36
BIRTH 14:1 March 1987
The Hut and the Hospital:
Information, Power, and Symbolism
in the Artifacts of Birth
Brigitte Jordan, Ph.D.
ABSTRACT: As the tools of birth change from familiar household objects, such as hammocks and beds, to
high-technology objects, such as delivery tables and fetal monitors, significant changes occur in the ability to give
physical support to women during labor and in who owns the tools and the information they provide. Data derived from
the laboring woman herself are less sought after and less valued.
Ironically, high-technology procedures and artifacts are more easily transported than are the household artifacts of
birth, which are embedded in the matrix of daily life. When different levels of technology are available, the solution to a
problem during childbirth is usually sought on the next higher level of technology—i.e., medication or surgery, even
when a simpler approach, such as human comforting or ambulation, might work more quickly and effectively. (BIRTH
14:1, March 1987)
Although our prehuman ancestors must have given birth without
the assistance of tools, there is no known contemporary or
historical society where some set of material objects is not used
at birth. However, the complexity of such artifacts varies
considerably between simple traditional societies and the
technologically sophisticated obstetric systems of industrialized
countries. One question of theoretical and practical interest is,
what kinds of changes take place in social interaction and
knowledge about the birth process as technology becomes
increasingly complex and elaborated.
To address this question I contrast obstetric settings that differ in
regard to the complexity of the array of artifacts routinely used
for managing normal
Brigitte Jordan is Associate Professor, Departments of Anthropology and Pediatrics, 344 Baker Hall, Michigan State University, East Lansing, MI 48824.
An earlier version of this paper was read at the Computer//Human Interaction Conference in San Francisco, April 17, 1985.
Fieldwork in Mexico, Europe, and the United States was supported by grant #HD MH 11575 from the National Institute of
Child Health and Human Development.
birth. The lowest level of technology is found in traditional
societies before they are substantially influenced by Western
medicine. For this I will draw on examples from my fieldwork
with Maya women in Yucatan, who give birth in their own hut,
attended by an empirical midwife, family members, and friends
(1). The artifacts required are few, simple, and mostly available
in the household: a hammock or chair on which to give birth, a
rope suspended from the rafters for the woman to pull on during
labor, a sharp instrument to cut the cord, and similar
multipurpose objects.
An intermediate level of technology is exemplified by home
births in Holland or in the United States, also typically attended
by a midwife, family members, and friends. Here the midwife
brings with her tools that are somewhat specialized though still
simple, such as a wooden trumpet for listening to the fetal heart
tones.
Finally, the most complex level is seen in the sophisticated
hospital obstetrics of the United States and similarly
technologized societies, where attendance by medical
specialists is standard and
37
where there is a high degree of reliance on complex, specialized
tools. Artifacts considered necessary for proper management of
birth in high-tech situations are never supplied by the woman or
her family and are in principle inaccessible and incomprehensible to nonspecialists.
I begin by focusing on one particular artifact— the physical
support used at the time the baby is born—in order to see what
shape that artifact takes with increasing technologization. This
may be a delivery table in a hospital, a hammock or chair as is
the case often in Yucatan, the woman’s own bed, or some
improvised arrangement as tends to be the case in home births.
One major change as we go from such simple objects as a
Yucatecan hammock to a special-purpose hospital delivery table
is the diminishing degree of familiarity the woman has with the
artifact. A Mayan woman in labor uses her hammock in ways
that allow her to exploit its properties for maximum comfort.
She can lie in it on her back, on her side, even on her stomach.
She can hold onto the strands of the hammock as she pushes. Her
movement is not restricted in any way, and as she senses the
requirements of the descending fetus, she can adjust her body
accordingly. Her attendants—most likely her husband, her
mother, experienced women of the family, and the midwife—are
equally familiar with the potential of hammocks. They may give
advice about appropriate positions, and they know how to
arrange their own bodies around it so as to give her physical and
emotional support. Thus their cumulative experiential knowledge becomes available to the woman in labor and provides a
valuable resource for solving problems of comfort, lack of
progress, or pain as they may arise.
In contrast to high-technology births, attendants’ behavior in
low-technology situations is characterized by a fairly high
degree of active physical involvement, which is clearly
facilitated by the characteristics of the physical object on which
the woman rests, be that a hammock, a bed, a beanbag, or some
other arrangement of household objects. In low-technology
situations the artifact, perhaps precisely because it is a
general-purpose artifact, makes the woman’s bodily
performance and state available to all participants, and in that
way is conducive to hands-on, collaborative birthing. These
considerations are important not only for the experience of the
woman and her attendants but also from a physiologic point of
view. Dystocia, for example, can often be remedied by changes
in position, so that facilitating mobility should be an important
consideration in designing an optimal birth environment.
BIRTH 14:1 March 1987
Beyond hindering or encouraging the active participation of
others, artifacts also influence the nature and flow of information
about the event. On videotapes of Mayan childbirth in Yucatan,
an interesting communication system can be observed. The
laboring woman’s body is held by a “helper” (one of her
attendants other than the midwife), around whose neck she
slings her arms. Whenever a contraction comes on, she pulls on
her helper’s neck, with the strength of her pull constituting an
analog to the force of her contraction. The helper is quickly
recruited into colaboring, breathing and pushing with the
woman. With the woman’s body in his or her arms, the helper
acquires direct bodily knowledge of the process and its rhythm.
The midwife, meanwhile, sits on a stool in front of the woman
with a cloth-covered hand on the perineum. She will feel the
bulge of the advancing head and will convey the tactile
information she acquires by saying something like “Push, push
now, the baby is at the door.” The overwhelming impression one
gets from participating in such births is that there is a close-knit
group of people, bringing all their resources to bear on getting
the baby born. Within the collaborating group, the woman is
always central as the object of attention as well as the source of
crucial information. Furthermore, because of the absence of
specialized tools for gathering information, all parties to the
event have fairly equal access to whatever data are available
within the system.
In sharp contrast is the process of giving birth on a hospital
delivery table. The woman is positioned on a narrow platform,
on her back, with her feet in stirrups and her legs covered with
sterile drapes. She may have a support person with her, usually
the father of the child in the United States, often nobody in other
countries, unless a friendly nurse takes this role upon herself.
But whoever this support person may be, his or her interaction
with the woman is severely restricted. The nature of the table
makes it impossible to give full body support. The woman lying
on it can no longer be held in anybody’s arms. There is literally
no space for her attendant to get into the scene. At the most, he or
she can hold the woman’s hand and talk to her. The lower part of
the woman’s body, separated from the top by the sterile drapes
over her knees, is inaccessible. And it is inaccessible to the
woman herself as well. She cannot touch herself, she cannot see
what is going on, and if she has had regional anesthesia, she
cannot feel the working part of her body, either.
In contrast to low-technology situations where
BIRTH 14:1 March 1987
participants tend to be actively involved, the delivery table is
designed to reserve activity (as well as convenience) for the
medical team. The arrangement of the woman on the table
effectively demarcates the lower part of her body as the domain
of the specialist. This territorial division is enforced in verbal
and nonverbal, direct and, most frequently, indirect ways.
Usually, the woman and her support person take great pains not
to breech the territorial injunction. But if, for example, the
husband should happen to stray into the specialists’ area, he
would probably find himself redirected to his proper place,
quite possibly by reference to the fact that he might contaminate
the sterile instruments and “field.”
The frequent reference to sterility raises an interesting
general point about the artifacts of birth. They seem to have,
beyond their use value, also an exchange (or symbolic) value. I
first began thinking about this question when I noticed that in
most hospital births I observed, sterility was broken at some
point or other. Nevertheless, reference to sterility was
frequently used by the hospital staff as justification for
procedures done on the woman, as well as for behavior required
of her and her support person.
In high-technology settings, ownership of the instruments
lies with the medical staff. They are not available for touching
or handling by nonspecialist birth attendants, in some sense not
even for visual examination since the trays are covered with
sterile cloths. By contrast, in low- and intermediate-technology
births, where instruments are simple and often provided by the
woman herself, such proprietary use does not occur. As a
consequence, there is no mystification of the object, its use, and
its effects.
Magic, which in traditional societies often focuses on health
issues, is also tied to secrecy and the proprietary use of objects
and procedures. The magician knows things that others do not,
such as certain words that are uttered and the names of curative
plants. Secret (magical) knowledge constitutes a source of
power that enhances both the efficacy of the cure and the power
of the magician. In modern medicine, where there is less
emphasis on incantations and herbal cures, proprietary secrecy
instead surrounds the instruments and equipment under the
practitioner’s control. Today the mystery rests in the technology
itself. There is a hidden function of the tools of the trade that
goes beyond their efficacy; it has to do with their symbolic
function as indicators and enforcers of the social distribution of
knowledge and the power to act in childbirth.
I suspect that this symbolic function is partly responsible for
the uncritical acceptance of the fetal
monitor in high-technology settings. A fetal monitor is a very
38
expensive piece of equipment, which, once present on an
obstetric ward, tends to be used in an increasing number of
labors, to the point where in many of our hospitals its use is
routine even in normal labor. One might naively imagine that
such rapid adoption is based on unequivocal scientific evidence
as to the efficacy and safety of electronic fetal monitoring. This
has not been shown (2). Its rapid adoption may have more to do
with reinforcing technology-based control than with benefits
for mother and child. It seems that one must look beyond the
stated function of a technology to ascertain what other kinds of
business get done with it.
Transformations from low- to high technology change who
controls the information relevant to the management of birth.
We have seen the shared distribution of knowledge in
low-technology systems, based partially on prior experiential
knowledge participants bring to a particular birth and partially
on the joint access these participants have to the information
generated verbally and bodily by the laboring woman.
“Authoritative knowledge’ —i.e., knowledge treated as
consequential for the management of birth—is fairly uniformly
distributed within such systems. As a consequence, decisions
about what to do when trouble arises emerge as joint decisions.
In high-technology obstetrics, on the other hand, specialized
instruments provide a kind of knowledge about the state of the
event that is privileged. Even if support persons are present,
whatever information, knowledge, or wisdom they or the birthing woman may bring to the situation become less relevant. The
crucial information comes no longer from the woman’s
experience, the state of her body as assessed by herself and her
attendants, but rather from a set of technical procedures, test
results, and machine outputs interpreted by nurse and physician
specialists. We observe that birth participants, including the
woman, look to the machine for information about her current
state, so that the machine becomes the attentional and
interactional focus. In spite of attempts (increasingly motivated
by fear of malpractice suits) to explain to the parents what is
going on, the information on which decisions about the
management of the labor are based is located in the technology
and its user/owners.
One important difference between low- and high-technology procedures is that they have different kinds of
“mobility” beyond their own environment. Contrary to
intuition, high-technology procedures are more easily
transportable because they are not so much anchored in daily
life but, rather, are inherent in their artifacts. Transferring the
artifact, thus,
39
transfers the procedure. Low-tech procedures, on the other hand,
are embedded in a social matrix and are thus not so easily
portable. They have to diffuse through social channels. Although
one imports a fetal monitor to do electronic fetal monitoring, it
would not make much sense to import ropes from Africa so that
women could hold on to them during labor. The information
must transfuse via persons who have bodily knowledge of the
procedures, including the incidental use of artifacts therein. But
low-tech artifacts are humble, replaceable, interchangeable, and
easily procurable general purpose objects with little prestige or
commercial value. The Leboyer bath, in that sense, is a low-tech
procedure. Anybody who has seen it done can improvise one. It
matters not whether the tub for bathing the baby is round or oval,
of plastic or tin. Thus, low-tech procedures are only loosely
connected to their artifacts, while high-tech procedures are
inextricably tied to them. In Yucatan, if there is no rope to sling
over the rafters, a shawl can take its place and nobody will even
notice the difference. But if there is no delivery table in a
hospital, there will be great disruption of the procedures
normally associated with birth in that setting.
The diffusion of artifacts often owes to their symbolic value
rather than their use value. High technology tools and techniques
may become associated with progressive medicine and,
especially in developing countries, with being modern and
Western rather than backward and ignorant. In Yucatan, the
indigenous low-technology procedures for cord treatment are
not associated with high-prestige artifacts. Traditionally, the
chord is severed with a freshly cut bamboo sliver or other sharp
object and then the stump is cauterized by slowly and carefully
burning it with the flame of a candle. The rationale Maya
midwives give for this procedure is that it prevents
“convulsions” (neonatal tetanus) in their babies. Ironically, in
training courses for indigenous midwives this simple “cooking”
procedure is condemned and midwives are told to cut the cord
with scissors and to apply alcohol and merthiolate to the stump.
This is hardly high technology, but “obstetric scissors” cannot be
treated like the household scissors the women are familiar with.
They must be sterilized—i.e., handled with specialist, and
therefore arcane, knowledge. Unfortunately, sterilization in a hut
without boiling water is impossible and alcohol is clearly much
less effective than the traditional “cooking” for killing bacteria
that may have been introduced by the instrument itself. As a consequence, the introduction of what may look like advanced,
scientific artifacts and procedures may backfire, to the detriment
of newborn infants.
If we examine the use and function of obstetric artifacts on
increasing levels of technological complexity, we see a
BIRTH 14:1 March 1987
concomitant change in the location of the event (moving from
home to hospital), in personnel (which changes from
nonspecialist to specialist attendants), and in the distribution of
authoritative knowledge. Sophisticated technology introduces
new conceptions of what counts as relevant information and
new judgments concerning who is competent to interpret
information, to communicate it, and to make decisions
regarding the management of birth.
I would argue that a politicized stance that blames
physicians and medical staff for iatrogenic effects is to some
extent misplaced. Knowledge based on complex machinery and
high technology is in principle not communicable. No amount
of goodwill on caregivers’ parts could possibly solve this
problem. It is one thing to appreciate the speed of the midwife’s
ticking finger as she assesses the heart rate; it is quite another to
try to explain to a woman in labor why a set of squiggles on a
piece of graph paper requires that she now undergo cesarean
section. High technology, thus, draws in its wake a hierarchical
distribution of knowledge and social authority that reflects the
equally hierarchical social position of birth participants in
medicalized settings. Here we find the physician who controls
the technology at the pinnacle and the woman not very far from
the bottom.
Childbirth is a process in which problems of major and
minor proportions often arise. It is curious that when different
levels of technology are available, the solution to problems that
arise at one level is almost always sought on the next higher
level and rarely on the next lower level (3). For example, if labor
slows down because the woman has been transferred to the
delivery table, she is not allowed to resume the previously
effective position; rather, a remedy is sought by administering
drugs that speed the labor, or, in the extreme case, a cesarean
section is performed. It may well be that this bias for upscaling
rather than downscaling the technology is a property of
technological systems in general, to which those of us who are
concerned with appropriate technology and the design of
physiological birth environments might pay considerable attention.
Acknowledgments
Many of the ideas expressed in this paper stem from discussions
and correspondence with colleagues. In particular, I want to
thank Carole Browner, Robert Hahn, Willett Kempton, Ann
Millard, Steven Nachman, Madeleine Shearer, and Lucy
Suchman
for
their
contributions.
40
BIRTH 14:1 March 1987
References
1.
Jordan B. Birth in Four Cultures. A Crosscultural Investigation of childbirth in Yucatan, Holland, Sweden and the United
States. Third Edition. Montreal: Eden Press, 1983.
2.
MacDonald D. Grant A, Sheridan-Pereira M, Boylan P, Chalmers I. The Dublin randomized controlled trial of intrapartum
fetal heart rate monitoring. Am J Obstet Gynecol 1985;152:524-39.
3.
Jordan B. External cephalic version as an alternative to breech delivery and cesarean section. Soc Sci Med 1983; 18:637