Book Addled

Intrigue! Obstetrics? Gynecology?




An anecdote first: The male doctors who authored a couple of the editions of Williams Obstetrics had their wives complete the index. In the 16th and 17th edition the women added subversively, "Chauvinism, male, voluminous amounts, 1-1102," which is the entire book, excluding the index. I love it.

Two papers presented at a Modern Language Association conference some years ago help to situate the rhetoric dominant in Williams Obstetrics, a primary obstetrical text. The two papers, presented back to back in a session entitled “Women and Science,” formed an interesting juxtaposition. Both papers centered on the scientific gaze, the gaze Michel Foucault articulates in The Birth of the Clinic as the “gaze that burns things to their furthest truth” (120). The first paper, “Marie Curie: Radium in Hollywood” by T. Hugh Crawford, discussed Hollywood’s interpretation of Madame Curie. Crawford argued that although Hollywood’s Curie, played by Greer Garson, appeared to successfully invade the male world of technology and access science’s empirical gaze, her privilege was undercut by the audience’s invitation to gaze at her. Greer, whose portrayal of Curie was as luminous as the radium ultimately uncovered, was as much an object of observation as she was the subject of observation.

The next paper, “The Body that Bears the Fruit: The Representation of Pregnancy in Seventeenth-Century England,” by Eve Keller gave a historical overview of medicine’s role in obstetrics. Keller explained how pregnancy, the cessation of the menses, was commonly thought of as troublesome since the womb—being hidden—could be breeding either life or a disease. Keller noted that the more a woman became subject to the medical gaze—a gaze that became increasingly penetrating with later technologies such as ultrasounds and other monitoring devices—the less the woman figured as the subject/participant of her own pregnancy. According to Keller it was precisely the unknowable and uncontrollable aspects of the woman’s pregnant body that triggered increased reproductive technology.

As I thought about the two papers, I found myself wanting to conflate the ideas. Crawford, although he touched on the idea of giving birth, did not really develop the Madonna-like portrayal of Curie that Greer depicted. In fact, Curie via Greer Garson might epitomize the perfect mother. If, as Keller argued, ideally medicine desires to completely “unveil” the womb and thus be in complete control, Curie’s pitchblende functioned like an exterior womb. As Curie slowly uncovered the radium, we were able to share her gaze. Unlike hidden and unknowable wombs, Curie’s scientific womb was completely visible. Further, an exterior womb would be distinct, separate from the body, echoing the sentiment of Andreas Huyssen, who postulates that “the ultimate technological fantasy is creation without the mother.”

Certainly, in the various editions of Williams Obstetrics, there is the sense that physicians are at war with the female body and in their desire to control fetal outcome work to make the maternal body as docile as possible. As Foucault explains, “A body is docile that may be subjected, used, transformed and improved.” Although Williams Obstetrics defines its study as being concerned with “the physiological, pathological, psychological, and social factors” (19th, 1) that affect pregnancy, the twenty editions published during the twentieth-century focus more on the woman’s body and how it best may be controlled.

With the rapid increase of women physicians in the past few decades, it would be reasonable to anticipate that their entrance into a formerly male-dominated field would have an impact on medical discourse and treatment. In particular, women have “invaded” the area of obstetrics and gynecology—an area that might be considered the “women’s studies” of medicine. Since a woman’s perspective in a field centering on women’s health and reproduction is especially germane, one would expect academic texts in gynecology and obstetrics to reflect a dramatic shift in focus.

In fact, the large number of women practicing gynecology and obstetrics has not affected the rhetoric of major academic texts in the area as much as one would predict. Williams Obstetrics, arguably the “bible” of obstetrics, published five increasingly longer editions from 1980 - 2000. Despite the fact that these editions were produced at the same time large numbers of women were entering the obstetrics’ field, the many contributing authors of the various editions are exclusively male, and there is little evidence of any increased awareness of women’s needs or perspectives in the texts’ rhetoric.

Rather than adopting a more feminist stance—a stance particularly appropriate given the topic—the texts persist in discussing the pregnant woman only in terms of her body parts and physiological functions. Further, the changes evident in the last five editions reflect an increasingly defensive mode of rhetoric (in response the rising number of malpractice suits in obstetrics) and an emphasis on the advances made in reproductive technology.

In contrast, the clinical practice of obstetrics has changed a great deal. Most women now play an active role in their reproductive care and are encouraged to become educated in each facet of their pregnancy and delivery. As if oblivious to the marked changes in clinical practice, these editions of Williams Obstetrics continue to discuss the pregnant woman as a passive subject. Not surprisingly, the exclusion of a woman’s perspective in a text dealing with perhaps the most profound aspect of womanhood is also reflected in the proportion of women obstetricians in academic medicine. In contrast to the number of women practicing clinical obstetrics, only a small proportion of women comprise the faculties of academic institutions.

Of particular interest in these editions is the opening chapter, giving a broad perspective of obstetrics, and a second chapter, entitled “Human Pregnancy: Overview, Organization and Diagnosis," which appears only in the 18th, 19th and 20th editions. The other chapter discussed, “Mechanism of Normal Labor and Delivery,” appears in all five editions.

Interestingly, the word normal is used throughout Williams Obstetrics and could, quite accurately, be replaced by the word ideal since it is the normal or ideal delivery, unhindered by complications and pain, that the authors use as the model of reproduction. In contrast to the word normal, the word natural takes on unfavorable connotations. Birthing Centers and home deliveries both represent attempts at a more natural childbirth setting. While not directly disparaging birthing centers, Williams cites statistics to demonstrate their dangers and then states that “such centers should be located in hospitals” (19th 5), a move that would, of course, undo the intended effect. Home deliveries are dismissed more abruptly. Williams refers to the proponents of home birthing as a “small but quite vocal group of dissidents” whose needs should be met without “sacrificing the safety that hospitalization for delivery can provide the mother and especially the fetus-infant” (7).

Accordingly, in the ideal or normal model of reproduction, the doctors function as knowing overseers, while the woman’s body—since there’s no sense of the woman herself in this discourse—functions with complete docility. I first noted the emphasis on “docility” when I read the 16th edition of Williams Obstetrics.

My initial reactions to the text were rather divided. The text emphasizes the inherent dangers of pregnancy, an emphasis Dr. Perri Klass similarly noted during her obstetrical training at Harvard Medical School. Klass, a medical resident who studied obstetrics at the same time she herself was pregnant, began to feel that pregnancy was anything but normal: “most of us, including me, came away from the course with a sense that in fact pregnancy is a deeply dangerous medical condition, that one walks a fine line, avoiding one serious problem after another, to reach the statistically unlikely outcome of a healthy baby and a healthy mother” (49). Klass also commented on how little her training focused on anything other than the physical aspects of pregnancy: “We learned nothing about the emotional aspects of pregnancy, nothing about helping women prepare for labor and delivery” (48).

Williams Obstetrics concentrates instead on the dangers of pregnancy and thus the need for continual monitoring. The text also suggests that the ideal patient, i.e., one who trusts her doctor completely, will deliver her baby painlessly and easily. Accordingly, all five editions begin their discussion on pain with this question: “Is labor easy because a woman is calm, or is she calm because her labor is easy?” (19th ed. 371). The question itself raises a couple of implications: that easy labors are somewhat common and that labor pain is dependent on the woman’s emotional status. Since most women do experience pain in childbirth and the reasons why labor is painful seem obvious, the implication that the pain might psychogenic is startling. Oddly, editions before 1950 did not debate the reality of labor pain. The fifth edition of Williams Obstetrics—published in 1923—clearly outlined the physical cause for pain in labor and refers to the pain as “very severe” or even “almost insupportable” (254). Further, the fifth edition contradicts the suggestion that easy labors are common and states, in fact, that only in rare instances will labor will “entirely painless” (254). While the standpoint on pain in the later versus the earlier editions of Williams may seem insignificant, the shift in ideology serves to make women feel that labor pain is abnormal.

Rather than interviewing women who have experienced or were experiencing labor, the authors relied on the findings of the British obstetrician Grantly Dick-Read. Although Williams Obstetrics has faithfully been citing Read’s study since 1950, they actually use his study out of context. Read’s aim, as he explains in his book Childbirth Without Pain, was to encourage a “natural childbirth . . . a childbirth in which no physical, chemical, or psychological condition is likely to disturb the normal sequence of events or disrupt the natural phenomena of parturition” (Arms qting Read 138).

Ironically, Williams Obstetrics uses Read’s study to reinforce their contention that an ideal patient docilely trusts her doctor and any mode of technological intervention he/she might advise. Williams quotes the portion of Read’s study where “after scrutinizing many cases” in 1944, he concluded that “Fear is in some way the chief pain-producing agent in otherwise normal labor” (17th edition, 405). The entire section on pain carries a number of implications. It is evident, first of all that the authors felt the second-hand observations of a male physician were more reliable than what they could learn from women themselves. Apparently, women could not objectively assess their pain or their emotional state.

Further, though it is obviously not clear how pain and fear precisely connect since Read commented that fear “in some way” causes pain, he nevertheless cited fear as the “chief pain-producing agent.” While other physiologic events—such as torsion testicle—will cause pain whether or not the person experiences fear, the pain a woman experiences in labor must be psychological. Read then stated that this fear (which causes the pain) may occur during an “otherwise normal labor.” If the labor was normal “otherwise” a reader can only conclude that pain and fear must be abnormal responses. Indeed, in every edition but the last two, the authors also add that fear (and thus pain) “may exert a deleterious effect on the quality of uterine contractions and on cervical dilatation” (405).

The domino effect of this argument may now be observed. The nervous woman—a woman not responding appropriately to her doctor’s calming presence—will experience fear. The fear will cause pain and the pain “may” inhibit normal uterine contractions and cervical dilatation. In short, this argument suggests that a woman is responsible for both her painful labor and the resultant complications her inappropriate response may incur.

The suggestion that a woman in labor controls or causes her own pain and complications serves both to encourage a woman’s docility and dependence on technology and, at the same time, to anticipate obstetrical malpractice suits. Malpractice suits are first mentioned briefly (a reference that is less than one line) in the 16th edition’s first chapter “Obstetrics in Broad Perspective.” By the 20th edition, the first chapter’s commentary on health reform and malpractice suits covers four pages. In Williams' last three editions a new chapter has been inserted the introduction. The reorganization of the last three editions demonstrates a dual purpose. When I first noticed the insertion of a new chapter in the last three editions entitled “Human Pregnancy: Overview, Organization, and Diagnosis,” I tried to determine its function. Ostensibly, the chapter provides a historical overview of menstruation and ovulation.

In this new chapter, the authors argue that, in earlier or more nomadic cultures, women had few, if any, menstrual cycles since they alternated between pregnancy and a sustained lactation during their child-bearing years. The rhetoric describing menstruation, as also noted by Emily Martin (The Woman in the Body), is one of failure, and, in fact, menstruation is specifically referred to as “fertility failure.” As the authors note, “women are physiologically ill-adapted” to be “non-pregnant” (16).

And, again, although the authors pay some homage to the intellectual/social problems modern women face, they stress that women now “experience 450 ovulatory cycles with massive progesterone secretion and withdrawal and attendant menstruation because they have chosen infertility” (emphasis added 13). In addition to causing numerous menstrual cycles, deferred pregnancy also exacerbates reproductive complications; older women are more likely to experience infertility and/or complications with labor and birth.

While the authors express sympathy for the modern woman’s plight, the rhetorical subtext is also apparent: women choose and control their own reproductive complications; doctors work to combat these technological challenges. This new chapter, then—strategically placed just after the first chapter outlining the increase in lawsuits—serves to provide historical reasons for women’s infertility and childbirth complications, a line of reasoning that is most assuredly a caveat to women as well as textual evidence in anticipation of obstetrical malpractice suits.

The changes that were observed in the these five editions of Williams Obstetrics, then, reflect advances in medical technology often justified, in part, to address the reproductive choices and attitudes of modern women and also to counter the massive increases in malpractice litigation initiated by “overzealous attorneys in search of huge settlements” (18th ed. 6). While the increase in malpractice suits is an unfortunate reality, the text’s target is more unfortunate. Increasingly, women are to blame. In all five editions, the authors argue that women cause their own pain and, in large measure, their pain causes less effective uterine contractions and dilatation. In the last three editions, the argument intensifies: by choosing deferred pregnancy and fewer children women wreak havoc on their reproductive systems: “Infertility can be chosen; but the physiological futility that results, and the endocrinopathy that may accrue in women from this choice, is appreciable” (16). While the authors go on to lament that they are not suggesting sustained pregnancy, the argument has been launched nonetheless. Women, and it is women alone who are targeted—no mention of participating husbands or partners is ever made—have created their own reproductive mess.

Consistently, Williams offers a mechanistic model of reproduction. In “A Case of Maternity: Paradigms of Women as Maternity Cases,” Ann Oakley similarly describes the medical view of women “not only as passive patients but, in a mechanistic ways, also as manipulable reproductive machines” (65). For example, Williams’ chapter entitled “Maternal Adaptation to Pregnancy” suggests a more holistic perspective but in reality discusses the woman only in terms of her body parts, i.e., the changes in her uterus, cervix, ovaries, etc. As a major academic text, the manner in which Williams Obstetrics presents women does matter. Often, women’s bodies are viewed as “battlefields.” In Williams Obstetrics, the modern woman—who might defer pregnancy, opt for alternative birthing methods or simply refuse to adopt a docile stance—is seen as jeopardizing fetal outcome. In the words of Dr. Peri Klass, “ all too often the patient comes to personify the disease, and somehow the patient becomes the enemy” (81).



Partially adapted from a prior publication