Trust, Power and Agency in Childbirth: Women's relationships with obstetricians

Abstract

[...] the inequality inherent within the woman/doctor relationship and the power of the medical model of birth renders the notion of mutual or voluntary trust problematic; therefore the relationship becomes more like one of dependence and the popular perception of women's agency or 'choice' in obstetric encounters is problematic. [...] women's understandings and expectations of birth often reflect medical ideology and are shaped by a culture of fear and ambivalence toward childbirth.

Introduction

The rhetoric of 'choice' in childbirth has become omnipresent both in Australia and internationally. However, many critics point to the complexity of this neo-liberal notion of autonomous choice in childbirth, highlighting the social, embodied and discursive constraints on women's agency in the context of a medically dominated system of institutional care (Anderson, 2004; Bewely & Cockburn , 2004; Beckett, 2005; Bryant, Porter et al., 2007; Bergeron, 2007). While women are commonly viewed as self-governing and independent, agency is often limited by the set of choices made available by obstetricians in localised cultural contexts and mediated through hegemonic medical knowledge and the workings of neo-liberalism (Bèhague, 2002; Bryant, Porter et al. 2007: 1197). Cultural ambivalence and fear surrounding normal birth in contemporary culture (Reiger & Dempsey, 2006) further complicates the notion of 'choice' in relation to childbirth, although little attention has been focused on the ways women experience these hegemonic cultural discourses within individual relationships with their obstetricians.

This paper draws on my doctoral research which examines contemporary social constructions of birth knowledge and the perpetuation of medical hegemony in popular discourse, by pregnant women and obstetricians. While the research project encompasses a diverse range of data sources including interviews with obstetricians, popular media and internet forums; the data presented here is largely drawn from interviews with 13 pregnant women. I sought to re-examine the dissonance between the feminist critique of childbirth "and the beliefs, desires, reactions, and behaviours of women" as identified in anthropologist Robbie Davis-Floyd's American research nearly twenty years ago (1992). As Kitzinger, Green et al put it: "why do women go along with this stuff?" By 'stuff' they are referring to interventions and practices such as electronic foetal monitoring, induction of labour, epidural and surgical births all of which despite lack of evidence regarding their effectiveness, or their ability to produce better outcomes for mothers and babies, continue to be routinely used in most hospital births (Enkin, 2006; Kitzinger , Green et al., 2006; Wagner, 2006).

This paper has a twofold argument: that women participating in this study enter into a relationship of trust with their obstetrician based both on their class positioning and their belief and entrenchment within the hegemonic biomedical model of birth; and that their confidence and trust in their own ability to birth without medical expertise is subtly eroded in the medical encounter as well as through cultural fears surrounding birth. I use this evidence to make a wider claim regarding the limits of choice and agency within the obstetric encounter. Women in medical systems of maternity care are not 'passive dupes' of obstetric hegemony but their autonomy is nonetheless constrained by their relationship with their obstetrician and an increasing normalisation of medical birth.

Methodology

Ethics approval was granted to recruit professional women aged over 30 with private obstetric care. These women were specifically targeted because they are the social group most likely to undergo and/or embrace technological births. In Australia and elsewhere, women in high socio-economic brackets, with private obstetric care, are more likely to experience medical intervention in childbirth than any other group (Baker 2005; Laws, Abeywardana et al. 2007; O'Leary, de Klerk et al. 2007) although, as Baker points out, this is somewhat anomalous given that this particular group of women tend to be society's healthiest and therefore the least likely to actually require medical intervention (2005:32). However, it is also for this reason that middle-class white women tend to be overrepresented in the empirical research on pregnancy and childbirth, while the experiences of women from non-Anglo and non-English speaking backgrounds are under-researched. Women were recruited through leaflets distributed at obstetricians' offices and through various internet pregnancy and birth forums. Semi-structured interviews were conducted with 13 women aged between 30 and 37 with an average age of 30.5. All were either married or partnered in heterosexual relationships. All except one were in a household income bracket exceeding AUD$100K per year and all but one had Bachelor level degrees or higher. Three women were born outside Australia in Denmark, America and Hong Kong, nine women were Australian born with Anglo-Celtic backgrounds, and one woman was Australian born with a Greek background. Women were between 16 and 32 weeks pregnant. Five were expecting their first child, six were pregnant with their second child, and two were expecting their third child. Women were interviewed once while pregnant and once following birth (one women however, declined to be interviewed the second time around). Four women had elective caesarean-sections, two had emergency c-sections, the remaining seven had vaginal births but with various medical interventions and pharmacological pain relief. General questions were asked about the sources of information about birth consulted during the pregnancy, their expectations of childbirth, their relationship with their obstetrician, decision-making and choice processes, general attitudes and beliefs about childbirth and the level awareness of contemporary media debates around choice in childbirth. The second interviews were much more reflective; I asked the women to describe the birth experience and relationship with care-givers as well as reflecting on how the birth was different or not to their expectations. Additional information and data were gathered via a private weblog created so that the women could journal aspects of their pregnancy and journey to childbirth and communicate among each other. All interviews were transcribed verbatim and then coded for key themes with the aid of QSR Nvivo software. Pseudonyms are used throughout the paper wherever names are given.

Obstetric Hegemony

The concept of hegemony is useful in relation to childbirth practices and knowledge because it helps shed light on the way an obstetric framework has been able to dominate popular childbirth knowledge as well as maternity care practices over hundreds of years despite sustained dissent and critique from midwives, activists, feminists and dissenting maternity care professionals. Hegemony is understood here as a description of the relations of power that rely on consent rather than force and that operate via ideological leadership. For example, Mumby describes hegemony as "a means to understand the processes through which certain conceptions of reality come to hold sway over competing worldviews" (1997: 343). Ideological hegemony is a powerful form of social control because of the insidious nature that dominant ideologies appear as "commonsense" or popular views of world. These commonsense views represent and legitimate existing social relations (Waitzkin, 1989; Purvis & Hunt, 1993; Fontana, 2008). Thus, hegemony is a process of struggle "over systems of meanings" (Mumby, 1997: 364).

A large body of feminist scholarship has convincingly argued that medical control and domination of childbirth has relied on the medical profession's privileged gender and class positions and its ability to monopolise knowledge production and dissemination based on specialised scientific, and therefore 'superior', expertise (Oakley, 1980; Arney, 1982; Rothman, 1982; Davis-Floyd, 1992; Papps and Olsen, 1997; Murphy-Lawless, 1998). Childbirth therefore, has been conceptualised within a biomedical framework of risk and pathology and perceived as best overseen by experts in hospitals where the emotional and psychological process of birth, and women's embodied knowledge, is devalued in favour of a professionally managed mass-production system compatible with industrial capitalist culture (Rothman, 1982; Martin 1987; Davis-Floyd, 1992; Plante, 2009).

However, traditional feminist analyses of the medicalisation and co-option of childbirth by a patriarchal medical profession have been problematised and questioned (Annandale and Clark, 1996; Pringle, 1998; Papps and Olsen, 1997; Lorentzen, 2008). It is argued that the medicalisation critique over-simplifies the patterns of power and "precludes the possibility" of women's agency (Lorentzen, 2008; 52). In these accounts, women are often presented as passive 'dupes' of self-interested, misogynistic male doctors and obstetric domination. As Pringle argues, the reality of the relationship between the medical profession and women is "a great deal more complex" (1998:43). For example, it could be argued that women contributed to the historical medicalisation of childbirth by demanding access to analgesia in the 19th and early 20th century (Beckett, 2005: 259). Moreover, feminist scholars have argued that as women are not a homogenous group, not all women are impacted in the same way by medical power (Lorentzen, 2008: 52).

Empirical research is also at odds with the earlier feminist analyses revealing that while some women experience medical birth as alienating and disempowering, many actually seek out medical intervention and management. The latter group of women are able to negotiate within the medical hegemony in order to exercise agency and control in the birth event (Sargent and Stark, 1989; Davis-Floyd, 1992; Lazarus, 1997; Zadoroznyj, 1999, 2001; Béhague, 2002; Martin, 2003). Thus, as Lorentzen argues, medical power relations can be better understood as a "process of negotiation in which women experience both benefits and costs" (2008: 52). Nonetheless, the research literature does not contradict the fundamental notion of medical knowledge as hegemonic or the assertion that women are embedded within this cultural system of understanding. Rather, it points to a more complex understanding of agency and choice that must, as Fox and Worts point out, always be understood in localised social contexts (1999; also McCallum, 2002).

Gagne and McGaughey's understanding of cultural hegemony, power and women's agency is useful (2002). In their analysis of women's decisions to undergo cosmetic surgery they argue that women make autonomous decisions but are guided by "hegemonic gender norms", beliefs and ideologies which are internalized as 'natural' and 'normal' (2002:819). Similarly, as Davis-Floyd points out, many Western women are culturally embedded in the values of medical birth - values that align with the very tenets of technocratic civilisation and which we all take part in (re)producing (1992). However, women are sometimes still able to hold some power within the system and have access to wider ranges of knowledge than just medical frameworks; thus are able to contest and resist medical power (Lorentzen, 2008; Edwards, 2005; Bèhague, 2002). While analyses of women's experiences of childbirth within medicalised systems are abundant (Oakley, 1980; Martin, 1987, Davis-Floyd, 1992; Lazarus, 1997; Fox and Worts, 1999; Martin, 2002), here I focus more specifically on the ways in which women in private obstetric care exercise their limited agency in contesting or accepting obstetric hegemony within their individual relationships with their obstetricians and with particular emphasis on the role that trust plays in this relationship (see also Zadoroznyj, 1999, 2001). As Lorentzen (2008: 54) points out "however ubiquitous medical power/knowledge may be in society" individual interactions with medical experts "constitute a more intensive engagement with medical power/knowledge" and therefore may hold "greater salience" for a patient than generalized knowledge in the wider society. Waitzkin also argues that it is often at the "micro-level" of doctor/patient interaction that discourses with ideological messages are conveyed - albeit often unintentionally as is the nature of hegemonic knowledge (1989). Likewise, in her ethnography of the private sector maternity care in Brazil, McCallum (2005: 234), argues that hegemonic medical culture is often "negotiated and imposed at a quotidian level" in everyday interactions between women and their obstetricians, hospital routines and family.

Reasons for choosing private obstetric care

Evidence-based medical researchers, governing health bodies and advocacy groups state that care for women with normal pregnancies is best overseen by midwives in low-tech settings (Goer, 1995; WHO, 1996; Enkin, 2000). Yet in Australia some 30% of women, who tend to be older and in higher socio-economic groups, use private obstetric care (Laws, Abeywardana et al., 2007). This is a higher figure than other countries with similar health care systems (Mander, 2007:61). Most women interviewed say they chose private obstetric care because they already had private health insurance and thought they "might as well use it". As Zadoroznyj's (1999, 2001) research shows, women take on a role as active consumers, "shopping around" for the right obstetrician. This was the case with the women I interviewed. However, the interviews also suggest that the reasons for choosing private obstetric care were more complex than simply a matter of pragmatics. In particular the influence of spouses, family and friends and cultural norms and expectations of what one 'should' do, were factors in women's reasoning for choosing this model of care:

I think it's just that thing about being 'just what you do' among my circle of friends.

Sandra, third pregnancy, interview 1.

I'd always had private health insurance, well I grew up with private health insurance...and I actually didn't know the alternative um methods of care. I didn't know about shared care, I didn't know about midwifery managed pregnancies. All I knew was that you had your own doctor and that you went to hospital to have your baby. And it wasn't until we started thinking about getting pregnant that I found out about all the costs that were involved and I was like 'oh' but um by that stage, 31 or 32 when I first got pregnant ... I'd decided that if I was going to have children after 30, I would go privately anyway, just cause I'm a bit of a princess

Teresa, second pregnancy, interview 1.

Some women also positioned themselves in class terms as "being able to afford the best possible care", differentiating themselves from women who face long waits, different caregivers and "less qualified staff", and whom they presumed received poorer quality care in the public system. One woman implied that private obstetric care was the choice of "educated" women-a view echoed in obstetric literature (c.f Molloy, 2005). While the importance of having one care-provider was something that most women reiterated, women's social positioning came across as an integral reason for choosing the private model of care. Most women interviewed, constructed themselves as particular kinds of women who would logically use private obstetric care. For example, some asserted that they would never choose a home water birth, or a birth centre with midwife-led care because "I'm not that kind of person" or "that's just not who I am". As Brooke put it

I was pretty resistant to that kind of, um, hippy's not the right word, I guess alternative, um, I was resistant, I didn't think I was that kind of person, and I'd hate to come across as someone pushing an agenda

Brooke, first pregnancy, interview 2.

Thus, it seems that choice of care provider was linked to particular mothering identities and class positions. Using a private doctor is tied to the women's identity as middle class, educated, privileged. In this respect they share the same "social habitus" (Bourdieu, 1977) and values as their obstetricians. This then provides the foundation of intense trust the women expressed in regards to their doctor.

Trusting the Experts

The majority of women interviewed expressed sentiments that aligned with the hegemonic medical model of birth; thus while their positioning as middle-class and educated was important, also paramount to their choice of obstetric care were views that espoused childbirth as a medical event in which doctors are the trusted experts;

I liked the idea of having medical things around me; it gave me a psychological safety blanket.

Sandra, third pregnancy, interview 1.

I don't see [birth] as a spiritual experience, no, um I see it as a medical event in your life ... I don't see it as ethereal or anything like that.

Jenna, Second Pregnancy, interview 1.

I'm not really interested in the birthing experience, I just want the baby and if I can have it pain-free, well as I suppose as pain-free as it can be, then, I will

Teresa, second pregnancy, interview 1.

Like that whole debate about women who have epidurals are stupid because they should do it as naturally as possible, because women have been doing naturally for thousands of years. It's like 'well, fine' but medicine has advanced in the last thousand years you know and I don't go to the dentist and get a drill in my mouth without an anaesthetic, so I don't want to have a baby without an anaesthetic!

Gabriella, third pregnancy, interview 1.

Moreover, all women interviewed reiterated that they trusted their obstetrician implicitly; not just in terms of their clinical expertise (although this was important too) but also as an individual person:

There's just something about his nature, that he's the kind of person that you just hung on to what he said. Um, you just trusted him ... I trusted him implicitly.

Sandra, third pregnancy, interview 1.

He's someone who's specialised and done 10 years of research and I'm figuring it out as I go a long so yeah. I'm big on subject matter experts and he knows more than me about these things, so I trust him.

Louisa, first pregnancy, interview 1.

He's very unobtrusive, he's not in your face. So basically he's there to look after you, answer questions, whenever I need him I can call him with any questions ... He's always there ... he's there just for you, to you know, guide you and stuff ...

I have the same ob again for this second pregnancy as I feel totally comfortable with him and trust him completely in this scary situation.

Kim, second pregnancy, interview 1 and blog.

I feel more comfortable being in the care of a specialist obstetrician as well. And my obstetrician is the head obstetrician of the hospital and he's a professor of obstetrics as well. I feel way more comfortable with this guy knowing that the buck stops with him and if anything ever goes wrong it always goes straight back to him anyway and if I've got him looking after me, I can't have anyone better on my side.

Gabriella, third pregnancy, interview 1.

Trust is clearly a significant aspect of maternity care for the women interviewed. Australian research has shown that women express high levels of satisfaction with the one-to-one care aspect of obstetric-led care (Bruinsma, Brown and Darcy, 2003). International research highlights the importance of trust and support in labour and birth, suggesting that continuity of care - the support of a trusted care-giver during pregnancy, labour and birth - greatly increases a woman's satisfaction with the birth and reduces the likelihood of interventions such as epidural, episiotomy and c-sections as well as shortening the length of labour (WHO, 1996; Hodnett and Gates et al., 2007). However, it is not the obstetrician's professional role to provide continuous labour support and in most cases women in private maternity hospitals are cared for by midwives during labour, whom they may or may not have met before and consequently have no relationship with. In the obstetric model of care, the obstetrician 'oversees' the labour and usually only attends the final stage of birth. Olivia, pregnant with her first child illustrates her doctor's attendance at her birth:

...yeah what happened was, the obstetrician, in that whole time I was in the hospital from 1:30 in the morning till the ob got there at about 10.20 that night to do the caesarean, other than then, the only time I saw the ob was about 1 o'clock in the afternoon for about 2 minutes...she told me than she'd be back between 6 and 7 but she never came ... I only saw her for a total of 20 minutes, not including the caesarean.

Olivia, first pregnancy, interview two.

Moreover, Olivia ended up with a different obstetrician to the one she'd built up such trust in during the antenatal period. Of the 13 women I interviewed, five ended up with an alternative and sometimes unknown, obstetrician from the one they had developed their trusting relationship with; this was due to either the obstetricians' holidays, attendance at another birth, or "personal" reasons. Olivia, had a very good relationship with her obstetrician who she'd been seeing for two years for fertility treatment prior to her pregnancy, however when she went into labour she was informed by the hospital that her obstetrician would not be coming in to see her:

M: so you didn't have your original obstetrician?

Olivia: yeah, because Dr (name) is like the head of the practice, but he's got other obs that he works with so they have like a roster where ... you get whoever is on ... I went in on a different day, I ended up with a different doctor

M: But had you met her before?

Olivia: no ... so it was a bit weird even though I knew it might be a possibility.

Other women (especially the first-time mothers) described feeling disappointed that they did not see their original obstetrician or, that they did not see their obstetrician enough during the actual labour. It seems redundant then that women place so much trust in a care-provider who does not actually care for them during labour and birth. Even so, women were reluctant to speak negatively about their obstetricians, and trust extended further than to their expertise and personal qualities but also to their general professional motives. For example, although all women were aware of the criticisms aimed at the obstetric profession, particularly surrounding the epidemic of caesareans, many women claimed that their doctor "wasn't like that" or that their doctor had a low intervention philosophy or that they wouldn't intervene unless "necessary" even when their own doctor was known for having a higher than usual c-section rate.

Gilson's (2003) analysis of trust in healthcare institutions posits that trust can become dependency in relationships that occur in the context of inequality such as that between a healthcare provider and a patient therefore constraining the agency of the patient. However where institutions have established ethical codes to protect the dependent partner, they "may also provide the basis for the emergence of voluntary trust" (2003: 1454). However, Reiger (2010) argues that while individual doctors might hold commitment to caring for women and babies, "obstetrics is clearly about more than what individual obstetricians do". Thus, while the obstetric profession has carefully constructed itself as "knights on white charges responsible for saving women and babies from the intrinsic dangers of childbirth" (2010: 6), in recent years important critics either within or close to the profession have begun to dispute this 'heroic' narrative of medical achievement (Reiger, 2010: 7). The profession has been slow to respond to evidence based practice, has manipulated research to its own agenda and has operated with a tribe mentality; covering up medical misdemeanours and often putting women's and babies' lives in danger (Goer, 2002; Perkins, 2004; Wagner, 2006; Roth, 2009; Reiger, 2010).

Epidemiologist and activist Henci Goer among others (c.f. Perkins, 2004; Roth, 2009), argues that the obstetric profession is primarily interested in ensuring the control of maternity care for their own gain. She argues for instance that in response to the growing criticism of obstetric medicine in the 1980s, the American College of Obstetricians and Gynaecologists (ACOG) waged a public relations campaign aimed at instilling the idea that obstetricians were "selflessly" doing their best at safeguarding women from the dangers of childbirth. ACOG's PR campaign and control over research publications in the 1990s argues Goer, was instrumental in upholding obstetric hegemony and thus ensured birth continued to be understood as risky and necessitating the need of a 'skilled' practitioner (2002). In Australia too, the Australian Medical Association (AMA) under the leadership of obstetrician, Andrew Pesce, has vigorously used the popular media to promote its anti-homebirth stance. In response they have been accused of using flawed research and manipulating perinatal mortality figures to advance their cause (Sweet, 2010; Meares, 2010). Submissions to the Federal Government's recent Maternity Services Review (Department of Health and Aging, 2009b) saw professional medical bodies and individual obstetricians claiming that only they had the knowledge and expertise required to preserve Australia's "excellent" low rates of maternal and infant mortality. This was used to justify their continuing control over maternity-care which was being threatened by the federal government's intentions to give midwives more autonomy (Department of Health and Aging, 2009a). In addition to the hegemonic discourses, the profession's continuing stranglehold on knowledge (Murphy-Lawless, 1998; Goer, 2002) its claim to expertise and the alignment of its values with the broader cultural values of a technocratic modern society (Davis-Floyd, 1992), and the fact that many obstetricians are male, renders the relationship between women and obstetricians extremely unequal.

If childbearing women, as the women interviewed here, share the same social class, share the same belief in the hegemonic biomedical model of birth and trust their obstetricians so implicitly-then agency or 'choice' becomes increasingly problematic. Several women in this project stated that they would "never question" their obstetrician's advice. Reiger and Taylor (2005) use a feminist psychoanalytic concept of "intersubjectivity" in the maternity care encounter to show how the "emotional space" between women and obstetricians involves domination and denial of subjective recognition and the potential for the doctor to take on the role of "father figure" (2005: 13). Thus, as Gilson argues, without a foundation for voluntary trust to make up for the lack of equality, relationships between health care providers and patients can become more about dependence rather than mutual trust (2003). The idea that women exercise 'free choice' in relation to obstetric interventions is therefore untenable- as Bergeron argues "the supremacy of individual choice [in liberal societies] validates those who already hold power" (2007: 484).

Mistrusting the birth process

Earlier research reveals that middle-class women use medical interventions to enhance or control their birth experiences and this was certainly the case of a minority of the women I interviewed; two women specifically said that they didn't care about the birth process at all and just wanted to "get the baby out". While another 2 women had opted for elective c-sections in order to achieve a more controlled and calm birthing experience after traumatic births the first time around. However, most women expressed strong desires for a vaginal birth. This confirms prior research showing that most women prefer vaginal birth (McCourt, Weaver et al., 2007). Still, there was a wide variety in women's expectations and desires in regards to pain relief and other interventions, and only one woman was adamant that she did not want any intervention at all. Of the women who expressed a desire for a normal birth, there emerged a common theme of doubt and lack of confidence in actually being able to birth without assistance. Moreover, most held strong beliefs that birth was not something that could be controlled and therefore medical intervention was always a possibility that couldn't be excluded. This was highlighted most prominently when women talked about birth plans:

But as far as formal [birth plan] like I want this, I don't want this, um I'm just going to basically take it as it comes because I can't predict anything...in talking to colleagues and family I know that birth is unpredictable

Louisa, first pregnancy, interview 1.

There was so many people I knew who had like a birth plan and said 'I'm not going to do this and I'm not doing that and I'm going to [have] dolphin music and... like really specific ideas about what they wanted and nobody actually ended up with that so I just thought that planning for a birth just seems ridiculous really in a way... you can only plan to an extent. So we just went into it with it...you just don't know.

Jenna, second pregnancy, interview 1.

Three women described how their doctors dismissed their birth plan anyway - this was even from the supposedly "low intervention doctors". For example Sandra's doctor told her to "forget it" in response to a question about a birth plan and that as far as he was concerned the "plan is to get the baby out". Jasmine's obstetrician told her that "only women who don't trust us use birth plans [and doulas]". Jasmine, a health professional in the maternity field, claimed that she'd often seen obstetricians "scoff" mockingly at "silly women's" birth plans, so she knew that even if she wrote one it "would mean nothing". Sally, pregnant with her first baby, wrote a birth plan however she says her doctor "didn't even look at it" telling her to "give it to the midwife". In this way, medical authority is reinforced and women's autonomy is undermined.

Several women based their views concerning birth plans on the experiences of family and friends. For example Brooke's three sisters all had emergency caesareans, thus she felt that "you never knew what could happen" and there was no point being prepared for a "certain kind of birth because you might not get it". However, their views also reflected obstetric ideology, where birth is understood as always potentially catastrophic and risky. The medical submissions to the Maternity Services Review in 2009 (Department of Health and Aging, 2009b) for instance were rife with assertions that birth is unpredictable and that therefore we should not assume that women are able to birth without medical assistance. May Lee & Kirkman's (2007) analysis of caesarean discourse showed that contemporary medical discourse centred on the assertion that "more women need caesareans today than ever before" and that vaginal birth was inherently risky and unpredictable while caesarean birth was safe and predictable (2007; 454; see also Bryant, Porter, et al, 2007). Like many health professionals concerned about the rising c-section rate, Lauren Plante, an American obstetrician and critic of what she terms "industrialised" childbirth, argues that surgical birth is in danger of becoming the norm as the "definition of normal becomes ever narrower" (2009:144). Women's assertions then about vaginal birth being unpredictable reflect 'commonsense' assumptions based on a hegemonic understanding of birth - medical birth has become the 'norm'.

This norm was often reinforced in the women's individual interactions with their obstetricians both in the antenatal period and during labour birth. Women described interactions in which doctors continually showed doubt and fear in women's bodies. For instance, some women were told during pregnancy that their pelvis might be too small (although this can only be ascertained through a vaginal birth attempt), or that their babies might be too big or that their baby was in the "wrong" position. Others were given a percentage of possibility for normal birth (i.e. Sally was told 'you have a 70% chance of delivering vaginally', presumably as the national c-section average in Australia is 30%). Sandra, pregnant with her third child and planning for her third caesarean had been seeing the same obstetrician for eight years; her story demonstrates how confidence in birth can be subtly eroded. Her first pregnancy resulted in an emergency c-section for 'failure to progress' due to her baby being too big for her pelvis. She had considered a vaginal birth after caesarean (VBAC) for her second baby but was constantly put off by her obstetrician who told her her pelvis was probably too small, that she probably only had a 3% chance of 'delivering' vaginally, that "I had too much amniotic fluid, I was getting too big, too quick. I was getting all kinds of things ..." Sandra was finally told at 38 weeks to have an elective c-section because her baby was breech. However when the baby was pulled out at the c-section, it turned out he wasn't breech after all. It was apparent from the interviews with Sandra that she had little faith in her own body; she was disappointed with not being able to birth vaginally, especially as she'd been so fit and healthy prior to birth:

I had myself prepared for a vaginal birth. The thought of a caesarean, I think because my pregnancy had gone so smoothly ... everything was going beautiful, my BP was ok, I was teaching, I was a personal trainer and teaching 6 hours of aerobics twice a week or something like that, you know I was quite fit, there was no reason, that I was aware of, that I couldn't have, that, you know that things would go wrong. I still kind of regret, not so much regret, I don't like the fact that I can't [have a normal birth] but you know, on an intellectual level I know that I can't sort of thing

M: and what do you think that regret is about?

Sandra:I don't know, just ... expecting something that I could never have...it would have been nice if I could have and it's a bit sad ...

Sandra says she "had no choice" but to have a c-section for her third pregnancy and she expressed a lot of anger at other mothers, media and family who she says unfairly put pressure on women to have a "natural" birth making her feel "inadequate" and less of a mother. Like Sandra, other women's confidence to give birth without intervention in subsequent births was eroded due to their first highly medically managed birth experience. Scarlett described what has been called the "cascade of intervention" (Goer, 1995) that occurred during her first birth. The cascade of intervention refers to the iatrogenic affects of medical interventions in birth. For example induction of labour can result in more painful contractions and foetal distress, which then require further medical intervention. Scarlett was induced at 41 weeks and although she had planned an active labour using movement, yoga, breathing, massage and other non-pharmacological pain relief, she ended up being hooked up to a monitor, unable to move and suffering intense contractions due to the syntocin drip. The labour resulted in highly traumatic forceps delivery, post-partum haemorrhaging and vaginal surgery. This experience led her to believe that women place too much emphasis on "natural birth":

The first time I had quite a narrow idea of what my perfect birth experience would be, and I really wanted that outcome; a natural, active birth with lots of movement, hopefully no drugs, that natural euphoria of your own body's endorphins; and for my baby to come into the world with minimal interference. I have since decided that although the process is still important to me, there are factors that I can't control and so I don't want to set myself up for disappointment or put undue pressure on myself.

Scarlett, second pregnancy, blog entry

Scarlett didn't blame the medical system, the hospital or her doctor for her traumatic birth experience; she blamed instead the "ideal" of "natural birth". Scarlett decided on an elective caesarean for her second baby based on the advice of a new obstetrician. She was very happy and "relieved" following the c-section that she'd made the right decision. Other women described how their doctors allayed fears they might have had about birth by suggesting more intervention. Such as Gabriella, who had a very bad physical reaction to an epidural (in a previous birth) but was "terrified" of the pain of labour. Gabriella's doctor had advised a c-section however she says she was more "terrified" of being "cut open" than she was of the epidural's effects. Therefore, in consultation with her doctor and an anaesthetist, they had come up with a plan which involved other drugs to counteract the negative effects of the epidural which was to be given to her at 3cms dilation and regularly "topped up". While Gabriella stated that she was well informed and comfortable with the decision, and was able therefore to exert some agency in this process, her choices were limited to the medical options on offer. The tendency of obstetricians to pathologise birth or offer 'choice' within the confines of perceived risks does not give women any confidence in their ability to birth (Bewely and Cockburn, 2004: 197). Midwifery researcher Lynne Staff's (2006) Australian research with women who request elective caesareans, found that women's fears about vaginal birth were often compounded by doctors who do not discourage women's decisions or counsel them about their fears, but instead reiterate the alleged 'dangers' of vaginal birth (also Bryant, Porter et al, 2007). However, as Schuecking, Rothman and Hellmers put forth "women who are requesting a caesarean section....may well be requesting support, information, advice, care and attention" which is probably better provided by independent midwives in community settings, rather than by surgeons in large institutions (Schuecking, Rothman and Hellmers, 2007: 6).

I am aware that I have focused here on the stories of women experiencing their second or third pregnancy and birth. For the first time mothers, the relationship of trust with their obstetrician in conjunction with the erosion of trust/belief in normal birth was also of paramount importance during labour and birth; all of the first time mothers in this project ended up with some kind of intervention in their births - including two who had emergency caesareans. However in the limits of this paper, I am unable to explore their stories in further detail.

'Ideal' birth?

Like Scarlett, other women also discussed natural or normal birth as an "ideal", a "view" or a "philosophy" rather than a real physical reality, again reinforcing the commonsense notion of medical birth as the norm (discussions on mainstream pregnancy and birthing forums also construct women's desires for normal birth as idealistic see fore example http://www.essentialbaby.com.au/forums). Some researchers have argued similarly, that the 'natural' birth discourse of feminists and consumer advocates sets women up with unrealistic expectations about birth, and to thus feel like failures when their pregnancies end negatively or result in highly technical births (Crossely, 2003; Layne, 2003; Frost, Pope et al., 2006). However, while this critique has many valid points, it is also somewhat problematic. Institutional structures and iatrogenic practices contributing to women's negative experiences of childbirth and resulting in over-medicalised births are overlooked and instead the 'idealistic' discourse of feminists and birth activists is blamed. It might be more useful to examine the role of neo-liberal discourse and the emphasis on "self-determination" (Layne, 2003:1889) which has meant that the message of the women's health movement has had the "unintended consequence" of making women feel responsible when pregnancies do not go according to plan (Layne, 2003). Blaming feminist 'idealism' also ignores other important cultural factors. For instance, there would appear to be cultural shift in the way women view their bodies and childbirth-discussions on mainstream internet pregnancy/birth chat forums also show a decline in women's confidence to birth without medical assistance.

Reiger and Dempsey discuss the ways in which a "culture of fear" surrounds childbirth in contemporary Australian society. This has resulted in the erosion of trust in childbirth on both cultural and individual levels (2006). They argue that as social processes have direct material/bodily outcomes, in contemporary culture anxiety and loss of confidence "can be seen as producing a normative frame of reference that becomes internalised and, most importantly enacted by individual women" (2006: 6). Germaine Greer noted this loss of confidence when she argued, in the context of the elective caesarean debate, that after years of misogynist medical ideology telling women their bodies were flawed, it was little wonder that women were rejecting normal vaginal birth entirely (Greer, 2004). As social historian Jo Murphy-Lawless argues, the practices and discourses arising from the medical model of birth sustain obstetric knowledge and power structures, but they also produce the subjectivities of women birthing in this model (1998). Thus, the hegemonic norms of childbirth literally become embodied in birthing women in our culture (Reiger and Dempsey, 2006).

Before concluding, I will retell Jasmine's story as it demonstrates the way in which hegemony is never stable and that hegemonic norms and practices can be contested. Jasmine, as mentioned above, was pregnant with her first child and previously worked as a medical specialist in the maternity field. Jasmine's situation was unique: as a medical professional she is enmeshed within the medicalised framework of birth. Jasmine noted that her work colleagues and friends did not put much faith in the normal birth process and often derided women who "insisted" on "natural" birth. She had also learnt "on the job'" that birth can be "dangerous sometimes". However, Jasmine was conflicted by her own ideas that women can birth without intervention and have been "doing so for thousands of years", even joking that she would ideally like to give birth "in a forest". Jasmine had family members with interests in Eastern medicine and her mother was very positive about "natural" birth claiming that "women just have babies, simple". Jasmine had considered a homebirth or having her own independent midwife with her in hospital but was concerned about what her obstetrician and colleagues would think of her. She decided to undertake a 'hypnobirthing' course but kept this secret from her obstetrician and friends/colleagues. The Hypnobirthing taught her meditation and breathing techniques and offered a more holistic approach to childbirth that was "much more positive...than the hospital antenatal classes which were all about what could go wrong". Jasmine described the relationship between herself and her doctor as "collegial" and involving "a lot of respect", however kept many of her feelings towards childbirth hidden from her obstetrician.

Jasmine's labour was very long but with the support of her husband (also a medico) she endured the birth using the techniques she'd learnt in the hypnobirthing course. She was continually offered drugs by both the midwives on duty and her obstetrician but she resisted all these offers, confident with the knowledge she'd gained from hypnobirthing, that her body "could do this". She also said she declined the electronic foetal monitor which would have restricted her movements and made her focus too much on the baby's heartbeat rather than her own body:

... it was great and I don't think I would have got through it if I was on the monitor and on a drip, I think I would have felt even more disempowered. The fact was I didn't have any of that so I was, everything that was happening to me was completely natural and was what my body was meant to do. I felt that the whole time, except for the last hour and half when I was like what's going on? It's been too long, even though labour had gone on for hours and hours and hours, I felt like everything was going on as it was meant to.

Her confidence wavered when her obstetrician and midwife kept implying that they could "help" the baby out with forceps; her obstetrician had already "scrubbed up" in preparation. In the end, Jasmine agreed to the forceps delivery and episiotomy. However, she maintains that if it were not for her hypnobirthing course:

I would have a c-section ... the thing was I got a lot of information from the Hypnobirthing...I think for me, if I hadn't have done the hypnobirthing, I would have been induced or I would have gone to the hospital earlier and I would have had an epidural. It was hard enough for me to resist that route, let alone for someone who hasn't done the hypnobirthing.

I spoke to one of my friends who is an obstetrician and she said 'I'd really like to have a natural birth' but she said 'but I know it's hard to go against the status quo' and all her colleagues had epidurals and c-sections and stuff like that and I said 'look I think you become your best self in your labour'. I was really encouraging other techniques and all that kind of thing. So I think I've changed from before the birth in not wanting to tell anyone about it, I'm not afraid now that I've been through it to be honest about it, and it is such a natural, amazing thing, the whole thing was so amazing, well that's how I feel about it anyway. My body just did what it had to do and I just went into that mode in labour and I wouldn't have wanted to interfere with that process.

Jasmine's exposure to an alternative model of knowledge allowed her to contest and resist the norm despite being professionally emerged within a medicalised framework. As a consequence she was able to make choices that reflected a wider frame of understanding, outside of hegemonic constructs. However, what is also important in Jasmine's story was that that she and her obstetrician "were equals" and therefore she felt her wishes during labour were largely "respected". Jasmine was able to have more of a role in the decision-making because she had the strength to "go against the status-quo" (hegemonic norms) but also because there was the "true foundation for voluntary trust" that Gilson discusses (2003).

Conclusion

This paper has argued that women who participated in this research trust their doctors but mistrust the birth process. The women interviewed enter into this relationship of trust based on their belief in the hegemonic medical model of birth and their social positioning and identity as middle-class, educated women. However, the inequality inherent within the woman/doctor relationship and the power of the medical model of birth renders the notion of mutual or voluntary trust problematic; therefore the relationship becomes more like one of dependence and the popular perception of women's agency or 'choice' in obstetric encounters is problematic. Moreover, women's understandings and expectations of birth often reflect medical ideology and are shaped by a culture of fear and ambivalence toward childbirth. These fears and beliefs are reinforced in individual interactions with obstetricians, again constraining women's options and experiences.

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Camp, Monica. "Trust, Power and Agency in Childbirth: Women's relationships with Obstetricians." Outskirts: Feminisms Along the Edge vol 22 online http://www.chloe.uwa.edu.au/outskirts/archive/volume22/campo