incident was transcribed during a meeting of Traditional Birth Attendants, women trained by their mothers, sisters and aunties in the art of catching babies. None had been formally trained by Western standards, but all had attended hundreds of births and most were mothers as well. Supported by a grant from Mama Cash, an organization that allocates funds to bolster the position of women’s rights, I was one of two Americans, a midwife and a doula, working alongside Ugandan midwives with the intent to exchange practices, share techniques and understanding of the birthing body. I hold a Masters degree in Performance Studies, which framed my understanding of this circle of tales as a performance of it.

The ‘devil’ is one of multiple answers to the question of ‘what’ came out of this woman instead of a baby. The biomedical rationale for a swarm of flies disguised as a pregnancy could be that the laboring mother had a parasite. According to the American Journal of Infectious Disease ‘Gasterophilidae’ or ‘Stomach Botflies’ can produce a pregnancy like distension of the pelvis. Another biomedical explanation may be that, as the World Vision doctor suggested, the birth attendant was delusional and imagined the entire incident. The institution of medicine produces a certain story of the body, one that is skeptical of personal experience narratives. From the biocultural perspective however, the rationale will be as diffuse as the experiences of the women sitting in the circle. Religious belief systems, myths and ritual may be used to make sense of the world in ways that move beyond scientific explanation and offer points of entry into understandings of health. dimension of narrative and voice as intrinsic to women’s health care in particular.

In war torn Northern Uganda, the biomedical conditions of women’s reproductive health are mediated and created by the circumstances of cultural warfare. For twenty-years a group of rebel soldiers attempted to tear down the Ugandan government to replace it with one, it claimed, based on the Ten Commandments. In the name of those religious principles the ‘Lords Resistance Army’ kidnapped more than 20,000 children, who made up the bulk of their fighting army. Some academic attention has been paid to the stories of boy soldiers but fewer accounts have been published of what happened to the girls, although we know that rape and servitude - as well as murder - are part of the tale. Most of the women in Unyama are refugees who have escaped abduction by rebel soldiers and are now giving birth to their rapists babies.

Even in rural Uganda, birth is managed from a technocratic model. “Traditional” birth attendants are trained in practices that date back only as far as British colonization. The story of the cell is privileged over the story of the woman. In spaces such as Unyama, I posit that the biomedical explanation of an ailment is not always the most helpful. Knowing that the flies were a parasite might be useful in America where one has access to clean drinking water and hand sanitizer in order to change future outcomes. In Unyama, knowing the conditions of emergence does little to change the circumstances of transmission. It is not surprising that it is the abnormal birth stories that create the necessary conditions for narrative sharing among the group of women who are both refugees and birth attendants. The tales are bound to overarching themes of religious morals, sin and punishment; themes that are not unlike the conditions that produced the pregnancies themselves. These tales of the devil mirror cultural circumstances and can be useful biomedical tools towards understanding what women think about their own bodies, the babies that pass through them and how they care for one another. The vocalizing of the tales demonstrates a certain level of ownership and rationalization of the circumstances, making possible the potential for personal decisions and choices about bodies and babies, which may be inclusive of safer biomedical practice. The two models overlap and intermix, the story of the woman informs the management of the molecular tale.

In a medical context, interpretation of narrative is critical; the successful transmission of information becomes intrinsic to the care that a patient receives. A scientific explanation may have its place in the treatment of physical ailments- yet it does not address the integral nature of women’s understanding of her own experience and therefore her ability to heal or prevent future instances.

I am interested in intersection of these two tales of the body– the spaces between what a woman speaks and a doctor understands, what a human experiences and science explains. I am interested in exploring the multiple narratives or means of framing one story, and locating the cultural influences between these narratives that can lend agency to both medical practice and patient care. While science may offer some explanations for the social conditions, to privilege the biomedical tale of the body misses opportunities for understanding and thus changes of practice that might be accessed through cultural narrative. The spaces and gaps between the story that is narrated by a patient and the story that is actually heard and interpreted by a health care practitioner should be explored to determine impact on women’s bodies and agency.

Personal Narrative as Medical History?

I am the daughter of a storyteller.
Personal narrative has been alive in my cell memory since I was born.
My research as of late has been on the medical history- this charting of abnormality we all fill out at the doctor, which helps them to pathologize and diagnose, yet misses most of our actual history of 'health'.

About two years ago I had Cellulitus (a bacterial skin infection) on my face.
I recently switched doctors and so I had my medical records shipped to me. In the ‘notes section’ of this chart, my Doctor had written:
Patient presents with swelling and rash on ears (and face). Bumpy and hot to the touch. Skin is swollen to capacity and has burst… oozing a sticky yellow fluid, between water and puss. Left ear grotesque. Diagnoses: Cellulitus. Treatment: Penicillin and Benadryl.

Aside from feeling slightly woozy from the description, I was intrigued. Here was a history of my body that somebody else had narrated, and I had never seen. Not only that, I remembered the experience completely differently. In my memory it was not my ears that mattered so much, but my eyes, mouth and cheeks: a parenthesis in the Doctors description, but the most painful for me. I remember that all I wanted to do was cry, but could not because my eyes were swollen shut. I remember my cheeks stung and dirt kept collecting on the moist (pussy) skin so I had to lay with a wet washcloth spread across my face to keep from further infection

As Foucault points out in ‘The Birth of the Clinic”, “I cannot be present to a temporality that exceeds my own capacity for self-reflection, and whatever story about myself I might have to give has to take this into consideration. It constitutes the way in which my story arrives belatedly, missing some of the beginnings and preconditions of the life it seeks to narrate”.

Interestingly, a year before I received these charts, I had a flare up of the exact same symptoms that landed me in a Brooklyn emergency room. When my medical history was taken, nobody asked if I had ever had the same thing happen before. I was diagnosed this time with an allergy to Penicillin, the very drug that was used to treat the initial condition. It is hard for me to narrate the significance of these events on my physical body, in part because it is impossible for me to understand them apart from the context in which they emerged. Swollen to the point of having no facial features, my body became unrecognizable to my ‘self’. In order to give an account of myself in a way that was meaningful to the Brooklyn ER Doctors, I needed to remove myself from the actual experience; citing exact moments of swelling and symptoms, and leaving out the rest of the story. Reflecting on this experience and flipping through the charts that documented my medical history I cannot understand them as ‘mine’ without attaching experience to them. In my present embodiment I carry a mark of those stories. I still have a scar on my left ear from the broken skin that the doctor described as the biggest he had ever seen. Yet if asked for proof, ultimately, it is the charts that become the ‘official’ history of my body and not the scar. The scar, however, carries a story, one that is more ‘mine’ than the chart.

In a medical history form there are a prescribed set of questions that are meant to engage and evoke answers that fit into a prescribed way of understanding the body and its past or present malfunctions. The chronological history of the ‘event’ of malfunctions as well as a number of vague lifestyle questions such as overall diet and exercise lead the practitioner to a fuzzy framework of understanding the body they are treating.

The Health Care Financing Administration (those who decide what medical procedures will or won’t be reimbursed) and American Medical Association require the history component of the examination to the following elements (commentary in italics is written in a guide for medical students by chairwoman Donna McCune ).
• Chief complaint (CC)
“The CC states why the patient is in your office. It is a brief description of the reason for today's visit including symptoms, conditions, problems, diagnoses, physician-recommended return, or other explanation. It is usually stated in the patient's own words. This entry is an essential part of every chart note. There must be a reason the patient is sitting in the examination chair.”

• History of present illness (HPI)
The CC and the HPI have a similar connotation. The HPI is a chronological description of the present illness from the first sign or symptom or from the previous encounter to the present. It contains subjective symptoms not observable by another (e.g., pain and nausea) and objective symptoms that are observable (e.g., redness, swelling).

• Review of systems (ROS)
An ROS is a listing of any signs or symptoms the patient may be experiencing or has experienced organized by body system. The ROS is not a history. It is a review of systems directly related to the problem(s) identified in the HPI as well as any pertinent current medical problem(s). There are 14 possible systems: constitution (general health), integumentary, eyes, musculoskeletal, ears nose throat, neurological, cardiovascular, hematologic lymphatic, respiratory, allergic/immunologic, gastrointestinal, psychiatric, genitourinary, and endocrine

• Past personal, family, and/or social history (PFSH)
The PFSH has three parts:
Past personal (current medications, allergies, prior illnesses/injuries, operations/admissions) Family (members living, health status, hereditary conditions related to the present complaint or illness) and Social (marital status, employment, tobacco, alcohol, drug use).


The author of this guide may provide insight into why health histories of the last one hundred years are only concerned with moments of rupture. Unless there is scientific capital to be gained, liability says that it cannot be done.
This locks Doctors into a system from which they must obtain very specific information and ignore the information that doesn’t fit into the box of what insurance says is important. In relation to what she is suffering from, the patient becomes an external fact; the medical reading takes her into account only to place her in parentheses. This enables classificatory medicine to presuppose a certain configuration of disease. The above framework for taking a medical history is used by all Doctors who are members of the American Medical Association. It takes into account a certain history of the body and completely ignores or bypasses another, assuming that illness happens in a prescribed and methodological way. Arthur Kleinmen, in his preface to Patients and Healers in the Context of Culture (1980) offers, “Clinicians tend to be simplistic about clinical practice. Their tendency toward positivistic scientism and atheoretical pragmatism discourages attempts to understand illness and care as embedded in the social and cultural world. Their reliance on ‘common sense’ often masks ignorance of relevant behavioral and social science concepts that should be part of the foundation of clinical science and practice”. (7)

Just a whole slew of thoughts today....

Byllye Avery

I attended this talk last week, given by Byllye Avery:

Breathing Life into Ourselves: Personal Stories as Research

For the past 25 years Black women have been engaged in telling the stories of their lives, their struggles and triumphs as part of the Black women's health movement. These stories are liberating for the women who tell them as well as the women who listen. The process of sharing personal stories, some obviously related to women's health, some less so, allows women to become active proponents of their own health. Active listening to such stories develops awareness of shared experiences and helps to suggest answers for addressing health and social issues. It also provides information for conducting research and understanding the power of acceptance and self esteem in self care and self healing.

Byllye Avery is a busy woman. Founder of the Avery Institute for Social Change and the National Black Women's Health Imperative and The Birth Place

It was so overwhelmingly inspiring to hear not only about the incredible projects she has effected, but also to think about framing and creating solutions to women's health issues from a narrative as evidence perspective. Listen to a podcast of her speaking here.

A quick shout out to the conference Byllye is organizing in Boston next week. Details are below. I so wish I could be there but I will be helping my good friend Ame at the Umami Festival that night. Also something worth checking out for all you NY foodies!

» Women Must Lead Health Care Reform: National Health Care Conference April 17-18

BOSTON (April 10, 2008) Some of the nation's leading women's health advocates, including former U.S. Surgeon General Joycelyn Elders, will convene at a national conference April 17 and 18 at Simmons College in Boston, to help mobilize a grassroots movement for creating a progressive U.S. health care system that meets the needs of women and their families.

More than 300 national, state and local women's health care advocates will attend the conference, "Hear Us Now! Raising Women's Voices for the Health Care We Need," to engage in an array of panel discussions and training sessions on topics ranging from health care insurance obstacles facing women and girls, to the vision of health care for all from a policy perspective.

This event is open to the public, but R.S.V.P. is required. To register, visit www.raisingwomensvoices.net.

The national conference is organized by the Avery Institute for Social Change, National Women's Health Network, and MergerWatch Project of Community Catalyst, to launch a campaign of actively involved women's health advocates in health care reform. The "Raising Women's Voices for the Health Care We Need" strategy focuses on identifying policy issues related to women's health and healthcare reform; engaging a national network of key women's health stakeholders; developing a women's vision of quality health care for all; and engaging women to become actively involved in the national health care reform debate.

Joycelyn Elders, M.D., former U.S. surgeon general for health and human services, will deliver the keynote address April 17 at 9:45 a.m., "The Crisis in Our Health Care System: Why Don't We Have Quality, Affordable Health Care for All?" in the Linda K. Pareksy Conference Center, 300 The Fenway, Simmons College.

Other featured speakers include Judy Ann Bigby, M.D., Massachusetts secretary of health and human services; Claudia Morrissey, M.D., MPH, president of the American Medical Women's Association; Byllye Avery, founder and president of the Avery Institute for Social Change and founder of the Black Women's Health Imperative; Miriam Yeung, executive director of the National Asian Pacific American Women's Forum; Judy Norsigian, director of the Boston-based Our Bodies, Ourselves; Jessica Rojas-Gonzalez, policy director of the National Latina Institute for Reproductive Health; Judy Waxman, vice president of the National Women's Law Center; and Maureen Corry, executive director of Childbirth Connection.

Conference topic titles include:
• "Uninsured or Under-Insured: Who is Left Out of the System Now?"
• "Making Our Health Care Culturally Competent"
• "Why Isn't Health Care Considered a Human Right?"
• "A Call to Action"

Women's health care advocates say that women's input in the debate on health is crucial, considering their frequent role as the decision-maker for their family's health care. Additionally, with 47 million Americans without health insurance, certain groups of women, such as Latinas, are often disproportionately affected. Those women who do not have insurance, or whose insurance coverage is inadequate or too costly to use, often postpone care or do not get prescriptions filled for themselves or their children. The Institute for Medicine reports that more than 18,000 women die from lack of medical care each year. Women face special concerns such as the loss of dependent health insurance when they become divorced or widowed, and the refusal by insurers in some states to insure women who are pregnant.

To determine specific health care needs and problems of women and their families, organizers have been conducting small group meetings with targeted women's health audiences, particularly underserved groups that are often excluded from health care reform discussions.

Blurring edges

This is one of the best things I have seen in a long time.
It directly addresses questions of the body, its boundaries and our relationship to those edges.
I am always in awe of how very very beautiful a scientific or mathematic understanding of this world can be.

Poo-phoria

Thanks for the link, Grace!

I always say that poop is a 'fringe benefit' of working in the birth field.

Avatar Birth

This is an avatar in Sims 2 giving birth .





Interesting to pay attention to what the programmers choose to 'keep' of the birth process. The woman appears to be in pain, however, the actual giving birth process involves spinning around and catching the baby and an outfit change all in one.

Historical Ruptures

“The knowledge of a disease is a doctors compass; the success of the cure depends on an exact knowledge of the disease; the doctors gaze is directed initially not towards that concrete body, the visible whole, that positive plentitude that faces him- the patient- but towards intervals in nature- like negatives- the signs which differentiate one disease from another, the true from the false, the legitimate from the bastard, the malign from the benign.” Michele Foucault, The Birth of the Clinic.

In the medical tradition of the eighteenth century, illness was defined in terms of ‘symptoms’ and ‘signs’. These were determined from one another by their semantic value. The symptom is the form in which the illness presents, all are that is visible- a cough, fever, a rash, they allow the invisibility of illness to ‘show through’. The sign on the other hand ‘announces’. The sign performs the illness: The prognostic sign: what will happen, and the diagnostic sign: what is happening now. Between it and the disease is the doctor’s interpretation of a patient’s narrative and symptoms. Medicine produces historical knowledge of the body. Medical ‘gaze’ as Foucault names it is like a magnifying glass, which when amplified to one part, has the potential to call into question that which one might not otherwise perceive and simultaneously has the power to only magnify what it deems important. During a medical interview, we are conditioned to respond to only the questions that the Doctor asks us, nothing more. So conditioned, that the answers becomes the story that we tell. The patient becomes the portrait of whatever the doctor diagnoses. We frame the history of our illness in clinical terms, the chronology of events in or on the body, rarely delving into physical feelings or emotional connection to and awareness of the body.

What happens to the history of the body that does not go into the charts? Does the person who has never seen a doctor not have a health history? In the framing of the body in medicine, the paper of a chart is more of an archive than the body itself. There may well be agency then in the un-narrated history of the body. The history that does not show up in charts, but is narrated through a repertoire of physical embodiment and the performance of ‘self’, as either a healthy or sick person.
Think about it. Is your health 'history' a portrait of your health or a portrait if your body in dis-ease? Is viewing the body through a series of rupture the best approach for comprehensive medicine?
More on the inadequacy of language to express of pain later....

Slippery Narratives

Sit with a group of new moms together and you will inevitably hear a story or two about birth. From the moment that a women reveals that she is pregnant she is surrounded by women telling their birth tales: in line, in the bathroom, in the park, over lunch; women participate in the ritual process of recounting birth experiences, forming those experiences out of the threads of memory and pieces of stories left after the ritual performance of birth itself. Pregnant women (and anyone around them who will listen) become members of a narrative ring; bound by a conspiracy of the body, contracted by maternity to hear, to tell and retell what others insidiously, joyously, even anxiously- tell and retell. In every act of childbearing two stories are simultaneously produced, a story of what the ‘body’ does and a story of what the ‘woman’ does; the ‘body’ might dilate slowly while the ‘woman’ screams out for pain medication. The body and the woman intersect and influence one another while still managing to maintain independent realities.

Human’s frame understanding of experience in terms of narrative account. When we try to understand why things happen, we put events in temporal order, making decisions about beginnings, middles and ends or causes and effects by virtue of imposing plots on otherwise chaotic events, creating what Rita Charon calls narrative knowledge. If narratives are stories that have a teller, a listener, a time course, a plot and a point, then narrative knowledge is what we naturally use to make sense of them. The narrating and sharing of birth stories play an important role in creating and recreating the performance of giving birth. A classic story of the marriage of childbirth and narrative, cited by Claude Levi-Strauss, is one of a woman who had difficulty giving birth. After a long night and eventually a stalled labor a shaman told the woman in labor the story of valiant warriors freeing a prisoner trapped by strangers, and on hearing the plot resolution, she gave birth to her child. After an imagined break-through, she had a physical break-through. Nature imitated narrative. In this instance narrative served as mental and emotional tool for the production of a woman in labor, and in the course of her giving birth, a new story was created. One that will be recounted time and time again, to her sisters, her friends, anthropologist’s and in a few years, the child herself.

Telling a narrative in any setting is a bridging performance. Most obviously it connects the teller and the listener. A pregnant woman becomes both the subject of and subject to birth stories. Depending on the community she is in, she could hear childbirth described as anything from a horrific and severely painful event to a cosmically orgasmic body quake – there is rarely any narrative in between. This discrepancy of experience, leads one to believe that what one hears about childbirth might influence and shape physical enactment of childbirth. When faced with the often frightening and confusing language of clinical medicine, it is the stories of other women’s experiences that serve as navigational guidance. Asked why she was opting for an elective Cesarean section, a woman recently said to me "my friend’s baby had a really big head and got stuck in her vagina. My Doctor says I have a small pelvis and I just don’t want to be stuck like my friend. She said it was the worst”. Whether a claim like this is ‘bio-medically’ true or not, it certainly is bioculturally interesting. This woman, backed by her doctor, is making a physical choice based on the medical fact of her small pelvis (small compared to what?) and the story of another woman’s birth experience. Another woman stated that she was scared to have babies because all of the women in her family have reported excruciating births. What gets passed on from generation to generation through the body is transmitted and constituted through oral narrative. Oral texts are slippery entities, the way that they are performed and made meaning of shift from person to person. Here I will explore how the sharing of birth stories shapes and reshapes the performance of childbirth within three women’s lives.

A woman walks into a birthing clinic to deliver her first baby. The midwives check her dilation, determine that she is only two centimeters dilated and send her home telling her to come back when her contractions are three minutes apart and lasting one full minute. The woman leaves, gets in a taxicab, and delivers her baby in the cab on the way home.

The dramatic story of a taxicab birth is not a new one; although nobody has formally written about it, this tale is one of the most commonly produced and reproduced birth stories (at least in places like NY where most people travel while in labor by taxi to the hospital or birthing center). I heard this story, and almost identical versions of it three times by three separate tellers in March of 2007. Each teller was pregnant with her first child. Presumably the events of this particular story happened in Brooklyn, NY but as is characteristic of folk and oral narratives its original source cannot be traced. Its interpretation is as diffuse as the tellers who make meaning of it.

The first teller is a forty five year old singer who is married to the drummer in her band. They are having their first child ‘late in life’ because they spent years on the road touring. They plan to deliver their child at home. In her version of the story the taxicab birth happened to her ‘friends cousin’. She told me the story in the context of a hospital versus home birth discussion that she and her husband had been having. Upon hearing this story she was swayed towards homebirth.

“I really see how very natural childbirth is. I mean, in a hospital they try to control everything, but like this woman her body just had its own thing going on. And the baby was fine. Like totally fine. In a taxicab. I mean she could have been squatting in the bush like most women do. I mean who cares if I am older, my body wouldn’t have let me get pregnant if it couldn’t have the baby. So anyway, it (the story) just made me less scared, and more like… no matter where you are babies come out and well if I am at home at least I won’t have anywhere I need to get except the bed.”

The second teller is a nineteen-year-old West Indian immigrant. She is having her baby without the support of her parents or the baby’s father. She plans to deliver at the hospital closest to her house. In her version of the tale, the woman giving birth was her ‘sister’s friend’. Upon hearing this story she felt fearful of her own circumstances and expressed desire for medical intervention and constant supervision.

“ I mean it’s totally crazy how fast it could happen. I just want them to like take it out of me. Not really, but I would hate for something like that to happen to me, to be all alone on my way to the hospital and have nobody to catch the baby, except you know, a dirty cab driver. So scary. So I just want them to umm, induce me when its time, like start the whole thing there that way I wont have to worry about being alone, the nurses will always be there."

The third teller is a corporate lawyer in her early thirties. Her husband is an entertainment lawyer. They plan to travel an hour to a hospital that has very high tech equipment and celebrity birthing suites. This woman did not admit to any personal connection to the woman who gave birth in a cab, but said she heard it from a coworker. In recounting this story to me, her intent was to confirm her decision to travel far to a hospital that was high tech and high intervention, which in her version intrinsically meant ‘better’.

“I wonder if there was a law suit against those midwives that sent that poor woman home. I mean clearly she knew that she needed care or else she wouldn’t have come in the first place, and those midwives that sent her away, well, it just makes me feel really good that we will be going to the hospital where all of the best doctors are and they understand that birth in this day and age is not something you treat lightly, we have the technology so why not use it! You know my sister had her baby at this hospital and she came in at 2cm and they just gave her a nice epidural, some pitocin to speed things up, and voila, she had a baby. That’s what I expect. To be treated like a human being. None of this animal stuff. “

The same story produces three radically different meanings and performative outcomes for each woman’s birth experience. It is not possible to view these oral narratives apart from issues of race, class, power and gender. In ‘Absent Gender, Silent Encounter’; Debora Kodish identifies one purpose of feminist scholarship as the deconstruction of ‘male paradigms’ and another as the reconstruction of models attentive to women’s experiences. Childbirth is certainly a woman’s experience, and yet is embedded in a medical narrative of the body that is historically male centered. As each woman wades through the creative, shifting, interstitial process of negotiating the meaning and value of birth, the taxi story dramatizes the convergence of multiple performativities on the birth experience. In telling the tale, she reclaims an identity for herself as a birthing woman within the context of an always constructed feminine performance. This identity is inextricable from the birth narratives that she has been told by others and chooses to align herself with. Each of these women is telling the taxicab story with the hopes of a better outcome for herself, and yet ‘what’ a better outcome is varies from woman to woman, community to community and ultimately story to story.

In many ways birth stories imply a radical inversion of established structures of meaning and action and so must be, it seems, counter-performed. Della Pollack writes about this counter performance of birth stories stating “They must be circumscribed, discredited, pushed to the margins of discursive practice, whether by identification with ‘gossip’ lore’ or anecdote, or to make a woman’s body and so her story conform to prescribed medical narratives”. This fundamental connection between tale and body has a narrative tracing to the Cartesian philosophical separation of mind and body inherent in the scientific medical view, which does not permit the interaction of individual consciousness with the molecules and atoms that comprise the ‘substance’ of scientific inquiry. Not surprisingly, the dominant metaphors describing birth in the late twentieth century are characterized by mechanical images in which a woman’s body is fragmented into working parts over which she has little control. As Emily Martin phrases it “medically, birth is seen as the control of laborers (women) and their machines (their uteruses) by managers (doctors) often using other machines to help,” The canonical obstetrics textbook Williams Obstetrics encapsulates the mechanicity of the dominant medical view; it defines birth as “the complete expulsion or extraction from the mother of a fetus”. Martin argues that “there is a compelling need for new key metaphors, core symbols of birth that capture what we do not want to loose about birth”. She argues that any attempt to conceive new languages for birth will be fraught with the contradictions arising from living within an andocentric society shaped by mechanical images of birth and bodies.

In the United States, pregnant women have two choices, to birth at a hospital with an obstetrician, or to birth at home with a midwife. Only one percent of the population chooses the latter . Choice is often rooted in privilege, and feeling free to choose where, how and with whom to birth is no different. Because western culture privileges medicalized, technological and interventionist birth over natural birth, it is ironically most often only the privileged who have access to ‘natural’ birthing options. Western women who choose to birth at home tend to have access to education that allows them to challenge the hegemony of the system, but to do so with the knowledge and confidence that hospitals and insurance companies are there for ‘backup’ should they need them; they therefore inhabit what theorist Donna Haraway calls post-biomedical bodies- bodies that do not entirely deny the usefulness of biomedicine, but are able to challenge its authority. Conversely, in areas of the world without large western influence, most new babies pass through the hands of midwives. In these areas, it is only the privileged who have access to ‘western’ style birth experiences in a hospital. These ironies provide ample room for questioning the intersections between cultural and medical practice as they are chosen, experienced, embodied and turned into tales.

A story like the taxicab tale, in its unpredictability, its high drama, and uncontrollable female body rupture, disrupts this ‘male tale’ of the body and perhaps is why women across race and class divisions feel so drawn to telling it. The middle-aged singer, who sees the ‘good’ in the tale, elaborates on the potential for a natural and un-interventionist homebirth; in doing so she disrupts the medical narrative that assumes the birthing body must be controlled. By invoking alternative systems of knowledge, this woman uses the story to challenge the hegemony of mainstream childbirth systems. The young woman, who reads into and interprets ‘fear’ as the dominant theme of the woman alone in a cab, aligns herself as a subject to medical practice and is comforted by the notion of her rupturing body under constant management. By virtue of her vulnerability as an ‘other’ this young, single, pregnant, woman of color trusts the institution of medicine to take care of her, exemplifying what Foucault called the clinical ‘gaze’. Finally the lawyer both expects and demands technology as an extension of her privilege. The body as machine is a removal from that which is primitive. For this woman, the ‘uncontrollable’ birth of the woman in the taxicab is a gross malpractice of a medical profession that should be better at monitoring and managing bodies.

One clear distinction is that none of these women wants the taxicab birth to happen to them, yet everybody wants to talk about it. The women told this story in the hopes of achieving for themselves and thus being licensed by what medical discourses describe as a ‘good outcome’, to elaborate and embellish dangers and conflict, with the intent of improving the climax, of ensuring relief in the final orderliness of all things. What Della Pollack calls the ‘almost but’ structure of birth stories, the expression of happiness depends on a ‘flirting’ with death: exposing the possibility of death only to deny it. Depending on her cultural circumstances, each woman sees a different path to denying it, yet is equally intrigued by the dramatic thread.

Perhaps unintentionally, the narrative ring of women telling these stories undermine the presumed neutrality of medical procedures and the apparent transparency of birth experiences with the pressure of their own reflexivity, effectively hot wiring a networked of rituals and resistances composed at least in part of medical techno-dramas, prenatal pedagogies, compulsive performance of the ‘good mother’, and the birth narratives that in various forms pervade, mock and sustain all of the above. Looping through multiple performativities, birth stories threaten not only the conventional isolation of birth from other episodes in the formation of cultural identity but also the concomitant isolation of birth from the broader body-politics, related issues that become silenced narratives such as miscarriage, abortion or even sexual orientation.

When women tell stories of the birthing body, the body becomes story; birth stories are always already performed. As performances they are unique constructions of bodies in time. As minor myths of origin, they loan history the authority of beginnings, through repetition and condensation, they become the founding facts of history. The convergences of performativity and maternity, in making history subject to the maternal body performing itself in ritual, spectacle and story.

Tell me what we gonna do

Joss stone wants to become a midwife.
Just had to share.

Performative Medicine

How do we change medicine? My thoughts are really questions and my questions spark further inquiry. How does one engage to change a system that doesn’t acknowledge its own malleability? Last year with the help of Anna Deveare Smith, I created a basic model for the collection of a medical history that was organic and comprehensive of a health narrative that moved beyond ‘ruptures’ of normal, and at times beyond words to describe events on and within the body. This model was based on practice as a midwife and my lifetime of observation of medical practitioners, performing on and around me. It is the beginning of an inquiry into better practices, better performance and better healing.

Modern medicine is based on the notion that what ‘science says’ is right. Even though what science says often changes, in the moment it is treated as the absolute and last authority. “Science Says” language positions the logic of science over the expression of human experience or knowledge of self. We are conditioned to believe and trust ‘science says’ over our own innate knowledge or feeling. Human voice, agency and desire are wrapped up in a system that is integral to their existence and yet does not acknowledge them as important. I believe that medicine must acknowledge human experience as intrinsic to what science says. The separation of the two is dangerous.

Science say is also related to ‘liability says’. Healing in this country is tied to money and to insurance coverage. Doctors and nurses are trained to heal from a liability perspective. Unless science says, liability says that it cannot be done. This severs the intuition present in genuine human interaction and also locks Doctors into a system from which there can be no creativity or out of the box thinking.

I realize that I can write a medical model for care but unless it is actually used, the model as a tool does not reach its full potential. It becomes like a script for a play that never gets produced; one that just sits in a file somewhere, or is performed for only an audience that likes and agrees with what it is saying. We need to challenge the audience who does not agree with us. Fortunately and unfortunately this is a very large audience. It constitutes most of the Doctors and the nurses who manage medicine and therefore what ‘science says’ is health in this country. Those of us working off the grid need to be a good enough engagers to work with other medical practitioners- to ask questions of the system we work in; to try new things; to trust the human voice and human emotion as intrinsic to the numbers, the cells, the blood and the skin.

As healers we are channelers. We take in another persons story, the account that they give about their embodied experience and channel what we have heard into some sort of action. I thought a lot about this in watching Anna perform her 'ADS' method, which is indeed a channeling; a taking in and a feeding back of words, gesture, expression so that you become a conduit for that person’s energy and story. As Richard Schechner would say, one becomes simultaneously ‘not and not not’ the person that one is performing. Intrinsic to this is a deeper understanding of a person’s role or position. I believe this to kind of transmission, of really listening and offering back, could transform medicine.

I want to think about and question the role of listening and the role of empathy in medicine. I once had a therapist who would cry every time that I cried. This made me terribly uncomfortable. In fact, it was inappropriate. He was taking on my emotion as opposed to staying removed from it. I expected him to be removed so I was unsettled when he was not. And yet, if ‘science says’ language told me that a therapist healed through empathy tears, I would most likely have expected and desired for him to cry with me. What is ‘normative’ we accept as healing. Truly, empathy does play a big role in healing. Healers take in an account of the body in dis-ease and the only way that we can relate to it is through our own embodied experience, or through the logic of science. Most people are informal healers all the time, suggesting that friends take a certain vitamin that we took that energized us, or offering soup to someone who is sick. Empathy is the reason that women often feel more comfortable with a woman gynecologist; aside from a scientific understanding, empathy (a not but not not situation) can make it easier to engage; easier to heal. So how do I engage with the medical institution so that the performance of healing is more holistic, more empathetic?

My personal primary care physician is a woman named Dr. Susan Massad. Six year ago, for fun she took a theater improvisation class and realized that all Drs should learn to improv, because it would make them better listeners, better reactors, better engagers, and thus, better healers. She partnered with an organization called ‘Performance of A Lifetime” and began teaching improvisation classes for medical residents in New York. You can check out an article about her at http://nymag.com/nymetro/health/bestdoctors/features/9259/ http://www.performanceofalifetime.com/press3.html

In my opinion, Dr. Massad has a proverbial ‘toe in the door’ into the way that medicine needs to be reframed and re-thought if we are going to truly improve health care in this country. I think the next step is to develop engagement workshops for healthcare practitioners. In order to do that we need to locate medicine in key moments where it both engages and disengages embodied experience. We need to understand where and why these practices both work and don’t work. I am concerned with what science says but also concerned with myth as lived experience and representation as product and practice.

How do we channel the story of the body into something that fits within science…. What would happen if we channeled science into the story of embodied experience? What if Doctors performed their patients? What if patients in return, performed their Doctors? What if Doctors were trained as extensively in listening as they are in anatomy? What if healing were to be approached from a ‘healthy’ perspective as opposed to only the moments when health ruptures? What if we learned from and shared healing practices with other countries…. we certainly share what ‘science says’ with other countries, why not performative healing as well? What would happen if we directly asked Doctors to imagine and think about their own position within the health dynamic?

We need to ask more questions to get more questions. Try things and fail at them, try things and succeed at them. Not every practice will work for every body. Be open to the futility of concrete answers, only a humble questioning. A celebratory loss of control. The story of medicine is as ancient as the human body itself. There is no point of origin. No beginning and no end. Only multiple points of entry. From this perspective, my engagement with medicine is a journey; one that starts in my body, in my inquiry, and lands itself in the resonance of questions and answers that follow. In my near future, I hope to make an offering to the medical communtiy, a series of workshops and performance practices whose boundaries will be also defined by the resonance of questions, thoughts, and action that are provoked through their telling.

Public/Private: Gloves/Bareskin

There has been a lot of talk in the birth community about The Business of Being Born.
Natural birth advocates seem happy since it is a film that is clearly promoting women's education and informed choices towards safe and empowered childbirth experiences.
The medical community is raising a threatened fist, with a lot of comments about skewed statistics and woowoo medicine.
Now, my sense is that statistics in general are a crock of BS used mostly for propaganda. They can usually be dis-proven with a different focus group. The statistics in this film may be skewed, but certainly not any more skewed than those that the medical establishment uses to frighten women into what is often unnecessary intervention.

What this film has done is to bring something that is usually very private into the public sphere. Sure, 'A Baby Story' on TLC did it first, but they tend to highlight only hospital births with doctors screaming, women hooked to machines, flat on their backs and drugged to the point of delirium. I cannot watch 'A Baby Story' without wanting to throw something at my TV. Fortunately, I don't have cable, so I still have a TV.

I went to see the film with a group of girlfriends and one girlfriend's brave male partner. There were seven of us, all in the birth community, in a theater full of pregnant women, midwives, doulas and a smattering of men. A bit tragic since the film was truly preaching to the choir with that audience, but we have to start somewhere.

Here is what made me cringe:
Cara, the NYC homebirth midwife featured in the film, is not wearing gloves in three of the highlighted births she attends. Gloves, as I see it, are something everyone can agree on.
An abundance of latex gloves is a tremendous benefit and privilege of first world medicine. Even if you know a woman's health status, gloves are smart. Personally, I don't care if Cara wears gloves. This is her choice, and for whatever reason, she doesn't see them as necessary. My cringe though, was for the attack that I felt coming from the medical community. It seemed fuel for the argument that home birth midwives are untrained and unsafe. "Cara", I thought, "you knew you were being filmed. Why didn't you throw on some gloves?".

I went home with this thought. But the more I thought about it, the more my own thought bothered me. Why would I want Cara to put on gloves to give some sort of illusion to the medical community? Isn't that exactly the point? Home birth midwifery IS off the grid. We all practice differently and while the medical community attacks that, we embrace it. We see this diversity as the juice, the good stuff, in helping women choose the best possible route to having an amazing passage into motherhood.

I locate this thought in the binary between public and private, most things that occur in the body live in this space (hence, the body politic). Somehow, I want to prove to the medical community that homebirth midwifery is a smart, effective, cost efficient and SAFE way to have a baby, while at the same time remaining true to the nature and essence of midwifery which supports individual choice and interpersonal relationships. Clearly, Cara felt safe enough with these women to expose her bare hands to their bodily fluids. We should trust that. I may not make the same choice (even with my closest friends), but I support hers and her bravery in exposing that to the scrutiny of those who want to shut us down.

Perhaps more on this later. I would love to hear thoughts.

Dr. Grant's Gift to Women

I ended up at NYU hospital a few months ago after we had to transport a mama (possible placenta separation which turned out to be fine once we got there... still, better safe than sorry).
She was totally committed to continuing laboring as home birth-like as possible, so we had sort of set up shop in the L&D room. We had our oils and birth ball out and my co-partera was doing some EFT. The nurses were surprisingly great and everything was moving along as smoothly as possible (of course mama was still hooked up to all sorts of machines), when this guy walks in.

He walks past everyone in the room and comes up to mama mid contraction and says with a huge grin on his face "Hi, I am Dr. Grant and I am the Director of Obstetric Anesthesia here. Tell me something, do you find labor painful?"

Mama breathes through her contraction and then looks up at him and nods.
Dr. Grant then begins to push the epidural like a high class drug dealer. I have never seen such a hard sell. "Look, you wouldn't have an appendectomy without anesthesia would you? Why would you suffer like this? My wife had an epidural from the first pain she felt and we have three wonderful children, all c- sections, all healthy!"

After his long winded pitch and still no candy takers, Dr. Grant pulls out the big guns.
"Look" he says "have you read my book? You never heard of it? It's called Enjoy Your Labor!"
He moves quickly out of the room and returns with two signed copies of a shiny book with the image of a pregnant belly with sunglasses balanced on the front; no doubt intended to conjure up feelings of lazing on the beach with a margarita.

The proselytizing did not stop.
It was as if Dr. Grant believed he had found Gods gift to women and it was his duty to spread the word. To share the gift. It had similar feeling to those moments when well intended born agains have tried to save my soul. After several unsuccessful attempts, Dr. Grant shook his head and stated that some women just feel they need to be a martyr and left the room.

At some point, I opened the book.
Here are a few choice excerpts found on his website:



A sure way for women to expericence painless childbirth


I did not read much more. Only to the point when he says that he believes the C-section rate should be higher than one in three because it is so safe.

I have read plenty of natural birth advocacy books, and believe me, I know many are every bit as slanted towards the positives of the midwifery model of care as this book is slanted towards complete interventionist and technocratic model- however, this book just infuriates me.
It is an abuse of power and obstetrics to be so medically one sided and opinionated. It is his job to inform the patient of the risks and benefits of the procedure, not sell it like a used car.

Dr Grant, who are you to decide what importance the labor process may or may not have on a woman's experience of transition into motherhood.
And honestly, comparing childbirth to an appendicitis? What? An appendicitis is an emergency surgery. Nobody is suggesting women go into c-sections without anesthesia. But the correlation between natural childbirth and men having an organ cut out of them is beyond ludicrous.
Stating that women will be able to push more effectively with an epidural because they will have better control? Excuse me, when is total numbness a better source of control than being able to move and feel your own legs? And Dr. Grant, the medical evidence on this one is not on your side. Most studies show that women with epidurals take significantly longer to push their babies out, often leading to increased fetal distress, forceps, episiotiomy and c-sections. There is no evidence that suggests epidurals help the pushing process in any way. You just can't find it.

And lastly, on his website under 'book reviews' you have a bunch of moms exclaiming the wonders of their epidurals:

"A must for all mothers-to-be! Enjoy Your Labor dispels the myths that are all too common. Finally, the straight scoop from the best source. Thanks to Enjoy Your Labor, I was able to make an educated decision regarding anesthesia and to finally rest easy knowing I could advocate for my own pain relief." - Katie Cullen, mom, San Diego, California

I have to question using phrases like 'able to advocate for my pain relief'. Since when did women have to advocate for the right to be made numb in a labor room? It seems we haven't come so far from the Twilight Sleep era after all.

Too Posh To Push

Last week at a restaurant on the Upper East Side of Manhattan, a group of women gathered for lunch, martinis, and to discuss their Cesarean sections. There was one pregnant woman, sipping cranberry juice and seltzer, she was deciding whether or not to become a member of “Too Posh To Push”, a collective of women who have scheduled and advocate for other women to schedule cesarean sections so that they do not need to enact the ‘primitive’ and ‘uncivilized’ drama of childbirth. The existence of the “Too Posh To Push” movement makes the embodied experience of childbirth a performance necessary only for poor, the rural, or those who (gasp) chose it

Who ‘should’ be having babies, and the method in which they do, is clearly socially constituted.
By its very animal nature childbirth is a rupture of civility and femininity. It is also a physical rupture, a rupture of skin, of water, of fluid and blood, and of two bodies separating. The “Too Posh to Push” women are advocating to enact a prescribed discourse of motherhood which says that the blood, sweat, tears and moans; the fluids and sounds of childbirth are threatening to their identity and thus, the performance of entry into motherhood. Those who advocate for it promote staying ‘honeymoon fresh’, suggesting intrinsically that after being stretched out women become less desirable to their men. The childbirth ‘event’ is thus planned and carefully staged within notions of ‘good’ femininity (one can even wear makeup and not sweat it off), rather than the random, un-timable and ‘out of control’ event of natural childbirth. The women scheduling cesarean sections, separate their ‘self’, their notions of motherhood, from their bodies. The fact that the medical institution agrees to these planned Cesarean sections speaks volumes about where pregnant women are located in ‘the body politic’.

Christina Aguilera is the latest celebrity to join the club. Christina honey, labor lasts a day or two. A scar will mess up your bikini style forever.

lessons in normality

It's the last day of 2007.
Yesterday a few of the November babies I caught came to brunch at my house (yes, the parents were also invited).
A few older babies came too and we munched and sipped mimosa (well, the parents did) and as is apt to happen among new moms, everyone traded birth stories.
These are all women I have worked with who entered into giving birth within the midwifery model of care. Each woman had varying levels of success with this, depending on where she chose to give birth (a few were home, one birthing center, one hospital).
So, after some swapping dramatic tales with happy endings, somebody asks 'does anyone ever have a 'normal' birth?'
I was shocked to hear this asked in my circle of mamas! We are so conditioned to think about birth from the biomedical model that even those who escape its boundaries and have positive, self fulfilled home births, compare their experiences to the parameters of 'normal' established by obstetrics! I exclaimed very quickly that yes! you ALL had normal births! It is not abnormal for a cervix to take a pause in its dilation (even a five hour pause). It is not abnormal to go two weeks over your 'due date'. It is not abnormal for pushing to take a couple of hours. These are things the body does to get a baby out! There is nothing more normal. It is trying to place the body in a box of time management that is abnormal!
Everyone laughed and agreed.
But I had to sigh a little inside. It truly is hard to escape something so deeply engrained. It's like unlearning how to breath.
Happy new year y'all. May you all remember how very, very normal and beautiful you are!

This is like watching a train wreck