Birthing While Black: A Critique of the Technocratic Model of Birth and the Potential of Doulas in Addressing the Black Maternal Health Crisis

Posted on by BUJPH
pregnant belly

Author: Sydney Fisher

Introduction

When 26-year-old West Bronx resident Amber Isaac became pregnant with her first child, she dreamed that she would not survive the delivery.1 Ridden with anxiety, Isaac spent time reading about maternal death, particularly regarding Black women in the United States where she learned that Black women are two to six times more likely to die in childbirth than white women depending on where they live.2 On April 20, 2020, doctors induced labor, and on Tuesday, April 21, 2020, Isaac’s fear became a reality. During an emergency C-section, as doctors delivered her baby boy, Elias, Isaac’s heart stopped, and she bled out.

Amber Isaac’s story is not an anomaly when it comes to the Black birthing experience. From 2007-2016, the United States overall pregnancy-related mortality ratios (PRMR) was 16.7 pregnancy-related deaths per 100,000 live births, with Black birthers experiencing higher PRMRs than any other racial or ethnic group at 40.8 per 100,000 live births.3 These numbers paint maternal health in the U.S. quite clearly: Black birthing people are the most severely impacted by the maternal health crisis.

Birthing in a traditional hospital setting may not always be in Black people’s best interest. Emerging research is showing that Black birthing people who choose alternative models of birthing may fare better than those who choose to birth traditionally.4 This paper aims to analyze and critique the technocratic model of birthing, a model that is managed by physicians as technical experts addressing what is viewed as technical problems of the body, while also considering alternative models of birthing, specifically doulas who are a type of trained professional who supports the birthing person throughout the entire birthing process.5,6 I will argue that alternative models rather than the technocratic norm show potential for reducing disparities in birth outcomes among Black birthers in the United States by looking at the outcomes of rates of cesarean section, low birth weight, and the intent and initiation of breastfeeding. Through this paper, I present a case for creating safe and equitable birthing experiences by moving away from the technocratic paradigm and embracing more holistic alternatives.

Racism and Black Maternal Health

The reason for racial disparity in maternal health can be traced back to racism. Fang and colleagues (2000) utilized death and birth certificate data from New York City from 1988 through 1994 to assess maternal mortality. The findings of the study showed that socioeconomic factors such as marital status and educational attainment had little impact on the maternal mortality rates among Black birthing people.7 This study’s findings are particularly important because they reveal a truth about the Black maternal health crisis: racism has everything to do with disparities in maternal health. Factors such as income, education, and access to health care cannot fully explain the Black-white divide in maternal and infant health. Even once controlling for other social determinants of health, due to racism, disparity persists.

Medical Racism

Racism extends itself into the structures of society, including into institutional practices in medicine. In an ethnographic study conducted by Khiara Bridges, Bridges sought to examine racism as a cause for disparity in maternal and infant health.8 The research explored the ways in which racism contributed to the disparate rates of maternal mortality that is seen among Black birthers. Bridges draws on the concept of “racial folklore,” which consists of beliefs about Black people’s obstetrical and gynecological hardiness. Black birthers are believed to be unrealistically durable and capable of withstanding pain, and thus are relatively unaffected by the pains of labor and childbirth.8 This idea of “obstetrical hardiness” is also rooted in the broader philosophy of the “primal nature” of Black people, which sees the Black body as a “primitive human type that is biologically and psychologically different from civilized man.”9 Within this notion of the “primal nature” of the Black body includes the idea of the primitive pelvis or that the pelvises of Black birthers are better suited for birth and complication-free delivery of the infant.9 This assumption that the Black body is suited to experience trauma may help account for the disproportionate rate at which Black people are subject to harsh procedures, dismissed of pain, and ultimately denied pain-relieving interventions.

Ideas of obstetrical hardiness and the primitive pelvis do not exist alone in terms of beliefs of the Black body. Instead, there are long-standing fallacies about biological differences between white and Black bodies still believed today among physicians. For example, a 2016 study on racial bias in pain assessment and false beliefs about biological differences between Black and white people found that out of 222 medical students and residents, half of them believed that Black people had fewer nerve endings than white people and that those nerve endings were less sensitive than white people’s.10  The medical students and residents ultimately concluded that Black people felt less pain than white people.10 Here, it becomes clear what Bridges names as a cause of racial disparities, particularly in maternal and child health–physician racism. Within medical institutions, physicians often harbor false, racist beliefs and biases that can result in Black patients receiving inferior care and ultimately can kill Black people.

The Technocratic Model of Birth

While racism contributes to disparate birth outcomes, it is essential to consider the context in which this racism exists in medical institutions—the technocratic model of birthing. In Feminist Theory in the Study of Folklore, anthropologist Robbie Davis-Floyd writes about the technocratic model of birth, a process of childbirth that is mechanistic.5 The data for the article was obtained through interviews with 100 mothers and many obstetricians, midwives, and nurses in Chattanooga, Tennessee; Austin, Texas; and elsewhere in the United States. In terms of demographics, the majority of participants belonged to the middle-class and were considered “mainstream” American citizens, with no information on race or ethnicity. These demographics reveal a limitation for this paper, which is focused on the Black birthing experience; however, the technocratic paradigm analysis may be applied more intensively to such marginalized populations as noted by Davis-Floyd.

In the article, Davis-Floyd found an exaggerated dependency on technology that stems out of fear of natural processes which has led to an intense ritualization of birth. Under the technocratic model, the medical institution reigns supreme over the individual and the metaphor of the human body, particularly the birthing body, as a machine emerges.5  The technocratic model asserts that as a machine, problems in the body are technical problems that require technological solutions. This assertion about the body rests on the conceptual separation of body and soul and the idea that the birthing body is inherently abnormal and defective, thus needing manipulation in birth.5 In accordance with this body-as-machine metaphor, the birther’s reproductive tract is treated like a birthing machine by skilled technicians. The development of tools and technologies to improve the supposedly defective and dangerous process of birth came from these assumptions and assertions about the birthing body.

Moreover, within the technocratic model of birth, the birthing process’s most desired result is a new member of society, the baby, with the birthing person as a secondary by-product.5 Physicians in hospitals are trained to produce a healthy baby, and the quality of the birthing experience remains an afterthought. With this baby-as-product phenomenon emerges the conceptual separation of the birthing person and baby, which parallels the body-soul divorce.5 Here, the technocratic paradigm suggests that the birthing body is merely a stage on which physicians, as technicians, can produce a baby, demonstrating conceptual ownership of that product. The hospital produces the “product” rather than the birthing person under the technocratic model.

Perhaps the most important component of the technocratic model of birth is the exaggerated dependency on technology through the birthing process. Within hospitals and this model of birth, there is a “basic model of high-technological intervention.”5 This pattern can be seen in the electronic monitoring of laboring people, analgesics, pitocin, epidurals, and perhaps most dramatically in rates of cesarean section (c-section). According to CDC birth data from 2018, 31.9% of all deliveries were by cesarean section.11 However, the World Health Organization presents an alarming contrast suggesting that the optimal rate of cesarean section is around 10 % to 15%.12 Some cesarean sections may be necessary due to complicated and high-risk pregnancies13,  but the comparison of the actual c-section rate to the optimal rate shows that some interventions are unnecessary and that birthing people, institutions, and physicians remain dependent on technology.

Implications of Racism and the Technocratic Model of Birth on the Birthing Body

While Robbie Davis-Floyd’s study did not include demographic characteristics, the assumptions of the technocratic model of birthing may have even more intense implications for Black birthers. For example, the body-as-machine metaphor may be applied more intensely to Black birthing people, especially with its assertion of the body as a defective machine needing intervention. While the technocratic model already dehumanizes the birthing body in this regard, racist fallacies surrounding the hardiness of the Black body assert that the Black body is even more defective than perhaps those of other birthers. As a result, the Black birther may be subject to more unnecessary interventions based on the false views of an abnormal body.14,10

The technocratic model also feeds into notions of how medicine sees its objects. That is, the technocratic model sees the Black birther as just that, an object with the only goal being extracting a healthy baby out of that object.15 The body-soul divorce of the technocratic model serves to show how the way medicine and racism both see the Black body works to further dehumanize the Black birthing body, ultimately resulting in the disparate health outcomes among Black birthers. Thus, the technocratic model of birth can harm the Black body by dehumanizing, devaluing, and disempowering the birthing person; however, the model does not work on its own but rather is compounded by pervasive racism in the United States.

Alternative Models of Birthing

As seen through the implications of the combined effect of racism and the technocratic model of birth, technical solutions may not always be in the best interest of Black birthers, and the potential for alternative models of birthing to improve the birthing experience and outcomes of Black birthers becomes increasingly relevant. The presence of doulas will remain the focus as an alternative to the technocratic model. According to DONA International, the world’s first doula certifying organization, a doula is a “trained professional who provides continuous physical, emotional and informational support to a mother before, during and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible.”6 By providing physical, emotional, informational, and partner support, doulas have been increasingly linked to having a positive impact on the well-being of both the birthing person and the baby.4

Evidence on Doulas

In moving towards alternative models of birthing, emerging research has begun to show that birthing with a doula often leads to better birth outcomes by looking at three specific outcomes: rates of cesarean section, low birth weight (LBW), and the intent and initiation of breastfeeding.

Rates of Cesarean Section

In the United States, cesarean sections are one of the most common procedures, with rates increasing from 20.7% of U.S. births in 1996 to 32.9% in 2009, an overall increase of 60%.16 Within these rates, however, are racial and ethnic disparities. In one study, David C. Aron and colleagues set out to assess the association between race and cesarean delivery rates after adjusting for clinical risk factors, such as maternal age and complicated pregnancy, that increase the likelihood of cesarean delivery.14 The study found that the odds of cesarean delivery were substantially higher among Black birthers than white birthers. Additionally, the racial disparity was largest among birthers with the lowest clinical risk, so high-risk pregnancies among Black birthers are not a cause of the divide.14

However, as Black birthing people are subject to cesarean deliveries at higher rates than non-Black birthers, available evidence on doula services suggests they could be an essential component in addressing these inequities. Gruber and colleagues sought to compare the birth outcomes of two groups of socially disadvantaged birthers at risk for adverse outcomes.4 One group received pre-birth assistance from a certified doula, while the other group was not selected to work with a doula. The sample of the study was composed of 226 birthing people, 129 of which gave birth without the assistance of a doula, while 97 worked with a doula. 78.9% of birthers without a doula and 77.3% of those birthing with a doula identified as African American. The study found that rates of cesarean birth were higher for non-doula assisted birthers with a 24.2% c-section rate compared to 19.6% for doula assisted birthers.4 The results show that birthers who were matched with a doula experienced lower cesarean section rates than those who were not matched with a doula, thus providing evidence for the positive impact of doulas on birth outcomes for Black birthing people.4

Furthermore, a systematic review of 22 trials of nearly 16,000 subjects done by Cochrane, a nonprofit network of independent researchers, assessed the effects of continuous care by a doula.17 The study found that birthing people with a doula were 39% less likely to have a cesarean delivery than birthing people who did not birth with a doula.17 The impact of doulas was also strongest when the doula was not a part of the hospital staff, as medical institutions are a notable part of the harmful technocratic model. Again, this study shows doulas can help to reduce c-section rates, which may have meaningful benefits for the birth outcomes of Black birthing people.

Low Birth Weight

Black birthing people also birth more low birth weight babies compared to non-Black birthers. In 1980, 6.8% of infants born in the United States weighed less than 2.5kg; however, the low-birth-weight rate among Black babies was 12.5%.18 To observe the differences of birth weight among different ethnic groups, Shiono and colleagues conducted a study analyzing differences in mean birth weight and low birth weight among Asian, Black, Hispanic, and white birthers who were enrolled in the Northern California Kaiser-Permanente Birth Defects Study, a prospective study of 29,415 pregnancy outcomes obtained from computer tapes containing information on Kaiser hospital admissions. Of the 29,415 women included in the analysis, 69.7% were white, 10.4% were Hispanic, 9.2% were Black, and 3.6% were Asian. The study found the rates of LBW varied by ethnic group, with Black birthers having the highest rate of 7.70% compared to the lowest rate among white people at 3.55%. Compared to white infants, the relative mean difference in birth weight was estimated at -246g for Black infants. Moreover, after control for the effect of factors such as marital status, education, maternal age, parity, sex of baby, cigarette and alcohol usage, history of miscarriage or stillbirth, and maternal prepregnancy height and weight, the odds ratio for a low-birth-weight infant was 2.41 for Black people, meaning the odds of having a low-birth-weight infant are 2.41 times greater for Black birther compared to white birthers.18 The findings of this study exhibit that racial disparities in low-birth-weight babies exist.

Conversely, the data on doulas presents evidence that their impact may be helpful in reducing low birth weight. The aforementioned study that provided evidence for the impact of doulas on rates of cesarean delivery also examined low birth weight as an indicator of the evidence of doulas on healthy birth outcomes.4 Non-doula assisted birthing people were four times more likely to have a LBW baby compared to birthers who were assisted by a doula.

Adding to the evidence on doulas is a New York City based program, By My Side Birth Support Program (BMS), which offers free doula services in Black and Latino neighborhoods of Brownsville, East New York, Bedford-Stuyvesant, and Bushwick.19 One study utilized data from the program to assess the impact of doulas.20 Between 2010 and 2015, BMS served more than 560 birthing people, and 489 infants were born. Within this group, 84.7% of births were assisted by a doula, and demographically participants were mostly non-Latinx Black (59%). The analysis of the program found that BMS participants who birthed with a doula had significantly lower rates of low birth weight (6.5 vs. 11.1%, p=0.001).20 These findings suggest doula support among disadvantaged populations may contribute to lower rates of LBW babies.

Intent and Initiation of Breastfeeding

The initiation of breastfeeding is also often a strong indicator of both maternal and child health. Research on the importance of breastfeeding indicates breastfeeding can be protective against child infection, malocclusion, obesity, and diabetes as well as be protective against breast cancer and improve birth spacing in nursing people.21 However, there are significant differences in breastfeeding indicators in Black and white populations. According to the CDC 2011-2015 National Immunization survey of children born between 2010 and 2013, breastfeeding initiation rates were significantly lower among Black infants than white infants22, showing racial differences in breastfeeding practices.

Evidence suggests doulas may reduce these differences in breastfeeding. A 2008 study looked at a hospital-based doula program and childbirth outcomes in an urban, multicultural setting to determine whether there are differences in breastfeeding outcomes for birthing people who received doula support compared to those who did not receive doula support.23 Researchers conducted a retrospective program evaluation to compare differences in breastfeeding intent and early initiation between births at 37 weeks or greater both with and without doula services. The study results showed that for the entire cohort, those who had the support of a doula had significantly higher rates of both breastfeeding intent and early initiation. Intent to breastfeed and early initiation was 85% and 46% among doula supported birthers, respectively, compared to 68% and 23% among non-doula supported birthers, which proved to be statistically significant.23 Those who birthed with a doula were substantially more likely to also initiate breastfeeding immediately during the postpartum period, about 1 hour after delivery, which is also associated with more successful long-term breastfeeding practices.23

Why Alternative Models of Birthing are Effective

The evidence on doulas is clear: having the support of a doula is associated with healthier birth outcomes and shows great potential for reducing adverse pregnancy outcomes for Black birthing people. Much of the reasoning behind the evidence on doulas has to do with the emotional support they provide. While the technocratic model of birthing dehumanizes the birthing person and is highly interventionist, the emotional, physical, and informational support of a doula may account for a more satisfying birth experience comprising fewer complications, fewer clinical procedures, and overall, less stress and anxiety throughout the birthing process.24 A doula serves as the birthing person’s advocate and works to encourage feelings of self-efficacy, control, and competency regarding the ability to influence their birth outcomes. The empowerment, confidence, and respect for autonomy that doulas provide–aspects that are absent in the technocratic model–are what make them such a critical piece in addressing the maternal health crisis. These positive feelings surrounding birth translate into positive outcomes, and the most marginalized communities, specifically Black birthing people, are the ones who benefit most from the birthing environment doulas help create.

Conclusion

The technocratic model of birthing is not meeting the needs of Black birthing people and is instead harming them. This is apparent in the significant disparities seen in rates of cesarean section, low birth weight babies, and the intent and initiation of breastfeeding. Thus, there is an intense and immediate need to reorganize the structure of the current birthing process. The Black birthing experience deserves to be an experience of empowerment, free from unnecessary interventions, and one where the birthing person is valued and listened to–all aspects a doula can offer. The evidence demonstrates that the support of doulas improves the birthing experience of Black birthers, so doula services should be the norm rather than the exception. Nevertheless, most state Medicaid programs have not covered doula services, leaving birthing people at risk of adverse outcomes. The most effective way to increase access to doulas would be to reduce cost barriers. However, only two states have passed legislation for Medicaid reimbursement for doula support: Minnesota and Oregon.25 As the evidence on doulas suggests that doulas could be a key strategy in the birthing process, doula services should be mandated as a Medicaid benefit for birthing people. Doula services have the potential to be one of the most effective tools for improving maternal and infant health. It is overdue to make doula support available and accessible to all birthing people, specifically all Black birthing people, as a means to reducing disparities and ensuring the right to a safe and equitable birthing experience.

References

  1. Olumhense, E. (2020, April 28). A Pregnant Woman Tweeted Concerns About a Bronx Hospital. She Died Days Later. The City.
  2. JAMA Network. (1999, October 6). State-Specific Maternal Mortality Among Black and White Women-United States, 1987-1996. JAMA, 282(13), 1220-1222.
  3. Peterson, E. E., Davis, N. L., & Goodman, D. (2019, September 5). Racial/Ethnic Disparities in Pregnancy-Related Deaths – United States, 2007–2016. Centers for Disease Control and Prevention, 68(35), 762-765.
  4. Gruber, K. J., Cupito, S. H., & Dobson, C. F. (2013). Impact of doulas on healthy birth outcomes. The Journal of perinatal education, 22(1), 49–58. https://doi.org/10.1891/1058-1243.22.1.49
  5. Davis-Floyd, R. (2017, February 1). The technocratic model of birth. DavisFloyd.com.
  6. “What is a Doula. DONA International. (2018, December 5).
  7. Fang, J., Alderman, M. H., & Madhavan, S. (n.d.). Maternal mortality in New York City: excess mortality of black women. Journal of urban health: bulletin of the New York Academy of Medicine, 77(4), 735–744. https://doi.org/10.1007/BF02344034
  8. Bridges, K. M. (2011). Reproducing Race: an ethnography of pregnancy as a site of racialization. University of California Press.
  9. Hoberman, J. (2005). The Primitive Pelvis. The Role of Racial Folklore in Obstetrics and Gynecology During the Twentieth Century. Body Parts. British Explorations in Corporeality. 85-104.
  10. Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016, April 19). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS, 113(16), 4296-4301. https://doi.org/10.1073/pnas.1516047113
  11. Martin, J. A., Hamilton, B. E., Osterman, M., & Driscoll, A. K. (2019). Births: Final Data for 2018. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 68(13), 1–47.
  12. WHO. (2015, April). WHO statement on caesarean section rates. World Health Organization.
  13. Reasons for a Cesarean Birth. American Pregnancy Association. (2020, September 3).
  14. Aron, D. C., Gordon, H. S., DiGiuseppe, D. L., Harper, D. L., & Rosenthal, G. E. (2000). Variations in risk-adjusted cesarean delivery rates according to race and health insurance. Medical care, 38(1), 35–44. https://doi.org/10.1097/00005650-200001000-00005
  15. Foucault, M. (2010). The birth of the clinic: an archaeology of medical perception. Routledge.
  16. Osterman, M. J., & Martin, J. A. (2014). Trends in low-risk cesarean delivery in the United States, 1990-2013. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 63(6), 1–16.
  17. Hodnett, E. D., Gates, S., Hofmeyr, G. J., Sakala, C., & Weston, J. (2011). Continuous support for women during childbirth. The Cochrane database of systematic reviews, (2), CD003766. https://doi.org/10.1002/14651858.CD003766.pub3
  18. Shiono, P. H., Klebanoff, M. A., Graubard, B. I., Berendes, H. W., & Rhoads, G. G. (1986). Birth weight among women of different ethnic groups. JAMA, 255(1), 48–52.
  19. Healthy Start Brooklyn. Healthy Start Brooklyn – NYC Health. (n.d.).
  20. Thomas, M. P., Ammann, G., Brazier, E., Noyes, P., & Maybank, A. (2017). Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population. Maternal and child health journal, 21(Suppl 1), 59–64. https://doi.org/10.1007/s10995-017-2402-0
  21. Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S., Krasevec, J., Murch, S., Sankar, M. J., Walker, N., Rollins, N. C., & Lancet Breastfeeding Series Group (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet (London, England), 387(10017), 475–490. https://doi.org/10.1016/S0140-6736(15)01024-7
  22. Anstey, E. H., Chen, J., Elam-Evans, L. D., & Perrine, C. G. (2017, July 14). Racial and Geographic Differences in Breastfeeding – United States, 2011-2015. MMWR. Morbidity and Mortality Weekly Report, 66, 723-727.
  23. Mottl-Santiago, J., Walker, C., Ewan, J., Vragovic, O., Winder, S., & Stubblefield, P. (2008). A hospital-based doula program and childbirth outcomes in an urban, multicultural setting. Maternal and child health journal, 12(3), 372–377. https://doi.org/10.1007/s10995-007-0245-9
  24. Meyers, B. A., Arnold, J. A., & Pascali-Bonaro, D. (2001, September). Social support by doulas during labor and the early postpartum period. Hospital Physician, 37, 57-65.
  25. Kozhimannil, K. B., & Hardeman, R. R. (2016). Coverage for Doula Services: How State Medicaid Programs Can Address Concerns about Maternity Care Costs and Quality. Birth (Berkeley, Calif.), 43(2), 97–99. https://doi.org/10.1111/birt.12213