Sunday, July 5, 2015

Midwifery, Prudence, and Protocols

Cyd Ropp, Ph.D.
As part of the naturalized ideological superstructure of Western thought, rationalism is held to be the ideal standard of reason.  Both the law and Western medicine strongly identify with the values of science and the larger philosophical agenda of rationalism.  Fortunately, midwives were never admitted to the academy in the first place, and so midwifery has remained insulated as an exclusively female prudential endeavor.  As English midwife Jane Sharp penned in 1671:
It is not hard words that perform the work, as if none understood the Art that cannot understand Greek.  Words are but the shell. . . . It is commendable for men to employ their spare time in some things of deeper Speculation than is required of the female sex; but the art of Midwifery chiefly concerns us.  (Donegan 28)
            The privileging of obstetric protocols and normative standards over midwifery's responsiveness to the particular case can be seen as a variation of the two thousand-year-old struggle between prudential reasoning and Aristotelian philosophy's penchant for rationalistic systemization.  Midwifery may thus be counted alongside the ancient philosophy of sophism as one of the prudential arts displaced by rule-based rationalism.    The art of traditional midwifery stems from an ancient worldview that privileges practical wisdom and intuitive knowledge over scientific methodology and technology-based authoritative knowledge.  Because traditional midwifery makes no attempt to demarcate itself as a medical or scientific profession, midwives are free to speak to the laboring woman's emotional, social, and spiritual needs in addition to her physical needs.    Traditional midwifery is an ancient art that not only predates Western scientism, it has been excluded and therefore insulated from Western scientism throughout history.  Because of its insular existence as an exclusively female endeavor, midwifery continues to actively employ the ancient form of reasoning known as prudence.  To seek acceptance within the conventional academic community by adopting their standards of thought and reason is to admit the superiority of patriarchal scientism over traditional female ways.
My studies have found that the midwifery model encourages the use of prudential reasoning, while the medical model encourages reliance on rationalism.  By rationalism, I refer to the employment of formal logical proofs, rules of objective evidence, and normative standards of care. 
The midwifery model relies far less upon formalistic standards and in many instances seems to violate rationalism.  For example, midwifery's reliance upon subjective intuition as a source of knowledge, as well as the midwife's holistic integration of mind/body and mother/fetus, violates rationalist principles of objectivity.  Irrationality, as I use the term, refers to using non-rational means to discern the demands of an exigency.  Using intuition, emotion, and body-knowledge to discern information, as well as acting-without-thinking--or its opposite, patiently-watching-and-waiting --are examples of non-rational modalities at work. 
  By the standards of conventional medicine, the irrationalism of the midwifery model amounts to an "anything goes" model of care, entirely without standards.  Midwifery’s counter to this charge is that, far from "anything goes," midwifery provides the most appropriate care by responding to the particular case. 
            Undiluted irrationalism, then, is not to be confused with prudential reasoning.  The midwifery model traditionally employs prudence in the management of birth.  Prudence does not confine midwifery's critical process to the irrational polarity of rationality.  Rather, prudential wisdom is the ability to range freely between rationality and irrationality in the pursuit of the best course of action to resolve the exigency at hand.  The midwifery model tends to develop and encourage irrational modalities of experience in pursuit of this goal, while the medical model tends to discount them.  It is possible that, in practice, the medical model actually employs both irrationality and prudential wisdom to a greater degree than they care to admit.
Rules and normative standards on the one hand, emerging exigency and timely resolution on the other.  Prudence involves shuttling back and forth between these positions in pursuit of the best response to the particular case.  A prudent person, therefore, lets the emerging exigency drive the application of appropriate rational norms.  The prudent person knows, usually by benefit of experience, if/when/and to what extent rationality applies to the situation.  An exclusively rational person, on the other hand, upholds normative standards and formalistic rules as the highest standard of care, and will apply those standards irrespective the suitability of their application to the particularities of the exigency. 
            The ability to employ both modes of thought, when required, is the hallmark of prudence.  In Court, juries may be instructed to hold the midwife to the "reasonable person" standard.  For the prosecution, that reasonable person standard is rationalism.  For the midwife, that reasonable person standard should be recognized as prudence.  Whereas conventional medicine claims there are no standards in the absence of rationalism, midwives actually employ an alternative standard to rationalism: prudence.
            In addition, the medical model and midwifery model radically differ in their approaches to the issue of standard protocols of care.  Medical experts are able to authoritatively declare, and usually quantify, which events shall be considered normal and which are considered abnormal at every stage of labor and delivery. 
This practice of holding patients to predetermined time standards ensures that physicians only deal with standardized norms; deviations from the norm are simply not allowed, which serves to further reinforce the artificially-mandated "norms" of the medical model.  By this reasoning, labor that progresses more rapidly or slowly than average comes to be regarded, under the medical model, as abnormal and therefore pathological.  This manner of defining pathology as any deviation from normative standards reflects what feminist Nona Lyons has identified as a more typically masculine orientation to caring--one that invokes impartial rules, standards, and principles. 
There are no hard and fast normative standards under the traditional midwifery model.  The midwifery model reflects Lyons' identification of a more typically feminine approach to caring that promotes the welfare of others on their own terms rather than through application of impartial universal standards of care.  Hospital-based midwifery care uses medical guidelines and time frames because of malpractice issues that require midwives to quite tightly follow medical protocols. In the homebirth arena, care is based on emerging exigencies rather than a predetermined "laundry list." 
While CNMs are allowed to attend homebirths, the standardized protocols they are legally required to uphold place primary agency with the absent physician and allow the midwife to operate as a secondary agent in his stead.  If the homebirth RN violates the Board of Nursing's standards by ceding agency to the birthmother rather than the absent supervising physician, her nursing license could be subject to revocation.  RNs who practice traditional, non-medicalized midwifery, in other words, necessarily lose their legal sanction to practice. California has recently loosened the supervising physician stricture for midwives, due to unavailability of backup obstetricians.
Midwives’ descriptions of the artistic aspect of traditional midwifery emphasize the manner by which a midwife intuitively responds to the unique exigencies of the particular case--by deviating from textbook recommendations through a process of "non-linear," non-rational thought.  This ability is developed through "experience" and "practice," and often results in unexpected-but-efficacious responses.  This is an excellent definition of the process of prudential wisdom.
The medical model equates the absence of fixed universal standards to having "no real standard" at all.  There is no room for the "fluid," "amorphous" response to the particular case typical of prudential rather than rationalistic reasoning.  Traditional midwifery's detractors reason that the absence of fixed standards is merely a camouflage for incompetence. 
Faith Gibson, speaking in Court in 1998 as an expert witness on behalf of the traditional midwifery model, countered the charge of camouflage by insisting that, "Births vary from situation to situation.  And what's appropriate is to respond to the specific situation." Gibson equated fixed standards with an inability to respond to exigencies on a case-by-case basis.  Gibson clearly believes that the enforcement of universal standards leaves no room for prudential wisdom--the ability to judge the best course of action for the given case at hand (Ropp).    
Conclusion
This whole-hearted recognition of midwifery's reliance upon prudence provides a contemporary site for practical reasoning and counters the prevailing belief that irrationalism and anarchistic behavior are what remain when the rationalism and protocols of medicine are not necessarily followed.  It is no accident that midwifery relies upon prudential reasoning, for historically women were excluded from formal academic training, and the entire field of midwifery, as an exclusively female endeavor, was cut off from the revolution that advanced the field of obstetrics as a medical science.  To reduce midwifery at this late date to a systematic, instrumental approach and conventional educational structure in the name of recognition and respectability not only diminishes the scope of the art of the midwife, it creates a kind of instrumental monster devoid of the capacity for prudence.  Capitulating to the dominant culture’s educational standards and methods is not the way to promote traditional midwifery and other feminine arts. Is it?
End Table:
Foundational Philosophical Distinctions
_____________________________________________________
Aristotelian, philosophic, tendency.....Isocratean, oratorical, tendency             
tame and bloodless phraseology.....powerful, elegant language
scientific rule.....opinion and likelihood
systematized medical skills.....a midwife who can acutely divine the birthmother’s thoughts,feelings,and hopes
medical mastery grounded in science.....deep midwifery
systematic, rule-based preparation..... here-and-now invention
generic pedagogy.....paradigmatic/imitative pedagogy
instrumental view of medicine.....childbirth as empowered feminine
rational, logical.....emotional, empathic
literal exactitude.....colorful, tropological speech, including humor
rule-based procedure.....prudential wisdom-based procedure
discrete disciplinary classifications.....holistic approach to knowledge
evidentiary proofs.....evidence via elegant, copious speech
abstracted topical premises.....culturally embedded; situationally responsive
fixed, precise standards of judgment.....judged by peer review

Works Cited
Cicero.  On Oratory and Orators, J. S. Watson (ed.).  Carbondale: Southern Illinois University Press, 1970.
Donegan, Jane B.  Women and Men Midwives: Medicine, Morality, and Misogyny in Early America.  Westport: Greenwood, 1978.
Garver, Eugene.  Aristotle's Rhetoric: An Art of Character.  Chicago: Chicago UP, 1994.
Lay, Mary M.  The Rhetoric of Midwifery: Gender, Knowledge, and Power.  New Brunswick: Rutgers UP, 2000.
Leff, Michael.  "Cicero's Pro Murena and the Strong Case for Rhetoric."  Rhetoric & Public Affairs, 1: 1 (1998), 61-88.
Leff, Michael.  "Genre and Paradigm in the Second Book of De Oratore."  The Southern Speech Communication Journal, 51 (Summer, 1986), 308-325.
Lyons, Nona Plessner.  "Two Perspectives: On Self, Relationships, and Morality."  Harvard Educational Review, 53 (1983): 125-145.
Ropp, Cyd C. The Rhetoric of Childbirth. Dissertation: U of Memphis, 2001.
Turkel, Kathleen Douherty.  "Midwifery and the Medical Model."  Women's Studies in Transition: The Pursuit of Interdisciplinarity.  Eds:  Kate Conway-Turner et al.  Newark: U of Delaware P, 1998.  218-235.
Warren, Virginia L.  "Feminist Directions in Medical Ethics."  Feminist Perspectives in Medical Ethics.  Eds. Helen Bequaert Holmes and Laura M. Purdy.  Bloomington: Indiana UP, 1992.  32-45.

p.s. what does learning to type up a Works Cited page have to do with learning to facilitate births?