Historically, childbirth was the domain of women only, for it was regarded as a female mystery, of which women alone had special knowledge and understanding. From the 1700s, with the rise of science and what was considered the more ‘modern’ and rational approach to midwifery theory, the old midwifery ‘ways of knowing’ were dismissed as superstitions and old wives' tales. The medical profession mostly consisted of men and they accused midwives of using ancient, dangerous and outdated practices.
In the 18th century in the Western world, the men in the medical profession, such as Fielding Ould in Ireland and William Smellie in Scotland, were gaining respect and developing new birthing theories that were based on the science, anatomy and technical knowledge (Murphy-Lawless, 1998). One of the most significant aspects of the new medical ‘science’, was the belief that the body operated like a machine. Within this discourse, childbirth was understood as a mechanical process.
During Victorian times, it was believed that women were subordinate to men in all areas of life. Men, with their superior knowledge, and being more practical and mechanically minded, were apparently more suited to preside over childbirth. Women's minds were seen as unscientific, they could not comprehend the mysteries of science, and, therefore, they could not be obstetricians in the modern world (Murphy-Lawless, 1998; Duffin, 2012). Doctors argued that danger in childbirth could arrive suddenly and, even if women were not precluded from attaining the necessary anatomical knowledge, they were ‘unfit by nature’ for all scientific mechanical employment. They could never possibly use the obstetric instruments ‘with advantage or precision’ (Donnison, 1977). This mechanical view of childbirth supported the idea that midwives – because they were women – did not have the knowledge or ability to understand the mechanisms of birth or deal with any defective mechanisms. Therefore, it made sense that the whole of midwifery would be safer in the hands of men (Ehrenreich and English, 2010).
Women were believed to be lesser in intellect than men, and were thus excluded from practising science and medicine professionally
Until the 20th century, many women were excluded from universities, teaching hospitals and from professional organisations. Medicine, like other professions, was a male preserve to be guarded jealously against incursion from the illogical, unscientific and weak women. Increasingly, over the next 200 years, faith in the science and technology available in the birth environment has led women and their caregivers to trust machines rather than women's reported experience of their own observation (Lawrence-Beech and Phipps, 2008).
From the 18th century, the rise of obstetrics and its eventual dominance over midwifery in the Western world, was achieved by the argument that those who cared for the female body could only do so by viewing it as a machine to be supervised, controlled and interfered with by technical means. Science and reason were – and continue to be – dominant in support of this approach. Initially, the scientific basis of obstetrics was limited; however, the 18th and 19th century doctors were committed to the ‘mastery of birth’. In the absence of an understanding of the process of birth, the control and management of birth were critical; childbirth and women had to be ‘mastered’.
The change in attitudes and caregivers also had an impact on the process of giving birth. The shift to male midwifery, and the associated change to the lithotomy position for birth helped to instil the idea that women were naturally passive in the process of birth and encouraged the infantilisation of pregnant and birthing women that is seen in 20th century maternity hospitals (Harley, 1993).
The medical philosophy and the midwifery philosophy are two different ways of looking at birth and the practitioners who attend it. Doctors deliver babies, and some see having a baby as something that happens to a woman, whereas midwives believe that pregnancy and birth are normal processes; therefore, midwives should assist women in birth as they believe that giving birth is something a woman does. The medical philosophy focuses on the pathology of pregnancy and birth; in other words, potential adverse outcomes, the things that could and probably would go wrong. Within medical thought, birth is only ever normal retrospectively. In contrast, the midwifery philosophy proposes that pregnancy and birth are, for most women, a normal physiological process that will require minimal intervention and only needs a supportive role, rather than an active role by the care provider.
Obstetrics is described as an assembly line production of goods; the woman's reproductive tract is treated like a birthing machine with the function of delivering the final product, the baby. The patriarchal profession of medicine is considered the leader in scientific thinking and therefore the management of the ‘machine’ (the woman) requires control by skilled operators, usually male doctors (Davis-Floyd, 1992). Although it is acknowledged that women now work as obstetricians, in this technocratic model of birth, they are still working within the patriarchal and male-dominated paradigm.
Feminist sociologist Anne Oakley writes extensively on the discourse of the body as a machine; this view produces well-known metaphors, for example, the garage analogy where the doctor is a mechanic and the pregnant woman a broken-down car. The garage is the hospital providing the tools to fix the malfunctioning parts (Oakley, 1989). The mechanical model of childbirth is not a good description of reality. The pregnant woman is much more than an ambulant pelvis; she is an individual with mind, emotions and a complex social and personal life (Oakley, 1989).
Feminist sociologist Barbara Katz Rothman asserts that within the medical model problems in the body are ‘technical problems requiring technical solutions, whether it is a mechanical repair, a chemical rebalancing or a “debugging” of the system’ (Katz Rothman, 1982). In this technocratic model, anything that goes ‘wrong’ is because the machine – the woman – is inherently faulty. In contrast to the medical model, the midwifery model presents an integrated holistic approach.
The medicalisation of childbirth in the Western world continues into the 21st century, with interventions in birth increasing. Over the past decades, the overuse of technologies such as induction of labour (IOL), electronic fetal monitoring (EFM), ultrasound, surgical births and other medicalised procedures have arisen (Kessler et al, 2006; McDougall et al, 2016; Wagner, 2006). Research shows that often the high levels of intervention are not justified, and, in some cases, the high level of intervention is actually detrimental to birthing women (McDougall et al, 2016).
The place of technology is a unique one as it highlights the difference between the techniques of watching and waiting as employed by midwives, and the intervention and pathological thinking inherent in obstetrics. The rising concern is that our increasing dependence on technology and the medicalisation of birth will erode these traditional midwifery skills. If we do not start to address these issues, the woman-centred midwife, with her trust in women and birth, may become a thing of the past and the medical machine may take over forever.