Always,already-medicalized: Women’s prenatal knowledge and choice in two Canadian contexts

Introduction

The medicalization of childbirth is characterized in popular and professional discourse as an epidemic of unnecessary interventions, ranging from inductions to cesarean sections. Despite differing complexity and tone, these discourses also often position women as complicit in pushing the medicalization of childbirth, frequently accompanied by an assertion that women’s choices, if better informed, are key to reducing interventions. This framing of women’s childbirth choices is tightly bound to normative constructions of risk management, knowledge consumption, and responsibility, in which women are assumed to be capable of making free choices by evaluating available knowledge before and during the medical encounter. Such assumptions underpin much of the discourse women encounter, whether that discourse is pro-medical or pro-natural, professional or populist. Women thus are charged with knowing and choosing appropriately in order to achieve a safe, yet not overly medicalized birth.

This article draws on interviews with 40 women from Lethbridge and Red Deer, Alberta, collected as part of a larger research project on childbirth and choice. These data indicate women’s decision-making extends beyond traditionally identified challenges to informed choice such as power and knowledge imbalances in the doctor–patient exchange, to include gendered imperatives about women’s attractiveness, selflessness, and heteronormative availability (Malacrida and Boulton, 2012). Likewise, although women express significant antipathy towards medicalized childbirth and deploy multiple strategies to reduce their chances of medicalization, they achieve varying and often unsatisfying results (Malacrida and Boulton, 2014). In this project, many of the women described the hospital as both friend and foe – a place that they understood as culpable in medicalizing childbirth but nevertheless a space that offered them an inchoate promise of safety and security.

These insights are intriguing given that since 2009 in Alberta national public health coverage includes midwives who are provincially regulated and are able to provide their services in most hospitals, in birthing centers or in women’s homes (Canadian Association of Midwives, 2014). All the interviewees were aware of Alberta’s cost-free midwifery, and almost three-quarters acknowledged the reputation of midwives as less interventionist than doctors and obstetricians. Nevertheless, most of the women, while expressing desire for a ‘natural’ intervention-free birth and a belief that hospitals can be sites of intervention and alienation, ultimately chose to give birth in a hospital. To explore these contradictions, we examined how women’s knowledge and choices were formulated. The women’s stories show that many of the critical choices women make concerning medicalized birth have already occurred long before childbirth. Rather, the women described learning about pregnancy and childbirth in ways that produced them as ‘already-medicalized’ subjects who despite their misgivings were hard-pressed to imagine giving birth outside of a medical and hence medicalizing context.

Choice and responsibility

Pregnant women are under considerable pressure to make responsible and appropriate choices concerning birth, a task complicated by the competing claims of feminists, natural birth advocates, and medical professionals. From the medical perspective, increases in medical interventions, particularly in C-sections, are often seen to be the result of women making inappropriate choices and pushing for interventions that are not medically necessary (de Zulueta, 1999; Marx et al., 2001; Paterson-Brown et al., 1998). Full issues of the British Medical Journal (BMJ) and The Journal of Obstetrics and Gynaecology (the flagship journal of the American College of Obstetricians) have examined the problem of increased C-section rates, with many of the articles concluding that doctors are not to ‘blame’ for medicalization, but that women overstep their patient role and push for inappropriate medicalization without a proper, physician-mandated assessment of the risks attached to C-section (Edwards and Davies, 2001; Irvine, 2001). These discussions posit women as medical consumers who are in a position to plan and execute the kind of birth experience they choose, and whose choices are frequently inappropriate – even selfish – in terms of birthing outcomes and their roles as patients (Aylin et al., 2004; Macfarlane, 2004). In this medical discourse, proper, medically informed consent is offered as the means of ensuring women make a rational and informed decision, assuming that this will reduce the number of unwanted or unnecessary interventions in birth (Emmett et al., 2006).

Natural birth perspectives also presume that women are able to choose the kinds of birth they want. In this discourse, hospitals are seen as interventionist and technocratic, and a drug-free, home birth is held to be the safest option for mother and baby (Beckett and Hoffman, 2005; Cheyney, 2008). From the perspectives of many natural birth advocates, increased C-section rates are the apex of an ongoing and increasing medicalization of childbirth, and it is medical professionals who drive this trend (Gamble et al., 2007; Irvine, 2001; Mansfield, 2008). Here, women are assumed to want to avoid medicalization, and can best do so by informing themselves, choosing a midwife or doula to attend hospital births, opting for home birthing, or using hypnotherapy, waterbirthing, or birthing ‘systems’ such as Lamaze or the Bradley method. In the natural/alternative discourse, women can and should protect themselves from medical interference, reflecting an assumption that women have the capacity to implement birth choices.

The question of choice is core to feminists who position the medicalization of childbirth within a larger project of controlling women’s bodies and reproductive choices, arguing that women should control their bodies and births regardless of the particularities of their choices (Beckett, 2005; Lee and Kirkman, 2008; Rowland, 1987). Feminist critics argue that the increased medicalization of childbirth occurs through a cascade of interventions, where routine practices of fetal monitoring and epidurals undermine women’s authority over their own bodies (Davis-Floyd, 1987; Inch, 1982; Martin, 2003; Oakley, 1980). In this view, similar to the natural perspective, the hospital setting is seen as culpable, because once a birthing woman enters a hospital there is a seemingly automatic and natural ‘transfer of power and responsibility for birth from a woman to her doctor’ (Brubaker and Dillaway, 2009: 36). A feminist improvement on the medical notion of ‘informed’ choice as a means of reducing interventions is the additional argument that physicians need to relinquish their position of authority and their power over women in the medical encounter. Feminists also differ from strictly natural childbirth advocacy by acknowledging that some women may experience the strong promotion of medication-free birth as disciplining rather than empowering; women’s control over their own bodies is the critical feminist goal (Brubaker and Dillaway, 2009).

Despite differences in what constitutes the ‘right’ choice, all three perspectives convey a notion of choice that assumes an autonomous, rational subject who is able to formulate her position based on a careful evaluation of the information available to her as a modern, reflexive citizen (Giddens, 1990). Additionally, these formulations rely on an assumption of a medical consumer who approaches her information-gathering and decision-making as a sort of innocent with no prior learning to complicate the moment of medically informed choice. As will be seen, however, the women in the study described how their ideas about childbirth, developed through exposure to media, social networks, and prenatal education, placed them in an ‘always already-medicalized’ frame of mind long before they were called to make choices during their actual births.

Methods

This analysis draws on qualitative, semi-structured interviews with 40 women from Red Deer and Lethbridge who were pregnant or recently became mothers, as part of a larger project examining the culture of birthing in southern and central Alberta. Interviews were semi-structured and typically lasted one to two hours. Interviews were tape-recorded, transcribed, and coded in Atlas-ti by myself and student assistants, drawing deductively on the literature on choice and working inductively to trace themes arising from the data. Participants were recruited through pregnancy and mothering support groups, social media, postings in childcare and community centers, and through snowball sampling. They ranged in age from 19 to 40, were predominantly white (which reflects the population of both cities), middle class, heterosexual, and all but two were in committed relationships with their children’s fathers. Their educations ranged from 10th grade to holding a medical degree, and occupations ranged from living on disability pension to running a private medical practice. While the sample is predominantly middle class, this is not as pertinent in terms of choosing a birthing site or professional as it might be in some medical contexts. In Canada, all women have access to free medical care, including prenatal education and the care of an obstetrician, general practitioner or licensed midwife (the latter, since 2009) (Canadian Association of Midwives, 2014).

Red Deer and Lethbridge are similarly sized cities. Both operate mid-sized hospitals and have predominantly white populations, with higher rates of political, social, and religious conservatism than much of Canada. The salient difference is that Lethbridge does not offer midwives hospital privileges so that midwifery there is exclusively home-based, while midwives in Red Deer have had hospital privileges since 2009. In Red Deer, we were able to speak with women who had experienced physician-attended hospital births, midwife-attended hospital births, and midwife-attended home births, while in Lethbridge we only were able to speak with women who had experienced physician-attended hospital births or, rarely, midwife-attended home births. Thus, the Red Deer women came to their decision-making in a different institutional context of available birthing professionals and interprofessional collaboration, and within a different cultural context of friends and family who had experienced or knew of women who had midwife-attended births in hospital and at home. Although these findings are not generalizable, they offer important insight into the normative qualities of medicalization in women’s lives.

In their interviews, women indicated their pre-pregnancy knowledge about childbirth came from three sources; media accounts, family and friends, and finally, prenatal education. The women described how these sources naturalized physicians as the appropriate professionals and hospitals as the appropriate setting for pregnancies and births. Within such a framing, despite the fact that most of the women hoped for a natural birth and stated they ‘knew’ that hospitals heighten women’s chances of medicalized childbirth (Malacrida and Boulton, 2014), all of the women in Lethbridge, and over half the women in Red Deer nevertheless ‘opted’ for an obstetrician-attended hospital birth. ¹ In the following sections, I outline how each of these domains – media, family and friends, and prenatal education – informed women’s already-medicalized understanding of childbirth, in effect limiting their choices long before pregnancy and birth.

Media accounts

I asked the women how they learned what childbirth was like, and how they chose a specific kind of birth professional. As discussed below, women’s responses to the second half of the question were varied, depending on their location and the perceived and actual choices available to them in that setting. However, the ways women spoke about their early knowledge of childbirth choices were virtually universal; the media were an early and pervasive source of knowledge. Media included books and website forums once the women became pregnant, but prior to that, women described how film and television left them with deep impressions about what to expect and how to think about safety and responsibility in childbirth.

Women described exposure to birth stories and portrayals on television and film as part of their regular consumption of popular media, so this learning was not intentional. However, much of the learning was foundational; almost half of the women described themselves like 25-year-old new mother Andrea, who said, ‘I didn’t have anybody close have kids until I was at least in my late teens, so my impressions of birth were definitely mostly media.’

Many of these women described media portrayals as unrealistic. Andrea said, ‘Oh, I used to just assume that birth was like it is in the movies – the water breaks, and you rush to the hospital, and you lay in the bed and uh, push the baby out. Whatever.’ Similarly, Ruth, 28 years old and 36 weeks pregnant with her first child, noted how movies portray hospitals as calm and orderly birth sites, with ‘lots of them [mothers] like with the epidural and makeup on and stuff.’ Women described portrayals of birthing mothers as passive and medicalized ‘patients,’ always in hospitals, hooked up to IVs, feet in stirrups, surrounded by medical attendants, and lying on their backs. Judith, who was 40 years old and 33 weeks pregnant with her first child, spoke tellingly about her pre-pregnancy learning:

The movies portray birth and it’s mostly in the most sterile medical environment – or in the middle of the woods and just crazy – it’s pretty unrealistic. In real life, you’re not ever like you are in the movies, on your back with your knees in the stirrups. Because that is not a good birthing position.

Judith had not yet given birth, but she had taken prenatal classes in which she had learned that the ideal, indeed the typical childbirth position was not and should not be as portrayed in popular media. However, it is worth noting that many women in the study who had given birth described being subject to precisely the kind of passive birth position portrayed in film. Thus, Judith’s assessment of the media portrayal of birth as unrealistic was correct, although ironically not in the ways she believed it to be.

While almost half the women described women portrayed as passive recipients of medical care, over a third mentioned that media show childbirth as a chaotic emergency best managed by medical professionals. Ruth, who earlier described media portrayals as idyllic, noted that at other times, ‘everyone is always screaming, and you know, yelling at people, and running down the hall.’ The sound of screaming was frequently mentioned, and that screaming left more of an impression than the calm, medicated portrayals. Andrea, who earlier described a routinized portrayal of labor as unrealistic, described how the portrayal of childbirth as chaotic and painful had left a deeper impression on her:

There was that stereotypical thing that you see on TV at night, you know, you have these women who are writhing in pain and screaming and yelling at people … I mean, even before I was pregnant, I mean you are really like, ‘Do I want to go through that or not?’

For Andrea, this imagery was a compelling cautionary tale about the importance of avoiding pain. Similarly, Susan, a 25-year-old mother who hoped for a natural birth, but had an epidural that stalled her labor and resulted in a C-section, described how media influenced her choices:

I chose an epidural, but I think it’s really just – it’s what you see. Just TV and movies and, like my mom and [my husband’s] mom never had an epidural. I didn’t know anyone else. It was more like, on a TV show when you see women screaming and pushing out their baby and screaming for the epidural, and then the camera pans to her all calm and happy afterwards.

Here, not only are epidurals portrayed as normal, but they are also portrayed as normalizing, taking a hysterical woman and returning her to a state of calm under the influence of medicine. Further, Susan’s comments indicate the primacy of media as an educative force: although both of the older women in her life had somehow managed to give birth without this intervention, the portrayal of epidurals as women’s calming saviors remained ascendant for Susan.

The mothers described media as normalizing the medicalization of childbirth by portraying women hooked up to tubes, legs in stirrups, calmed by medications and epidurals, and not infrequently being saved by emergency C-sections. Although Carrie had wanted a natural birth, following a spiral of interventions, she agreed to a C-section. She described how the media had affected her perceptions of that surgery:

I thought it was kind of like inevitable. If the baby didn’t hurry up and get out, you were going to end up with a section … it just seemed more likely. It was just kind of like on TV shows. All the mothers always ended up with a C-section, and the baby was good, so I just assumed that it was normal.

Given her positive impressions of C-section portrayals, it is not difficult to understand why when faced with her decision, she found it easy to agree to surgery.

Very few women even recalled portrayals of home births or midwife-attended births, but those who did described natural birth ‘in the middle of the woods’ or similar to Rheanna’s description of ‘some terrible water birth show and everybody’s naked and it’s like this big hippie party thing, and it’s really weird.’ In short, these portrayals positioned a non-hospital, non-medicalized birth as something both extraordinary and irrational. This is clearly conveyed on The Learning Channel’s popular reality show I Didn’t Know I Was Pregnant. Almost a quarter of the women recalled this show, and spoke about the way it portrays mothers who do not have medical care before and during childbirth as irresponsible and endangering, covertly offering an indirect message about the safety and appropriateness of hospitals as birthing sites. Carmen, a 27-year-old mother, clarified:

Have you ever watched I Didn’t Know I Was Pregnant? The women are a bunch of idiots. And on every single episode they mention how miraculous it is that without any medical care that this baby could have been delivered safely. They ALWAYS say it! And they’ll say, ‘I can’t believe that without any medical care that this baby could be born.’ Like, how do they think most babies in the world get born?

Carmen, despite having experienced a full ‘cascade of interventions’ during her birth, remains a firm advocate of natural childbirth, and to her these media portrayals about the necessity of medical intervention are ‘infuriating – that show is hysterical.’

Family and friends

A second source of knowledge informing women’s already-medicalized views came from family and friends. It is often mentioned in both natural and feminist childbirth literature that the lore and folkways of women-centered childbirth have been lost to modern women (Cheyney, 2008; Davis-Floyd, 1993; Oakley, 1980). Echoing this, almost all women in both cities described how their mothers had birthed in hospitals in a medicalized way. Further, women characterized family birthing stories as irrelevant because, in the women’s minds, birthing has changed considerably. These observations were twofold: either the relatives’ births were highly medicalized and the women believed that this was no longer as prevalent, or they were ‘primitive’ home births that were not seen as desirable options for today’s women. For example, Louise described her father being born at home because ‘that was normal, you know, back in, back on the prairies.’ Alexis, whose family hearkens from northern Europe described that her grandmother and mother both had home births because, as she laughingly reported, ‘they couldn’t get to the hospital because they were too far away, they were farmers so they gave birth on their land all the time.’ In both these narratives there is a sense that their family’s home births, although natural, were also somehow backward, occurring only because of a lack of modern, medical options. Indeed, Alexis finished her story saying, ‘things got easier as they moved on. I know with my youngest brother, she walked to the hospital.’

In contrast, most women described their mothers’ birth stories as irrelevant because birth in North America has historically been even more medicalized and less empowered than it is today. Rita, Andrea, and Lindsey all described their mothers stories as unhelpful because they had full anesthesia during birth, and, as Rita said, ‘the baby was just taken away from her right away and that’s the way it was.’ Even more women discussed the alienation of women during childbirth in their mothers’ era because their fathers were not allowed in the delivery room. Ironically, given the tremendous increases in intervention in modern childbirth, the shift to include fathers not only rendered the women’s mothers’ birth lore irrelevant, but it also conveyed that childbirth in today’s hospitals is much more woman-friendly than in the past. In a subtle way, the narrative of an old-fashioned absent father and a modern present father in labor and delivery rooms seemed to soften the women’s perceptions of hospitals as sites of medicalization, because having the father present is, as Rita put it, more in keeping with ‘the way it can be, that having men there is a part of what birth can be.’

Friends were generally cited as important sources who provided women with a strong sense that medicine is necessary, through what many referred to as birth ‘horror stories.’ For many women, these narratives about the heroics of birth and all the things that can go wrong presented dramatic evidence that without doctors and hospitals, childbirth is dangerous and chaotic. As Ruth said, ‘being pregnant is when you start talking about birth a lot, and anybody that’s had a bad or at all negative experience is definitely going to tell you all about it!’ Whitney concurred, describing her sister’s story and its effect on her:

She said it was the worst thing she’d ever gone through. She wouldn’t push it out, and ended up throwing up and pushing the baby out. Maybe that’s why, later on – because she was telling me this closer to before we got pregnant – so, maybe that’s why subconsciously maybe I was leaning towards hospital birth because if something did happen like that, I’m in the facility, they can help me right there.

For Whitney, who had hoped for ‘as natural a birth as possible’ but ultimately gave birth via C-section, her sister’s horror stories planted a seed of doubt that made the hospital seem like her safest option.

Typical horror stories followed a narrative arc in which things began ‘normally’ then went terribly wrong, often requiring an emergency C-section by a doctor/hero who saved mother and child. Judith, 33 weeks pregnant and planning a hospital birth, was ambivalent about the potential for avoiding medicalization. When asked whether she might try home birthing if this first birth went well, she indicated the normative strength of the doctor/savior narrative:

No, I wouldn’t. I might go to a birthing centre, but not at home. I want to be certain, to have the medicine available – it’s there, and there’s no reason to not use it. I think a lot of the complicated pregnancies discussed amongst my friends, those children would have died if they would have been birthed without the intervention of Western medicine.

Like many of the women, Judith characterizes midwifery as not-medical, a perception that is belied by the reality that in Alberta, registered midwives are highly trained professionals who provide a full range of obstetrical and medical services.

For a small minority of the women, these powerful horror stories were taken up as portrayals of hospitals as medicalizing and doctors as overly intervening. This was most likely to be the response among the Red Deer participants, several of whom conveyed that the ubiquitous bad birth story made them want to avoid the hospital and its medicalized approach. The different interpretation of the typical horror story may have to do with the availability of alternative interpretations and possibilities within a local birthing culture. In Lethbridge, because the hospital does not permit midwives, knowing of a woman who ‘successfully’ receives midwifery care in hospital or gives birth at home is relatively rare. However, in Red Deer, where the culture of midwifery is less marginalized, the ubiquitous medicalized narrative was open to alternative readings. Women who knew family members, friends or acquaintances who had midwife-attended non-hospital birth were likely to be more skeptical about the ‘doctor knows best’ moral of those horror stories because they knew stories about midwife-attended childbirths that typically did not involve intervention but nevertheless ended well.

A final, and very frequently cited theme conveyed by family and friends was that medical intervention was desirable, or, at the very least, not that bad. Almost a third of the women mentioned mothers or friends who had given birth tell them to, as Stacy said, ‘Get it! Get whatever you can!’ to aid in pain management. Helen’s best friend told her, ‘You’ve gotta have an epidural, it’s so easy.’ Rebecca’s co-worker said, ‘You’re crazy if you plan not to have an epidural.’ Rita’s sister told her to ask for an epidural right away when she got to the hospital, and she responded:

Well, of course I am gonna go in and have an epidural, because that’s what the hospital is there for. And of course I am going to take whatever is – I don’t want to handle pain, I’m scared of pain, so I’m definitely going to do it the easy way.

The normalization of medicalization was also conveyed through stories that minimized the effects of medical intervention. Almost half of the women in the Lethbridge portion of the study described hearing before their births that C-sections are easy. Sharron said, ‘I heard it from two other moms, two people in particular who had elective C-sections the second time around, and they were saying, “Oh it is so much better [than vaginal birth]. It’s fine.” ’ Similarly, Katherine described that, ‘My girlfriend had had a C-section and kind of explained her story to me, and she said it was really calm and it happened fast’ noting that when her own childbirth stalled, this made her decision to agree to a C-section feel quite positive. Some of these narratives even positioned medicalized birth as superior to natural childbirth. Nora described her sister who, ‘had a C-section, then a V-BAC [vaginal birth after cesarean], and then chose to have a C-section for her third, and she preferred the C-section as opposed to natural.’

It is worth remarking that none of the Red Deer mothers described hearing positive stories about epidurals or C-sections from their circle of friends and acquaintances. They were more likely to describe hearing stories about midwifery and home births as positive, perhaps reflecting a culture that is moving away from medicalized childbirth as normative.

Prenatal education

A final source of women’s knowledge was prenatal education. Surprisingly, despite the fact that prenatal care is inexpensive and routinely recommended, six of the 40 women did not attend prenatal classes. These women reported that for them, by the time the recommended prenatal classes began, they felt confident enough in their birth knowledge that the classes were redundant. Three more women noted that although they did attend classes, as Stacy said, ‘they didn’t sway me one way or the other. The only thing I knew was, I wanted drugs. I didn’t care what was said.’ Finally, 11 of the 22 Red Deer women chose midwife-attended births, which involved frequent prenatal visits of an hour or more in which information about pregnancy and childbirth was exchanged. None of these women attended the standard Alberta Health Service (AHS) classes because prenatal education was embedded in their midwifery care. Thus, in this section, data are reported only from those 23 women who continued to formulate their ideas about birth choices through AHS classes. Women’s perceptions about their classes ranged from a few women’s sense that classes focused on natural birthing as a choice, to a more common impression that the classes were misleading because they under-reported the negative aspects of medicalization and over-reported women’s choices.

Only three of the 23 women who attended AHS classes described their instructors as pro-natural, and all of these were in Red Deer, where midwives practice in the hospital and where interprofessional relations between nurses, doctors, and midwives are reportedly cordial. Examples of pro-natural education ranged from instructors who suggested mothers hire a doula, to showing a film depicting a groggy newborn ‘trying to breastfeed after the mom had had medication’ and a perfectly latching baby who was born without medication (Ashley).

Such messages were rare, and more often women described feeling misled by prenatal educators about hospital births, saying, ‘you can be in whatever position you want, you can have whatever doctor you want, but then the nurses come in and they tell you to do this, so you do it’ (Shirley). Andrea also noted, ‘During prenatal classes, they had shown us some labor positions to try and stuff, but [in hospital] they were like, “Oh, just try and rest. Lie down.” ’ A common complaint pertained to misinformation in the classes about room options available to women in the hospital. Ruth, heavily pregnant at the time of our interview, described that she had been practicing labor visualization in her bath at home, but that when she toured the hospital, there was only one bath, ‘with no window so it seemed really closed in and really sterile and, not cozy, so I don’t think I will use that.’ The AHS classes in Lethbridge use curricular materials written in Vancouver, a city almost 1000 kilometers away, where there may actually be the birthing suites with personal tubs described in the materials, but these were absolutely unavailable in the Lethbridge hospital. A final source of misinformation related to the level of pain women felt led to expect. Victoria’s insights are instructive:

For the most part I liked our instructor ’cause she said, ‘This is natural, you can do this. Our bodies are made to do this.’ But this was the most painful thing I’ve ever gone through, and I just wasn’t able to do it. So I went in thinking it was a lot easier than it ended up.

Victoria’s birth involved a classic cascade of interventions beginning with an epidural. In retrospect Victoria felt that she might have labored better (i.e., without epidural) if she had expected worse.

Occasionally, women did describe their prenatal classes as realistic. Sheena described having her ‘eyes opened about the cascade of interventions’ and the potential risks of early induction, although in the end both of those things occurred to her. Three women described how their birth educators, while on the one hand encouraging them to write up a birth plan, also made it clear that frequently births unfold in ways that preclude following them. ²

Mothers’ descriptions indicate that medicalized assumptions were conveyed in overt and covert ways. Sharron in Lethbridge and Corrinne in Red Deer noted that there was no mention of doulas or midwives, but an entire class was dedicated to the role of doctors and nurses in the labor and delivery room. In Red Deer, when Ashley specifically asked how well her doula would be accommodated in the hospital, she said, ‘everyone was like, “what’s that?” and I was like, oh my God, not only is this class not covering it, but none of these people even know that!’ Ashley’s observation is astute; women who do not know what is being excluded can hardly be described as well-informed about their options.

Several mothers in both sites recalled being shown pictures of women with horrific vaginal tears but not photos of C-section incisions. For Stacy, ‘the only thing that really terrified me with the whole natural birth, was the episiotomies and ripping and the tearing … the pictures they show you in the prenatal classes, like, that was terrifying.’ One wonders, had Stacy been shown photographs of abdominal surgery, if she would not have been equally as terrified of surgical birth. Of course, terrifying mothers is hardly the goal, but the information she was provided (and that was omitted) in class may have informed Stacy’s birth choices.

While vaginal birth was portrayed as messy, unpredictable, and dangerous, the risks of intervention were sometimes minimized. Lauren described learning that the risks to the baby in a C-section were minimal. Conversely, she described the following benefits:

When the baby is out they can clean everything out, so everything is flushed out. And you don’t have any vaginal tearing, so that’s nice, you know. What was the other one? Oh, with a good surgeon, you heal, you recover quicker.

Thus, Lauren described the information conveyed in her birthing classes as actually depicting surgical intervention as the ‘least harm’ option.

A covert yet pervasive form of medicalization in AHS classes in both cities was that they took place in the hospital rather than a more neutral site, and the classes included a tour of the hospital, which seemed to naturalize it as the normal site for birthing. Many of the women, in fact, recalled this as a highlight of their birthing classes, because as Abby said, ‘I could kind of see where I was going to be,’ or as Rita said, ‘it made me more comfortable, already seeing the labor and delivery section.’ Conversely, none of the women recalled any discussion in class about home births or birthing centers. In sum, these women’s prenatal classes produced a seamless narrative of hospitals as the only sanctioned and reasonable location in which to give birth.

Conclusion

Women encounter a range of discourses that hold them responsible for making appropriate birthing decisions, offering a number of compelling yet contradictory claims about what constitutes the ‘right’ choice. In particular, the medical perspective assumes women, as rational medical consumers, will be assisted in making proper choices through improved informed consent, reducing medicalization (Emmett et al., 2006). Similarly, natural childbirth advocates presume a logical, consumer mother who can avoid medicalization by choosing the ‘right’ kinds of birth location, birthing ‘system’ or birth attendant (Beckett and Hoffman, 2005; Cheyney, 2008). Even in feminist literature, it is assumed that women’s birth choices would be ‘better’ if women were more informed (Brubaker and Dillaway, 2009).

The women interviewed were very well-informed; they frequently ‘knew’ that hospitals were sites of medicalization, and yet their pre-pregnancy learning within a highly medicalized culture led them to an ‘always already-medicalized’ frame of mind despite their antipathy. Their pre-pregnancy and prenatal learning normalized hospitals as safe, sanitized spaces, and doctors as normative birth attendants so that the process of ‘informed’ choice about medicalization began long before labor and delivery. The women’s stories indicate that improving informed choice – by providing accessible information or giving women time to consider their options – may not suffice in countering women’s readiness to accept the powerful promises of medicine. Further, the interviews expose the dearth of powerful alternative narratives. These women lacked an intergenerational birthing lore to counter the medical model, and women’s social networks conveyed birth ‘horror stories’ in which doctors and medicalization figured as heroic saviors. In prenatal classes, a strong pro-hospital message conveyed in subtle and not-so-subtle ways that the safest – in fact, the only – place to give birth is in a hospital, despite a superficial message about the value of ‘as natural a birth as possible.’

The normalization of hospital births is echoed in popular media portrayals of ‘normal’ birth as medicalized, and non-hospital births as ‘matter out of place’ (Douglas, 1966) by portraying such births as ridiculous, crude, and animalistic. In this vein, as noted earlier, the two research sites comprise differing institutional and cultural contexts, and these seemed to work in feedback loops of sorts: women in Red Deer were more likely to consider non-hospital births precisely because the hospital permitted midwives to practice in the hospital, an endorsement that made women perceive midwifery as safe and legitimate because it operated within the still-powerful promise of medical safety. Red Deer is in a transitional moment, where hospital-integrated midwifery has begun to legitimate the activities of midwives, who also offer home birth services. Women in Red Deer were more likely to describe friends or relatives who had experienced both hospital-based midwife care and home birth midwifery services, and those non-horror stories were powerful evidence that midwifery is a safe birthing option. Conversely, women in Lethbridge, who have literally no access to hearing about medically legitimated midwifery in their community and social networks, described that anything but a hospital-based and hence medicalized birth seemed both unusual and risky.

Despite Red Deer’s cultural shift, women in both communities described their pregnancy and pre-pregnancy learning as a hegemonic presentation of hospital birth and medical intervention as safe and responsible ‘choices.’ Within this context, women are ‘already ready’ to accept medicalization as the norm, and it becomes extremely difficult if not impossible for pregnant women to abandon the hospital, despite their misgivings about medicalized birth. It is also important to acknowledge that the idealized modern, reflexive citizen who is expected to inform herself and evaluate her risks is also one who is held liable for failure should her risk assessments lead to undesired outcomes. Mary Douglas, for example, has argued that where risks are perceived to be high within a culture, they are strongly connected to moral principles and norms, and failure to comply is seen as blameworthy (Douglas, 1992). The risks associated with pregnancy and childbirth are even more morally charged than most health choices, which makes going against the grain of hegemonic medicalization very difficult because the stakes are so high. For women who are held liable for making these high stakes ‘choices’ within such a normative and medicalized culture, the processes of informed choice idealized in much of the literature are almost certain to offer women too little, too late in terms of women’s actual choices.