Thursday, April 10, 2008

Western, pathological paternalism and the woman...

Pelli's mom, Randi, asked me about yesterday's post. I have my own theories about why the apparent dispute about this issue even exists in our culture.

I believe part of the problem began around the turn of the 20th Century (slightly after) when both birth and death were institutionalized. Birth gradually came under the control of a male-dominated industry and there is evidence to support this (Murphy Lawless, 1998). Physicians became the decision-makers around birth-related issues, reducing women to merely background noise throughout their own experiences of birth, where they should, rather, feel empowered and capable. In the book, The Politics of Maternity Care, editors Garcia, Kilpatrick, and Richards (1990) discuss the struggle between woman-centered midwifery and the obstetrical medical model during the early 1900s. 

Maternity care, the authors posit, is an economic and political phenomenon ( "The Business of Being Born"). Mothers have become the passive participants in an orchestrated ritual of medical intervention that often renders them helpless during their own birth experiences. "The pregnant woman became a "parturient" [sic] conditioned to jump through the flaming hoop of labor" (Kitzinger, 1990, p. 203), that "asserts the control of society over both the mother and the newborn" (Kastenbaum, 2004, p. 99). Those in power define its terms– the language, service methods, protocol, and culture of care. Soon, not just pregnant women but most of society looked to physicians as the absolute and unquestionable messiahs of medicine. And today people still do not question. Why? Piety. Because of their allegiance to the medical model and because the 'doctors know what's best for you.' *

Hershey (1985) defines paternalism occurring in situations wherein (1) the paternalistic action is intended to benefit the patient, and (2) the patient's feelings are disregarded and irrelevant. Paternalism in medicine is rooted in hegemony, and includes actions taken for the patient's own good as perceived by the practitioner, even when these are expressly against the will or desire of the patient.

True feminism-- which is often not practiced by feminists today who have aligned themselves with the patriarchal and paternalistic system and have become a larger part of the problem for women and mothers-- emphasizes the autonomy of the female body and mind, and "strongly recommends an active role for women in childbirth– many women now wish to give birth rather than passively deliver" (Doering, et al, 1980, p. 13). Yet, in today's medicalized world of obstetrical care – where a powerful medical lobby has appropriated control over all issues pertaining to pregnancy and childbirth – doctors and mammoth healthcare organizations indisputably have more power than mothers and midwives (Garcia, et al, 1990; Finch, 1982).

"Paternalism is most likely to manifest in settings where both bureaucratic and institutional pressures conspire to undermine women's autonomy" (Walsh, 2005, p. 708). "In maternity care, a gendered layer is added… it manifests, not just in withholding information and choices from women 'for their own good', but in assuming professional authority on all" maternity matters (Walsh, 2005, p. 708). When mothers and midwives then seek to change the political milieu of birth, they are often overpowered by the special interests, whereupon they typically acquiesce, compromising their positions, to appease those holding power (Garcia, et al, 1990).  It is the politicization of the female body, whereby individual women "could only hope to change things by being charming and tactful" (Kitzinger, 2003, p. 203).   Many of today's "feminists" are not only betraying the feminist heritage which seeks to empower women and mothers, but they are actually impeding those interests.  As the politically recognized representatives- voices- of women, today's feminists- instead of vehemently defending motherhood and womandom- actually deliver women into the hands of the paternalistic establishment.

So what about when the baby (or child) dies? How does this fit into the discussion? Babies and children often die in institutions, hospitals, and are most often under the care of an obstetrician or other physician. The woman is often subjected to the beliefs, values, and practice of a paternalistic archetype of birth and death that pathologizes and medicalizes a uniquely female experience:

If I were to tell you all the pain and mental anguish I experienced when my baby died, it would take hours. Although it happened 29 years ago, I have never forgotten the cruelty meted out to me under the guise of hospital regulations. As a result, I never saw my daughter, but to this day I wished I had (as cited in Peppers & Knapp, 1980, p. 53).

Authentic feminists buck the notion that "frail women [need] to be protected from the harsh world" (Weiss & Young, 1996).  Here's the issue in Western culture now: Since the time of Jean-Martin Charcot and Salpetriere, paternalism has sought to quash what is misperceived to be feminine hysteria, even when it would be a normal response under other tragic circumstances:

Not long ago, a baby's death was an unspeakable event in a hospital. Hushed silence greeted the delivery of a stillborn. The baby was whisked away before parents could see or hold their baby. They were told to forget what happened and have another baby as soon as possible. The mother was given tranquilizer if she became too upset, if she lost [control] (Leon, 1992, p. 7).

Does a mother experiencing life's worst tragedy need protection from her own legitimate experiences by those who know what is "best" for her? Should doctors have the right to dictate whether a mother traumatized by the death of her child should be permitted to see or hold her child? Is the answer to swiftly medicate a grieving mother so that her hysteria and grief do not impinge on the lives of others?

Perhaps, the most appropriate answers come from the initiates themselves. In response to the Hughes study (a study misrepresented by the media that discouraged hospital administrators nationwide from allowing mothers to hold stillborn babies) and the media's overreaction to the outcome, bereaved mothers wrote letters to editors of The Lancet (2002), later published, about their own experiences:

I lost my daughter in March, 1998. I was allowed to hold her and dress her, and was given footprints and plaster handprints… and was given the option of having some photographs taken with her. I personally feel it was the best thing for me.
- Angela McCabe, Canada

After reading the paper… I felt compelled to write regarding my personal experience. I am the mother of a full term stillborn girl who died 15 years ago. The only regret I have is not spending more time with my daughter. I was encouraged by the staff and my husband to hold her, but was very reluctant… today, I thank my husband and the staff for allowing me the few minutes I did spend with my daughter… my biggest regret has been my reluctance and the years of silence, not talking about her. The hospital did give us one photograph, a lock of hair, her measuring tape, and her hand and foot print, which I treasure clearly with no regret… Even after 15 years, talking about the death of a stillborn child is difficult for everyone, and among African Americans, it seems to be taboo.
- Deborah Brooks, United States (p. 1601).

But wait...the hospital is only the first step of intervention. Enter the medications. After all, we can't have hundreds of thousands of "hysterical" women running 'round the country, can we? Certainly, the patriarchy couldn't allow the female  hysteria of the Victorian era (more specifically, 1835 to 1900 or so, when physicians accepted the Greek idea of a "wandering womb seeking its proper place") to prevail in a civilized society.

According to psychiatrist, Elio Frattaroli (2006) psychiatric treatment, like maternity care, has also been paternalized. With the resounding qualities of a feminist analysis, Frattaroli's critique of psychiatry hinges on the objectification of patients that occurs in relationships which are devoid of intimacy and interpersonal connectedness. One example of this is the overuse of prescription medications for women.

The use of pharmaceuticals to help grieving mothers cope with normal responses is commonplace after the death of a baby. Frattaroli discusses the use of psychopharmacology to replace human relationships after difficult life experiences: "The idea that we can avoid the inherent pain and struggle of human existence, and be transformed, simply by taking a pill is a subtle but powerful dehumanizing force that undermines the life of the spirit and subverts the fundamental human quest for a more genuine transformation of the soul" (Frattaroli, 1997, p. 369). He is critical of the tendency for clinicians to ignore what people feel. He tells the story of novelist William Styron and his battle with depression that nearly ended his life in 1985:

(Styron) came to understand his own depression in particular as the result of an incomplete mourning of his mother's death when he was thirteen years old and he believes more generally that depression always originates in some profound experience of loss. "In the nethermost depths of one's suicidal behavior," he writes "one is still subconsciously dealing with immense loss while trying to surmount all the effects of its devastation" (as cited in Frattaroli, 1997, p. 96).

Styron decided to end his life after being prescribed an antidepressant from his psychiatrist. He felt more hopeless than ever, taking several days to prepare for his suicide. Unwittingly, he happened upon a piece of music that reminded him of his mother. "Flooded suddenly with poignant memories… he realized that killing himself would be an act of desecration" (p. 96).

Etymologically, the word psychiatry means healing the soul – "a healing of the soul," from the Greek psykhe– "mind" + iatreia– "healing, care." This type of healing would require a psychotherapeutic process and meaningful relationship between the patient and therapist. Frattoroli is not an absolutist who never prescribes medication for his patients. Rather, he does so judiciously and in the context of consistent, therapeutic intervention that include both one-on-one therapy and a relationship with patients.  

He asserts that by focusing on emotions such as anxiety, guilt, and shame, "we become more accepting, less alienated from ourselves" and that it is the "awareness of feeling, not thinking, that we can discover who we really are" (p. 19). Frattaroli warns against what Freud termed furor sanandi, the rage to cure. Instead, he suggests that clinicians treat with compassion, respecting culture as well as the symptoms of the patient. 

Healthcare providers should avoid paternalism because it is "incompatible with woman-centered principals" (Walsh, 2005, p. 708). They should, instead, build rich relationships that empower women to make their own healthcare choices after the death of a child, from holding and seeing the child who died to whether or not they need to stay in bed for a day, cry at work, or express their grief publicly. Physicians should facilitate rather than denigrate their maternal and feminine responses to loss and trauma, remembering that ritualization is a crucial part of the human experience, and is especially important for women (Kastenbaum, 2004) after the death of a child.


Because of the nature of my work, I have the great privilege of working with some amazing physicians such as Drs Peter Barr, Diep Nguyen, Michael Berman, Barry Schifrin, Guillermo Gutierrez, Jason Collins, and others who respect women, mothers, and their choices.  They don't practice from the ivory-tower, they abandon academic arrogance, they listen intently to their patients, they take their concerns seriously, and they act as advocates.  They recognize women as the experts of their own bodies and minds.

Guillermo Gutierrez, a neonatologist in Phoenix, even attends the funerals of babies who die at his hospital.  

These physicians epitomize the axiom of primum non nocerepri- first do no harm- and they exceed it. They are to be applauded and modeled. Perhaps, larger systemic change can be modeled after their practices vis-a-vis the larger, governing institutions. I believe in these types of analyses, it is critical to separate the individual from the institution. 
Individuals are capable of compassion and they are directly accountable to the public.

However, institutions affect the macrosystem. They hold a great deal of power which they are not reluctant to wield, yet they are incapable of compassion, respect, and they are unwilling to accept responsibility for the influence they exert on grave decisions in the political arena. They are wholly unaccountable. For example, the California chapter of the American College of Obstetrics and Gynecology (ACOG) opposed the bill in California that was overwhelmingly supported by California mothers and that would allow mothers the choice to receive a "Certificate of Birth resulting in Stillbirth (CBRS)".  

They were successful in halting the bill's progression in 2003; however, their efforts to defeat the bill were unsuccessful in 2007 (thanks to the efforts of three powerful mothers in this state) and the legislation was signed into law in October.  Mothers expressed outrage at ACOG for their assaults on this measure, yet, who was accountable? No single person could come forward as the deciding authority- as the foe of grieving mothers. After all, which kingpin is willing to accept public responsibility for denying a grieving mother what is so rightfully hers?   

Their opposition will soon be a part of the historical travesty that fades into the background and remains unspoken and unknown (though not if I can help it), while the public goes on to blindly believe that these types of bureaucracies actually serve women and their causes. These institutions, by their inherently bureaucratic nature, seek only to advance their agendas.  

Shifting blame and abdicating responsibility is also easier for a non-entity. For example, the National Organization for Women (ironic) stated on CNN's American Morning that they would not oppose the CBRS legislation as long as it was optional.  Yet, behind the scenes in many states, leaders in that institution have worked to kill the CBRS bill, using their political power to incite fear in the legislators in whom they have 'invested' well. In New Mexico, Richardson vetoed the bill, purportedly due to pressures from "women's" rights group. In another state, one legislator committed to authoring the bill; that is, until lobbyists from these groups met in his office and threatened to undermine his efforts for reelection. I don't know, but last time I checked, women were the ones giving birth.  Should (true) feminists not be championing this instead of opposing it? Oh, sorry- I forgot what I said above about some feminists "delivering women into" the very paternalistic and patriarchal systems which oppress them..

Institutions are culpable for this cultural dis-ease I describe above, in my opinion. This makes them dangerous to us as women, mothers, and individuals. Ah, this is an entirely new post for another day...


Cheryl Haggard said...

"Unless we remember, we cannot understand."
So true...My pain has been trying to get those who are supposed to be closest to me, to remember. That I don't understand... You are right when you say that you feel sorry for them, because I do. They are missing out on something great.

Your blog is beautifully written, and easily understood. Thank you for your wisdom, description and knowledge about your experience with your daughter Cheyenne. You continue to move mountains...

Kara Chipoletti Jones of GriefAndCreativity dot com said...

As a self-proclaimed feminist, I marched to protect choice for ALL women -- ALL their choices. But when I chose to keep my pregnancy and then my baby died, my "sisters" did not come to my side, did not protect my choices. It was dismaying. I've had to completely redefine myself as a person, mother, feminist, partner, woman, everything. I did not just lose my child. I lost the entire context of the life I was living previously. Thank you for doing what you do, Dr. Jo! Your research and heart gave me context again!

Dr. Joanne Cacciatore said...

Kara- I'm profoundly sorry, and I hope to be there by your side, one day, when you receive precious Dakota's recognition he so rightly deserves.

Amy Philo said...

Perhaps we should promise to campaign against the reelection of any candidate who does not support the Stillbirth Birth Certificates etc. Why would the powerful organizations out there want women to be allowed to grieve and complete the healing process? Surely they benefit more if women are made to suffer and if they are subjected to inhumane treatment from ignorant or arrogant psychiatrists. As though being in grief is reason to put a woman on drugs. You're SUPPOSED to be sad after the death of your child, that is not ABNORMAL or PATHOLOGICAL.

Thanks for this article.


The soul still sings in the darkness telling of the beauty she found there; and daring us not to think that because she passed through such tortures of anguish, doubt, dread, and horror, as has been said, she ran any the more danger of being lost in the night. Nay, in the darkness did she, rather, find herself.

--St. John, Dark Night of the Soul

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