Treatment of Women in Childbirth: Implications for Family Beginnings SANDRA KLEIN DANZIGER, PHD
Abstract: This paper presents an ethnographic analysis of a woman's interaction with staff members during the early stage of labor, focusing on the factors that shape the childbirth experience. The observational data were gathered in several hospitals as part of a study of the medical context of childbearing. The pa-
per presents a model of naturalistic inquiry into the transition to parenthood. Nurses and physicians are found to offer arbitrary, uniform, and often inappropriate responses to birthing women that may inhibit well-being. (Am J Public Health 69:895-901, 1979.)
The social-psychological and culturally patterned aspects of childbirth, a critical transition in women's lives, have received little clinical attention. A model for such research may be adapted from ethological studies of mammals that differentiate the multiple factors in parturition that affect maternal-infant bonding. 1-4 Bowden, et al., in particular have documented the behavior occurring during pregnancy, birth, and the initial mother-neonate contact period (in the squirrel monkey, Saimiri sciureus). I The parallel first step of documenting human birth behavior in its "natural" cultural context, in this case in the typical U.S. hospital labor and delivery suite, is necessary for understanding the environmental factors affecting the childbearing experience. Sociological inquiry can illuminate the meaning of the birth event in a woman's life and, thereby, its effect on initial parental adaptation. In this paper, I present qualitative data on one important part of the birth experience, the content and style of interaction between the staff members and patients. Data derived from conversations during labor are examined for congruence versus conflict of interests between the laboring women and the staff experts for whom childbirth represents a series of work routines. After reporting some patterns of communication, the paper offers hypotheses about the quality of this interaction during labor and its influence on the transition to parenthood. This analysis of naturally occurring social behavior is considered as a pre-
liminary step toward understanding the relative importance of the childbirth experience for the long-term well-being of the family.
Address reprint requests to Sandra Klein Danziger, PhD, Department of Sociology, University of Wisconsin-Madison, 1180 Observatory Drive, Madison, WI 53706. This paper, submitted to the Journal September 1, 1978, was revised and accepted for publication March 30, 1979.
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Review of Prior Research Clinical studies of human birth behavior have examined only narrow concepts of the woman's experience, such as cultural variations in expressivenesss or pain tolerance.6 Other studies use physiological indicators of difficulty in birth,7-9 such as complications rate, labor length, and volume of analgesic medications used. In addition, previous studies have not focused on the variety of stress-producing aspects of the childbirth environment, such as the presence or absence of the father,10 the relationship with attending medical personnel, or the woman's expectations and degree of preparation for birth. For example, in a classic study of mothers' reactions to their newborns, Newton and Newton found that women who were less disturbed during labor, who remained calm and cooperative, tended to accept their babies upon first seeing them."l The accepting group and the indifferent or rejecting group of mothers also differed in terms of their personality, social class, education, and attitudes toward breast-feeding and other female biological functions. Calmness and cooperation during labor served as a proxy variable for tolerance of the birth environment. Newton and Newton do not consider that a woman's disruptiveness, rather than signaling an inability to cope, might represent a positive response to low pain threshold, uterine inefficiency, or lack of emotional preparedness or realistic expectations for birth. This suggests 895
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that further research distinguish environmentally induced from internal physical stresses as elicitors of emotional behavior. In addition, the fact that both calmness during birth and accepting behavior towards the new baby are socially approved responses confounds the results. Marshall Klaus* suggests that many normal women who later become positively attached to their infants do not "fall in love" with their newborns at first sight, despite what was previously thought about initial contact.'2' 13 Socialization may thus impel them to express maternal delight and to cooperate politely with the staff attendants.'4 Thus, a possible source of environmental stress could be the extent to which medical personnel exert pressure on laboring women to react in patterned ways. The issue of how behavior during labor is shaped by current situational pressures arises in my ethnographic work on obstetrical staff-patient interaction.** While this study does not address all the problems posed by other studies, it analyzes one neglected aspect of the childbirth environment, interaction with medical staff.
Data on Birth Interaction Data on the style and content of conversations during labor were obtained in a participant observation study of the medical context of childbearing. Ethnographic field notes were collected over nine months in 1975-1976 in two of the three hospitals of a medium-sized Midwestern city. Interactions of specialist obstetrician-gynecologists, family practitioners, and nurses with patients and partners of patients were observed and recorded over the period. The data collection was designed to document the totality of events and activities that occurred and to describe the full context in which they took place. Like an anthropologist in an exotic land, I attempted to capture the full flavor and nuances of the sample of obstetrical activity that I witnessed. Any ethnographic work, however, is open to question as to whether the interpretations emerge from or are imposed on the field data. I attempted to ensure the representativeness of interaction occurring in this setting throughout the research process, particularly in the methods employed in selecting the settings and participants and in collecting and analyzing the data.
graphic locale was chosen out of convenience, the third hospital was eliminated from inclusion in the sample settings beits obstetrical services were similar in population served and in staff and facilities to the other two units. In addition, less systematic preliminary observations were conducted in private and public maternity wards in a large urban area in the Southwest during 1974. Although the range of obstetrical procedures and the rates of complication varied considerably in the two regions, the style and content of staff-patient communication were quite similar. After I had gained access to the two Midwestern hospitals, I chose one clinic associated with each hospital. The clinics were selected to provide systematic variation in medical staff.'5 One was staffed by three obstetrician-gynecologists and the other was a medical school-based family practice clinic where four residents had substantial case loads of obstetric patients. Having chosen the two facilities and, hence, seven physicians, I accompanied each one as s/he attended pregnant patients over randomly chosen clinic sessions. After observing for about two months, I obtained a sample of women whom I had observed receiving first or second trimester prenatal care. I included only low-risk patients who were typical of the patient population of each practice. This resulted in my collecting data on all staff-patient interaction occurring over much of prenatal care and the full labor and delivery of a dozen women.t The patients in the sample were fairly homogeneous, middle class, pregnant with a first or second child, and enrolled in some form of childbirth education. In addition, I followed labor and delivery nurses over a two-month period, observing patient care in the hospital used by the three specialists. I collected this hospital data by working a full 7-3, 3-11, or 11-7 shift two or three times a week for about eight weeks.tt I thus recorded interaction at all times of the hospital day with almost all its maternity staff, the registered nurses and licensed practical nurses. This produced a second sample of 13 patients, who were observed only during childbirth. These women were randomly chosen by their being in labor or delivery while I happened to be at the hospital. Thus, the total number of birth episodes in which data were collected, including the first longitudinal and second samples, was 25 cases. cause
Selection of Research Settings and Participants The two maternity wards in which observations took place represent the full range of care available to "lowrisk"*** women in the geographic region. While the geo-
Data Coflection Procedures Conducting observations in a field setting involves the careful balancing of one's involvement in the participants' everyday world against the research goal of obtaining accurate information.'6 First, one attempts to collect field notes that are representative of what actually occurred by writing
*Marshall H. Klaus, talk on "Biologic Basis for the Process of Parental Attachment" at Milwaukee Birth without Violence Conference, 1978. **Sandra Klein Danziger, unpublished PhD dissertation, "The Medical Context of Childbearing: A Study of Social Control in Doctor-Patient Interactions," Boston University, 1978. ***The term "low-risk" is used loosely to designate all women not diagnosed as "high-risk" cases. Women with difficult pregnancies or with histories of serious obstetrical problems were excluded from the sample. High-risk care is presumably not comparable to treatment administered during a normal childbirth.
tOf the 18 women selected for inclusion, five refused to participate. The reason used in each case was that the husband preferred that an outside observer not be allowed to attend the birth. The thirteenth woman was followed prenatally, but she was unable at the time of her labor and delivery to contact the researcher. ttOf the 20 eight-hour work shifts on which I collected observations by following the nurses, eight were a.m., nine were p.m., and three were night shifts. I was less able to avoid nights when I observed the labor and delivery of the longitudinal cases. Of the dozen women followed, four had labors that lasted less than seven hours, five labored seven to 15 hours, and three labored 24 hours or longer.
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everything down soon after leaving the field and having others read the notes for consistency and clarity. Whenever there were uncertainties in the data, I inquired about the instance later during the same observation period. I asked doctors after the patient left about his or her choice of procedure or, when the doctor left, I asked the patient about her views of what had transpired. During labor and delivery, I listened carefully to all conversations in my presence and concentrated on writing verbatim conversations between staff members and patients. Apart from this selectivity in my attention while in the field, I attempted to remain atheoretical or ahypothetical. A cardinal rule of ethnographic observation is to remain open to the situation. letting it guide your interests and concerns.'7 Only in this way can one refrain from adopting the perspective of any one group of participants and thereby obtain data that reflect the actual situations. Thus, after selecting the interaction between staff and patients as the primary object of my documentation, all things within that category were considered potentially relevant for the research. In addition, I collected supplementary data from sitting with patients during clinic and hospital sessions while they were between staff encounters and from spending long hours with staff members in "backstage" areas of the clinic and hospital units while they were not working directly with the patients. 1 8
Qualitative Analysis The strategies used to code and analyze the field notes were similar to Becker's stage three in the analysis of qualitative data.'9 I catalogued the data, inventoried the content of situations, and thus devised a list of topics, activities, and sequences in which these occurred. The field notes were then sorted chronologically, forming a model of the course of interactional events. I developed a composite narrative of the medical experience of low-risk women. The next stage involved the creation of the explanatory variables to account for the particular order in which topics occurred, the reason some never occurred, and the contradiction between remarks made to different patients. Certain features of the situation began to emerge as thematic clues: e.g., routinization of conversation between medical personnel and patients, and the providers' attempts to maintain control over both the physiological and social process of the pregnancy. I searched for competing interpretations that might also fit this course of interactions. I checked for negative findings by comparing my model's examples of a particular topic or sequence of the interaction against the full range of field notes filed in that category.20 I also compared my emerging interpretation with the perspectives of participants, as indicated in their own explanatory accounts, thereby incorporating but not limiting myself to the participants' causal beliefs or theories.2' In sum, representativeness of the data sampled, collected, and analyzed was maintained through a series of ethnographic techniques. One can only assume that were another researcher to sort through the material and reanalyze it, s/he would arrive at a similar model of obstetrical staff-patient interaction patterns. AJPH September 1979, Vol. 69, No. 9
The Findings A major theme in provider-patient interaction is the medical professional's attempts to assert control over the social process of labor. As I demonstrate, this type of control behavior is common among labor attendants, despite the fact that its risks and benefits are largely unknown. The dynamics of this social control are complicated because the doctor(s) and attending personnel have the option to exercise leverage over not only the interpretation of the labor and delivery, but also its physiological process. Thus, every assessment during labor and delivery has an instrumental component that cues the primary attendant to hold off, to continue on current course or procedure, or to modify that course and intervene in the events. Apart from those complications that necessitate recourse to radical intervention strategies, there are a variety of drug options, nursing staff protocols, monitoring and assessment technologies, and supportive and coaching techniques that can be utilized during childbirth. However, the patients were not usually presented with these possible treatment choices. Furthermore, a broad range of complications can occur. For example, from the "really natural" childbirth to the cesarean section deliveries that I observed, there was a wide range of analgesic aids and techniques for the stimulation of labor. Despite these variations that can dramatically affect the quality of the laboring experience, I observed little variation from one case to the next in the style and content of interactions between staff members and patients. This basically routinized manner of interpersonal interaction with patients differed only slightly from one staff person to the next, from one patient to another, and across the hospital settings. Illustrative data are presented from interactions occurring from early labor up to the point at which a woman is transferred to the delivery room. Throughout other stages of care, standard patterns of interaction are found. Only by viewing the childbearing process sequentially, however, and conducting a stage-by-stage analysis of its style and content can one appreciate the similarity that transcends individual situations. Furthermore, some implications of this routinization for the quality of the birthing woman's personal experience can be derived even when examples are limited to the early labor segment of the birth process. First Stage Labor: Staff Member Concerns The main task of the primary attendant at the early point in a woman's labor is to define the situation, both in terms of what is to be done about the physiological process and also in terms of interpreting the physiological indicators. What is occurring makes for either "good progress," "not much progress but normal," or "it's looking like you may need some help along the way here." The largely positive, global assessments given to patients are based on interpretations and instrumental decisions that carry predictions as to overall duration of birth and probable outcome. Patients and partners often listen to what the physicians are saying in the hope of learning such prognostic implications. They are not told, however, of the constantly changing predictions that are common throughout a typical routine labor. 897
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The reason given for providing general rather than more detailed assessments to patients is that patients in labor are believed to be in a state of anxious arousal. Nurses generally assumed that more information would be more stressful to the laboring women. Patients are thus told very little for therapeutic reasons. Attendants concentrate on calming activities rather than conveying information about, for example, the unpredictability of a typical labor. Staff members expect repeated questioning from patients, such as, "how much longer is it going to be?" The common reply is an uncertain, "I don't know; we just have to wait and see." What nurses discuss with one another, however, are the available contingency protocols. I frequently heard nurses discuss the ways in which a doctor might proceed and predict the factors affecting his/her decision-making. The patient generally does not know the extent to which factors other than her own physiological progress influence the choice of interventionary measures. For example, nurses at one unit often knew that pitocin augmentation of labor would not be undertaken until the primary doctor's office hours were finished. At another unit, they knew that the decision to perform a cesarean section generally came after office hours. It is not that after 5 or 6 p.m. the rhythms of labor in these patients could be more clearly established, but rather that this was a more convenient time for the doctor to begin a course of action that demanded closer and more concerted medical attention. Patients primarily hear variations on the theme of their "normal progress." Attendants assure them either that the labor is going well or that the staff is perfectly capable of handling minor problems. What is suggested to others, but not directly to the patient or couple, is a more complex version of the labor progress. This assessment includes possible intervention strategies, changing prognoses, and external, organizational contingencies that affect outcome.
Communication Range and Patient Passivity Constraints upon the interaction appear mutual. Yet they do not evolve in each particular case from a negotiation of the normative rules of the situation. The guides for conduct are taken as preconceived for individual patients by both parties. Staff make assumptions about categories of the needs of birthing women that fit their conceptions of their own work. Individual patients direct themselves to birthing in their own private way and to somehow avoiding disruption of the staff. Neither party seems to be aware of the extent to which their perspectives diverge. A good example of the way staff interests guide interactional norms is the discretionary practice of talking to women during contractions. The expectation that women become ego-oriented, reflective, withdrawn, or absorbed is common to many attendants. This belief leads to the proscription that the staff person should not interrupt a woman in this trancelike withdrawal, that s/he should "leave the quiet ones alone" during contractions. On the other hand, patients who, in response to contractions, act out anguish and despair by screaming, writhing, or thrashing about in bed are highly sanctioned. Such 898
behavior is not viewed as acceptable, but often leads to medical intervention, usually in the form of verbal admonishments or the administration of tranquilizing and/or pain-relieving medication. Among themselves, staff members view such patients with hostility or pity for "not being able to take it." Usually, an expressed low pain threshold is attributed to a person's weakness, not to the possibility that her labor might be difficult. If analgesic medication is not appropriate or warranted, a staff member may intervene with harsh instructions to quiet the patient. The following remarks from several nurses, delivered in a harsh, sharp manner, are evocative of a drill sergeant: "'Don't get so excited. C'mon. Don't let them overtake you." "Look, breathe with me. Blow the air out like you're blowing out a candle. Concentrate on it. That's it." "Slow down on your breathing, Irene." "Are you breathing that hard because it makes the contraction easier for you? You're breathing awfully hard, almost like you're not getting enough air." "Grow up, Diane." This type of talk suggests to the patient that the appropriate response to contractions is to remain calm and quiet, presumably because such behavior reflects the ability to cope well with the pain. Whether or not it is indicative of one's tolerance capacity, it clearly means less work for the staff members. Acting excited, on the other hand, signifies to the nurses that the women are not tolerating the pain and thus must need instruction, medication, or some other help. Nurses argue (as does Lamaze training) that fighting labor makes it harder and brings on fatigue and tension. Although the actual therapeutic benefits to remaining quiet are not known, patients are led to believe that they will "do better" by acting in such a fashion. In one instance, a nurse and a doctor were talking to a woman about how well she was doing her Lamaze breathing. They emphasized that the "correct way to do it is the quiet way. We don't need to hear 'em down the hall." The rules for proper birthing conduct are laid down for rather than negotiated with individual patients. The operating norm, while justified as relevant to the internal experience of coping, appears to bear more clearly upon staff work routines than it does upon the experience of contractions. Patients by and large conform to and accept these normative constraints and rarely question the rules as conveyed, much less disregard or violate them. Birthing women and their partners defer to the implicit and explicit rules and regulations of staff members. The only time their own views are solicited is when labor is about to be seriously altered by a staff procedure or when some form of patient permission is deemed necessary. As a pitocin induction is being set up, patients often will be asked if they understand the procedure. Before a cesarean section, patients' questions may be sought, even though most patients sign a waiver of certain rights in a blanket permission form upon hospital admission.
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Patients and expectant fathers who do not behave in deferential ways and who openly display dissident views are treated as if they are violating accepted norms. Husbands who express reservations about procedural actions on the part of staff are met with hostility. Patients who make requests for nonroutine variations in procedure are barely acknowledged, given some vague assurances, then disregarded. An illustration of the disregard of requests is given in the following excerpt: Early on, before labor was begun in a woman with ruptured membranes, the patient makes a comment to the observer and nurse who is setting up the IV drip machine. Patient: "I'm glad it's Dr. _ _that's in today. He'll do Leboyer." Nurse: "Oh, yeah, he does pretty much what you want him to do. What do you want, the lights dimmed, or what?" [Very dry tone of voice, eyes rolling.] Patient: "Well, whatever." The conversation drops off. As it turned out, she had a rapid delivery and no other mention or action was ever made with respect to this request for Leboyer methods. It was clear from the nurse's response that the inquiry would not be taken seriously, that the option to do this set of things suggested by Leboyer was not present.
Suspicious reactions to a doctor's plans for intervention are usually met with the doctor's hostile declaration of his/ her superior ability to judge, based on years of experience, as in the following example: The husband first presented his objection to pitocin stimulation of labor to the nurse, who replied, "Well, she's putzying around." She further explains that when a patient has ruptured membranes, "we like to get the baby out within 24 hours." Later, he repeated to the doctor that he "'thought this wasn't recommended." The doctor answered him by referring to his 10 years of obstetrical experience and giving greater weight to his judgment that the risks of complications from waiting and not implementing the induction were greater than those posed by the procedure. He equated the father's implied suggestion with medical irresponsibility, by portraying the possible negative consequences of not complying with his order. This classic use of authority strips the lay person's perspective of any validity in comparison to the expert's privileged access to information.22 Thus, the patient is left with no option except to conform to the passive stereotype and place complete trust in the doctor's autonomy. In fact, encouraging such patient behavior is defined as therapeutic. Just as the bus driver says, "let us do the worrying," and the insurance agent claims, "you're in good hands," the staff experts assume that "the less anxiety you have, the better off you'll be." This suggestion is the implicit normative rule provided in the pattern of restricted exchanges between staff AJPH September 1979, Vol. 69, No. 9
and patients in hospital labor settings. The two types of feedback commonly given during early labor are: a) assessments that normalize the situation and protect a patient from full information; and b) directions that encourage a manageable form of patient behavior. Both patterns of verbal behavior have advantages for the work routine of birth attendants, even though they promote distance between lay and professional understanding of the situation.
Potential Inconsistency with Patient Welfare Thus, throughout a typical course of labor, neither staff members nor patients learn much about the other's very different concerns. While there may be some reciprocal exchange of information, the staff seek only minimal information as to the woman's experience of labor, and the patients obtain only bare knowledge of the prognostic evaluation of labor. Neither party requests large amounts of patient input into the decision-making process. Basically, the patient's perception of the situation remains unexplored, irrelevant to the course of labor. It is as if the woman's views have no effect upon the physiological events. At least, this is the modus operandi of the staff as long as her perceptions are not verbalized by her or her partner. And, as is evidenced in the above examples, patients frequently refrain from expressing their views or questioning the staff. Only expressions of pain or pain tolerance are recognized or dealt with throughout the labor. Undoubtedly, contractions are the primary concern of the women: enduring each one and getting through the seemingly unending series. However, it is possible that by dealing with other ramifications of the pain, the quality of the pain and thereby one's coping capacity could be modified. Some women might cope more easily with the sensations by talking about their intensity, while others might find relief through expression of altered mood states or emotional duress. Some might interpret their sensations in terms of the baby's activity in utero and/or the uterine changes that bring about his/her emergence into the external world. Some might monitor their own ability to cope and have their opinions of the situation, of themselves, and of their coping behaviors validated by others throughout the labor. Some of the literature on pregnancy lends support to the notion that women may exhibit a heightened sense of vulnerability and dependence on others while undergoing these vast biological changes.23-25 Miller, in a sociological study of the social meanings people attach to pregnancy, finds that women rely on their doctors' assessments of well-being to validate their own feelings and confidence.ttt In my study, general, nonspecific assessments to this effect were automatically given by labor attendants, regardless of patient cues. I was not able to systematically investigate the effects of this nonvarying feedback. However, the restrictive potential of the limited range of interaction between women and those who in some sense tttRita S. Miller, unpublished PhD dissertation, "Pregnancy: The Social Meaning of a Physiological Event," New York University, 1972. 899
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control the birth process poses the question of an outcome effect on the transition to motherhood and on the health and well-being of both mother and baby. The general issue of the erects of staff-patient transactions in birth has to do with the complex set of factors of environmental stress, emotional or psychological distress, and onset or aggravation of illness. My suggestion is that future studies attempt to measure actual effects of providers' actions and interventions on the individuals under their care and separate out the various effects of structures of communication and other environmental factors on the outcomes of well-being. This data base was not large enough to examine, for example, what variations in initial contact behavior and in mothers' evaluations of childbirth were associated with different patterns of interaction with birth attendants.
Implications for Family Beginnings By describing one stage in the childbearing process in terms of the types of responses to the woman from staff members, I have characterized one factor that shapes the birth experience and indirectly influences the initial contact experience. What happens when a woman is handed her child for the first time may have tremendous consequences for the child's development, for family relationships, etc. What happens in the entire birth event-from how a woman experiences pain to how she is treated by others to how she feels about her baby-may affect the woman's psychological status: her self-esteem, her attitudes toward role performance in various spheres, her marital relationship, etc. If all women are routinely processed in the particular fashion I described, the results for birth experience are likely to depend upon the woman's expectations for birth. Shereshefsky found these expectations to be highly variable and important for adaption.26 While some women in her study looked forward to labor and delivery with a sense of completion and discovery, others expressed fears of bodily intactness and viewed it as a personal assault. For some women, the restrictive and normalizing feedback (coupled with a lack of physiological complications) might conform to their preconceived views of their births. They could feel quite gratified and their first attempts at parenting could be colored by the feeling of comfort and satisfaction. The opposite could be posited for women whose expectations leave them ill-prepared for the limited set of behaviors they are encouraged to display. Thus, staff communication may serve as a mediating influence upon the woman's assessment of childbirth and thereby her initial parenting experience. The woman's reactions, however, have not been analyzed in the manner in which I have treated the content and style of providerpatient interaction. Naturalistic understanding of women's attitudes would be an important extension of this study. Recently, the options available for maternity care have increased.27 Alternative types of birth settings and arrangements for postpartum/neonatal care have proliferated in the 1970s. The findings presented here imply the necessity for greater flexibility in the interpersonal treatment of women during labor. Another study on the importance of support 900
during labor for reducing pain and increasing enjoyment suggests the clinical benefits of more personal attention.28 In conclusion, it should be emphasized that communication with hospital staff is only one of many important influences on one's childbearing experience and on initial parenting. I have examined staff-patient interaction during childbirth, and interpreted the findings in terms of the routinization of work and the inhibition of patient behavior. The facts that (a) obstetric practices have been modified since the data were collected in 1976, and that (b) the associations suggested here have not been statistically tested do not affect the questions raised. Because the findings of restrictive treatment of women are representative of the environments in which this sample was drawn, they demonstrate that restraint on patient behavior may well occur without reference to individual patient welfare. In fact, such restrictions perpetrated by staff members and adhered to by patients appear to stem from the preconceived, untested, stereotypical models that doctors and nurses have of "'manageable" patients. Reassuring interactions and the imposition of behavioral norms are based on assumptions about what patients need, even though their effects on women and families are unknown.
REFERENCES 1. Bowden D, Winter P, and Ploog D: Pregnancy and delivery in the squirrel monkey (Saimiri sciureus) and other primates. Folia Primatologia 5:1-42, 1967. 2. Rosenblatt JS: Prepartum and Postpartum Regulation of Maternal Behavior in the Rat. In M Hofer (Ed): Mother-Infant Interaction. New York: Elsevier, 1975. 3. Hinde RA: Mothers' and Infants' Roles: Distinguishing the Questions to be Asked. In M Hofer (Ed): Mother-Infant Interaction. New York: Elsevier, 1975. 4. Hinde RA and Simpson MJA: Qualities of Mother-Infant Relationships in Monkeys. In M Hofer (Ed): Mother-Infant Interaction. New York: Elsevier, 1975. 5. Mead M and Newton N: Cultural Patterning of Perinatal Behavior. In S Richardson and A Guttmacher (Eds): ChildbearingIts Social and Psychological Aspects. Baltimore: Williams and Wilkins, 1967. 6. Rosengren W: Some social psychological aspects of delivery room difficulties. J Nerv Mental Disease 132:515-521, 1961. 7. Nuckolls KB, Cassel J, and Kaplan BH: Psychological assets, life crises, and the prognosis of pregnancy. Amer J Epidemiol 95:431-441, 1972. 8. Yang RK, Zweig AR, Douthitt TC, et al: Successive relationships between maternal attitudes during pregnancy, analgesic medication during labor and delivery, and newborn behavior. Dev Psych 12:6-14, 1976. 9. Zax M, SameroffAJ, and Farnum JE: Childbirth education, maternal attitudes, and delivery. Am J Obstet Gynecol 123:185190, 1975. 10. Davenport-Slack MS and Boylan CH: Psychological correlates of childbirth pain. Psychosom Med 36:215-223, 1974. 11. Newton N and Newton M: Mothers' reactions to their newborn babies. JAMA 181:206-210, 1962. 12. Klaus MH and Kennell JH: Maternal-Infant Bonding. St. Louis: Mosby, 1976. 13. Klaus MH, Leger T, and Trause MA (Eds): Maternal Disorders: A Round Table. Sausalito: Johnson and Johnson, 1974. 14. Werts CE, Gardiner SH, Mitchell K, et al: Factors related to behavior in labor. J Health Hum Behav 6:238-242, 1965. 15. Arnold DO: Dimensional sampling: An approach for studying a small number of cases. Amer Sociologist 5:147-150, 1970. 16. Danziger SK: On doctor watching: fieldwork in medical settings. Urban Life 7:513-532, 1979.
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TREATMENT OF WOMEN IN CHILDBIRTH 17. Bogdan R and Taylor SJ: Introduction to Qualitative Research Methods. New York: John Wiley, 1975. 18. Goffman E: The Presentation of Self in Everyday Life. Garden City, NY: Doubleday, 1959. 19. Becker HS: Problems of Inference and Proof in Participant Observation. In GJ McCall and JL Simmons (Eds): Issues in Participant Observation. Reading, MA: Addison-Wesley, 1969. 20. Denzin N: The logic of naturalistic inquiry. Social Forces 50:166-182, 1971. 21. Lofland J: Analyzing Social Settings. Belmont, CA: Wadsworth, 1971. 22. Danziger SK: Uses of expertise in doctor-patient encounters during pregnancy. Social Sci and Med 12:359-367, 1978. 23. McKinlay JB: The sick role-illness and pregnancy. Social Sci and Med 6:561-572, 1972. 24. Bardwick JM: Readings on the Psychology of Women. New York: Harper, 1972. 25. Anthony EJ and Benedek T: Parenthood-Its Psychology and Psychopathology. Boston: Little, Brown, 1970.
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26. Shereshefsky PM and Yarrow LJ (Eds): Psychological Aspects of a First Pregnancy and Early Postnatal Adaptation. New York: Raven, 1973. 27. Mehl LE: Options in maternity care. Women and Health 2:2942, 1977. 28. Norr KL, Block CR, Charles A. et al: Explaining pain and enjoyment in childbirth. J of Health Social Behav 18:260-275, 1977.
ACKNOWLEDGMENTS The research for this paper, based on data collected in 19751976, was sponsored through a predoctoral Health Services Research Traineeship, NIH, directed by George Psathas, Boston University, and a postdoctoral traineeship from NIMH, directed by David Mechanic, University of Wisconsin-Madison. I am indebted to Patricia MacCorquodale, Lewis Leavitt, and anonymous reviewers for their comments on earlier drafts.
Nursing Research Colloquium at Adelphia University Nov. 1-2
The Project for Research in Nursing (PRN), Adelphi University, School of Nursing, Garden City, LI, NY, will present its fourth research colloquium on November 1 and 2, 1979. Carol Lindemann, PhD, Dean of the School of Nursing and Associate Director of Nursing Service, Health Sciences Center, University of Oregon, is the featured speaker. On Thursday evening, November 1, she will present her extensive research on measuring quality of nursing care, and Friday morning, November 2, she will report on multiple studies investigating nurse-patient interactions. Dr. Lindemann will also be available by appointment for individual and small group research consultation during her two-day stay. The conference is free of charge and is open to the health-care community by reservation. For further information and/or reservations, contact the project co-directors, Dr. Jacqueline Rose Hott or Dr. Pierre Woog, (516) 294-8700, ext. 7674, or write to Adelphi University, School of Nursing, Garden City, Long Island, NY 11530.
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Abstract: This paper presents an ethnographic analysis of a woman's interaction with staff members during the early stage of labor, focusing on the factors that shape the childbirth experience. The observational data were gathered in several hospitals as part of a study of the medical context of childbearing. The pa-
per presents a model of naturalistic inquiry into the transition to parenthood. Nurses and physicians are found to offer arbitrary, uniform, and often inappropriate responses to birthing women that may inhibit well-being. (Am J Public Health 69:895-901, 1979.)
The social-psychological and culturally patterned aspects of childbirth, a critical transition in women's lives, have received little clinical attention. A model for such research may be adapted from ethological studies of mammals that differentiate the multiple factors in parturition that affect maternal-infant bonding. 1-4 Bowden, et al., in particular have documented the behavior occurring during pregnancy, birth, and the initial mother-neonate contact period (in the squirrel monkey, Saimiri sciureus). I The parallel first step of documenting human birth behavior in its "natural" cultural context, in this case in the typical U.S. hospital labor and delivery suite, is necessary for understanding the environmental factors affecting the childbearing experience. Sociological inquiry can illuminate the meaning of the birth event in a woman's life and, thereby, its effect on initial parental adaptation. In this paper, I present qualitative data on one important part of the birth experience, the content and style of interaction between the staff members and patients. Data derived from conversations during labor are examined for congruence versus conflict of interests between the laboring women and the staff experts for whom childbirth represents a series of work routines. After reporting some patterns of communication, the paper offers hypotheses about the quality of this interaction during labor and its influence on the transition to parenthood. This analysis of naturally occurring social behavior is considered as a pre-
liminary step toward understanding the relative importance of the childbirth experience for the long-term well-being of the family.
Address reprint requests to Sandra Klein Danziger, PhD, Department of Sociology, University of Wisconsin-Madison, 1180 Observatory Drive, Madison, WI 53706. This paper, submitted to the Journal September 1, 1978, was revised and accepted for publication March 30, 1979.
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Review of Prior Research Clinical studies of human birth behavior have examined only narrow concepts of the woman's experience, such as cultural variations in expressivenesss or pain tolerance.6 Other studies use physiological indicators of difficulty in birth,7-9 such as complications rate, labor length, and volume of analgesic medications used. In addition, previous studies have not focused on the variety of stress-producing aspects of the childbirth environment, such as the presence or absence of the father,10 the relationship with attending medical personnel, or the woman's expectations and degree of preparation for birth. For example, in a classic study of mothers' reactions to their newborns, Newton and Newton found that women who were less disturbed during labor, who remained calm and cooperative, tended to accept their babies upon first seeing them."l The accepting group and the indifferent or rejecting group of mothers also differed in terms of their personality, social class, education, and attitudes toward breast-feeding and other female biological functions. Calmness and cooperation during labor served as a proxy variable for tolerance of the birth environment. Newton and Newton do not consider that a woman's disruptiveness, rather than signaling an inability to cope, might represent a positive response to low pain threshold, uterine inefficiency, or lack of emotional preparedness or realistic expectations for birth. This suggests 895
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that further research distinguish environmentally induced from internal physical stresses as elicitors of emotional behavior. In addition, the fact that both calmness during birth and accepting behavior towards the new baby are socially approved responses confounds the results. Marshall Klaus* suggests that many normal women who later become positively attached to their infants do not "fall in love" with their newborns at first sight, despite what was previously thought about initial contact.'2' 13 Socialization may thus impel them to express maternal delight and to cooperate politely with the staff attendants.'4 Thus, a possible source of environmental stress could be the extent to which medical personnel exert pressure on laboring women to react in patterned ways. The issue of how behavior during labor is shaped by current situational pressures arises in my ethnographic work on obstetrical staff-patient interaction.** While this study does not address all the problems posed by other studies, it analyzes one neglected aspect of the childbirth environment, interaction with medical staff.
Data on Birth Interaction Data on the style and content of conversations during labor were obtained in a participant observation study of the medical context of childbearing. Ethnographic field notes were collected over nine months in 1975-1976 in two of the three hospitals of a medium-sized Midwestern city. Interactions of specialist obstetrician-gynecologists, family practitioners, and nurses with patients and partners of patients were observed and recorded over the period. The data collection was designed to document the totality of events and activities that occurred and to describe the full context in which they took place. Like an anthropologist in an exotic land, I attempted to capture the full flavor and nuances of the sample of obstetrical activity that I witnessed. Any ethnographic work, however, is open to question as to whether the interpretations emerge from or are imposed on the field data. I attempted to ensure the representativeness of interaction occurring in this setting throughout the research process, particularly in the methods employed in selecting the settings and participants and in collecting and analyzing the data.
graphic locale was chosen out of convenience, the third hospital was eliminated from inclusion in the sample settings beits obstetrical services were similar in population served and in staff and facilities to the other two units. In addition, less systematic preliminary observations were conducted in private and public maternity wards in a large urban area in the Southwest during 1974. Although the range of obstetrical procedures and the rates of complication varied considerably in the two regions, the style and content of staff-patient communication were quite similar. After I had gained access to the two Midwestern hospitals, I chose one clinic associated with each hospital. The clinics were selected to provide systematic variation in medical staff.'5 One was staffed by three obstetrician-gynecologists and the other was a medical school-based family practice clinic where four residents had substantial case loads of obstetric patients. Having chosen the two facilities and, hence, seven physicians, I accompanied each one as s/he attended pregnant patients over randomly chosen clinic sessions. After observing for about two months, I obtained a sample of women whom I had observed receiving first or second trimester prenatal care. I included only low-risk patients who were typical of the patient population of each practice. This resulted in my collecting data on all staff-patient interaction occurring over much of prenatal care and the full labor and delivery of a dozen women.t The patients in the sample were fairly homogeneous, middle class, pregnant with a first or second child, and enrolled in some form of childbirth education. In addition, I followed labor and delivery nurses over a two-month period, observing patient care in the hospital used by the three specialists. I collected this hospital data by working a full 7-3, 3-11, or 11-7 shift two or three times a week for about eight weeks.tt I thus recorded interaction at all times of the hospital day with almost all its maternity staff, the registered nurses and licensed practical nurses. This produced a second sample of 13 patients, who were observed only during childbirth. These women were randomly chosen by their being in labor or delivery while I happened to be at the hospital. Thus, the total number of birth episodes in which data were collected, including the first longitudinal and second samples, was 25 cases. cause
Selection of Research Settings and Participants The two maternity wards in which observations took place represent the full range of care available to "lowrisk"*** women in the geographic region. While the geo-
Data Coflection Procedures Conducting observations in a field setting involves the careful balancing of one's involvement in the participants' everyday world against the research goal of obtaining accurate information.'6 First, one attempts to collect field notes that are representative of what actually occurred by writing
*Marshall H. Klaus, talk on "Biologic Basis for the Process of Parental Attachment" at Milwaukee Birth without Violence Conference, 1978. **Sandra Klein Danziger, unpublished PhD dissertation, "The Medical Context of Childbearing: A Study of Social Control in Doctor-Patient Interactions," Boston University, 1978. ***The term "low-risk" is used loosely to designate all women not diagnosed as "high-risk" cases. Women with difficult pregnancies or with histories of serious obstetrical problems were excluded from the sample. High-risk care is presumably not comparable to treatment administered during a normal childbirth.
tOf the 18 women selected for inclusion, five refused to participate. The reason used in each case was that the husband preferred that an outside observer not be allowed to attend the birth. The thirteenth woman was followed prenatally, but she was unable at the time of her labor and delivery to contact the researcher. ttOf the 20 eight-hour work shifts on which I collected observations by following the nurses, eight were a.m., nine were p.m., and three were night shifts. I was less able to avoid nights when I observed the labor and delivery of the longitudinal cases. Of the dozen women followed, four had labors that lasted less than seven hours, five labored seven to 15 hours, and three labored 24 hours or longer.
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everything down soon after leaving the field and having others read the notes for consistency and clarity. Whenever there were uncertainties in the data, I inquired about the instance later during the same observation period. I asked doctors after the patient left about his or her choice of procedure or, when the doctor left, I asked the patient about her views of what had transpired. During labor and delivery, I listened carefully to all conversations in my presence and concentrated on writing verbatim conversations between staff members and patients. Apart from this selectivity in my attention while in the field, I attempted to remain atheoretical or ahypothetical. A cardinal rule of ethnographic observation is to remain open to the situation. letting it guide your interests and concerns.'7 Only in this way can one refrain from adopting the perspective of any one group of participants and thereby obtain data that reflect the actual situations. Thus, after selecting the interaction between staff and patients as the primary object of my documentation, all things within that category were considered potentially relevant for the research. In addition, I collected supplementary data from sitting with patients during clinic and hospital sessions while they were between staff encounters and from spending long hours with staff members in "backstage" areas of the clinic and hospital units while they were not working directly with the patients. 1 8
Qualitative Analysis The strategies used to code and analyze the field notes were similar to Becker's stage three in the analysis of qualitative data.'9 I catalogued the data, inventoried the content of situations, and thus devised a list of topics, activities, and sequences in which these occurred. The field notes were then sorted chronologically, forming a model of the course of interactional events. I developed a composite narrative of the medical experience of low-risk women. The next stage involved the creation of the explanatory variables to account for the particular order in which topics occurred, the reason some never occurred, and the contradiction between remarks made to different patients. Certain features of the situation began to emerge as thematic clues: e.g., routinization of conversation between medical personnel and patients, and the providers' attempts to maintain control over both the physiological and social process of the pregnancy. I searched for competing interpretations that might also fit this course of interactions. I checked for negative findings by comparing my model's examples of a particular topic or sequence of the interaction against the full range of field notes filed in that category.20 I also compared my emerging interpretation with the perspectives of participants, as indicated in their own explanatory accounts, thereby incorporating but not limiting myself to the participants' causal beliefs or theories.2' In sum, representativeness of the data sampled, collected, and analyzed was maintained through a series of ethnographic techniques. One can only assume that were another researcher to sort through the material and reanalyze it, s/he would arrive at a similar model of obstetrical staff-patient interaction patterns. AJPH September 1979, Vol. 69, No. 9
The Findings A major theme in provider-patient interaction is the medical professional's attempts to assert control over the social process of labor. As I demonstrate, this type of control behavior is common among labor attendants, despite the fact that its risks and benefits are largely unknown. The dynamics of this social control are complicated because the doctor(s) and attending personnel have the option to exercise leverage over not only the interpretation of the labor and delivery, but also its physiological process. Thus, every assessment during labor and delivery has an instrumental component that cues the primary attendant to hold off, to continue on current course or procedure, or to modify that course and intervene in the events. Apart from those complications that necessitate recourse to radical intervention strategies, there are a variety of drug options, nursing staff protocols, monitoring and assessment technologies, and supportive and coaching techniques that can be utilized during childbirth. However, the patients were not usually presented with these possible treatment choices. Furthermore, a broad range of complications can occur. For example, from the "really natural" childbirth to the cesarean section deliveries that I observed, there was a wide range of analgesic aids and techniques for the stimulation of labor. Despite these variations that can dramatically affect the quality of the laboring experience, I observed little variation from one case to the next in the style and content of interactions between staff members and patients. This basically routinized manner of interpersonal interaction with patients differed only slightly from one staff person to the next, from one patient to another, and across the hospital settings. Illustrative data are presented from interactions occurring from early labor up to the point at which a woman is transferred to the delivery room. Throughout other stages of care, standard patterns of interaction are found. Only by viewing the childbearing process sequentially, however, and conducting a stage-by-stage analysis of its style and content can one appreciate the similarity that transcends individual situations. Furthermore, some implications of this routinization for the quality of the birthing woman's personal experience can be derived even when examples are limited to the early labor segment of the birth process. First Stage Labor: Staff Member Concerns The main task of the primary attendant at the early point in a woman's labor is to define the situation, both in terms of what is to be done about the physiological process and also in terms of interpreting the physiological indicators. What is occurring makes for either "good progress," "not much progress but normal," or "it's looking like you may need some help along the way here." The largely positive, global assessments given to patients are based on interpretations and instrumental decisions that carry predictions as to overall duration of birth and probable outcome. Patients and partners often listen to what the physicians are saying in the hope of learning such prognostic implications. They are not told, however, of the constantly changing predictions that are common throughout a typical routine labor. 897
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The reason given for providing general rather than more detailed assessments to patients is that patients in labor are believed to be in a state of anxious arousal. Nurses generally assumed that more information would be more stressful to the laboring women. Patients are thus told very little for therapeutic reasons. Attendants concentrate on calming activities rather than conveying information about, for example, the unpredictability of a typical labor. Staff members expect repeated questioning from patients, such as, "how much longer is it going to be?" The common reply is an uncertain, "I don't know; we just have to wait and see." What nurses discuss with one another, however, are the available contingency protocols. I frequently heard nurses discuss the ways in which a doctor might proceed and predict the factors affecting his/her decision-making. The patient generally does not know the extent to which factors other than her own physiological progress influence the choice of interventionary measures. For example, nurses at one unit often knew that pitocin augmentation of labor would not be undertaken until the primary doctor's office hours were finished. At another unit, they knew that the decision to perform a cesarean section generally came after office hours. It is not that after 5 or 6 p.m. the rhythms of labor in these patients could be more clearly established, but rather that this was a more convenient time for the doctor to begin a course of action that demanded closer and more concerted medical attention. Patients primarily hear variations on the theme of their "normal progress." Attendants assure them either that the labor is going well or that the staff is perfectly capable of handling minor problems. What is suggested to others, but not directly to the patient or couple, is a more complex version of the labor progress. This assessment includes possible intervention strategies, changing prognoses, and external, organizational contingencies that affect outcome.
Communication Range and Patient Passivity Constraints upon the interaction appear mutual. Yet they do not evolve in each particular case from a negotiation of the normative rules of the situation. The guides for conduct are taken as preconceived for individual patients by both parties. Staff make assumptions about categories of the needs of birthing women that fit their conceptions of their own work. Individual patients direct themselves to birthing in their own private way and to somehow avoiding disruption of the staff. Neither party seems to be aware of the extent to which their perspectives diverge. A good example of the way staff interests guide interactional norms is the discretionary practice of talking to women during contractions. The expectation that women become ego-oriented, reflective, withdrawn, or absorbed is common to many attendants. This belief leads to the proscription that the staff person should not interrupt a woman in this trancelike withdrawal, that s/he should "leave the quiet ones alone" during contractions. On the other hand, patients who, in response to contractions, act out anguish and despair by screaming, writhing, or thrashing about in bed are highly sanctioned. Such 898
behavior is not viewed as acceptable, but often leads to medical intervention, usually in the form of verbal admonishments or the administration of tranquilizing and/or pain-relieving medication. Among themselves, staff members view such patients with hostility or pity for "not being able to take it." Usually, an expressed low pain threshold is attributed to a person's weakness, not to the possibility that her labor might be difficult. If analgesic medication is not appropriate or warranted, a staff member may intervene with harsh instructions to quiet the patient. The following remarks from several nurses, delivered in a harsh, sharp manner, are evocative of a drill sergeant: "'Don't get so excited. C'mon. Don't let them overtake you." "Look, breathe with me. Blow the air out like you're blowing out a candle. Concentrate on it. That's it." "Slow down on your breathing, Irene." "Are you breathing that hard because it makes the contraction easier for you? You're breathing awfully hard, almost like you're not getting enough air." "Grow up, Diane." This type of talk suggests to the patient that the appropriate response to contractions is to remain calm and quiet, presumably because such behavior reflects the ability to cope well with the pain. Whether or not it is indicative of one's tolerance capacity, it clearly means less work for the staff members. Acting excited, on the other hand, signifies to the nurses that the women are not tolerating the pain and thus must need instruction, medication, or some other help. Nurses argue (as does Lamaze training) that fighting labor makes it harder and brings on fatigue and tension. Although the actual therapeutic benefits to remaining quiet are not known, patients are led to believe that they will "do better" by acting in such a fashion. In one instance, a nurse and a doctor were talking to a woman about how well she was doing her Lamaze breathing. They emphasized that the "correct way to do it is the quiet way. We don't need to hear 'em down the hall." The rules for proper birthing conduct are laid down for rather than negotiated with individual patients. The operating norm, while justified as relevant to the internal experience of coping, appears to bear more clearly upon staff work routines than it does upon the experience of contractions. Patients by and large conform to and accept these normative constraints and rarely question the rules as conveyed, much less disregard or violate them. Birthing women and their partners defer to the implicit and explicit rules and regulations of staff members. The only time their own views are solicited is when labor is about to be seriously altered by a staff procedure or when some form of patient permission is deemed necessary. As a pitocin induction is being set up, patients often will be asked if they understand the procedure. Before a cesarean section, patients' questions may be sought, even though most patients sign a waiver of certain rights in a blanket permission form upon hospital admission.
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Patients and expectant fathers who do not behave in deferential ways and who openly display dissident views are treated as if they are violating accepted norms. Husbands who express reservations about procedural actions on the part of staff are met with hostility. Patients who make requests for nonroutine variations in procedure are barely acknowledged, given some vague assurances, then disregarded. An illustration of the disregard of requests is given in the following excerpt: Early on, before labor was begun in a woman with ruptured membranes, the patient makes a comment to the observer and nurse who is setting up the IV drip machine. Patient: "I'm glad it's Dr. _ _that's in today. He'll do Leboyer." Nurse: "Oh, yeah, he does pretty much what you want him to do. What do you want, the lights dimmed, or what?" [Very dry tone of voice, eyes rolling.] Patient: "Well, whatever." The conversation drops off. As it turned out, she had a rapid delivery and no other mention or action was ever made with respect to this request for Leboyer methods. It was clear from the nurse's response that the inquiry would not be taken seriously, that the option to do this set of things suggested by Leboyer was not present.
Suspicious reactions to a doctor's plans for intervention are usually met with the doctor's hostile declaration of his/ her superior ability to judge, based on years of experience, as in the following example: The husband first presented his objection to pitocin stimulation of labor to the nurse, who replied, "Well, she's putzying around." She further explains that when a patient has ruptured membranes, "we like to get the baby out within 24 hours." Later, he repeated to the doctor that he "'thought this wasn't recommended." The doctor answered him by referring to his 10 years of obstetrical experience and giving greater weight to his judgment that the risks of complications from waiting and not implementing the induction were greater than those posed by the procedure. He equated the father's implied suggestion with medical irresponsibility, by portraying the possible negative consequences of not complying with his order. This classic use of authority strips the lay person's perspective of any validity in comparison to the expert's privileged access to information.22 Thus, the patient is left with no option except to conform to the passive stereotype and place complete trust in the doctor's autonomy. In fact, encouraging such patient behavior is defined as therapeutic. Just as the bus driver says, "let us do the worrying," and the insurance agent claims, "you're in good hands," the staff experts assume that "the less anxiety you have, the better off you'll be." This suggestion is the implicit normative rule provided in the pattern of restricted exchanges between staff AJPH September 1979, Vol. 69, No. 9
and patients in hospital labor settings. The two types of feedback commonly given during early labor are: a) assessments that normalize the situation and protect a patient from full information; and b) directions that encourage a manageable form of patient behavior. Both patterns of verbal behavior have advantages for the work routine of birth attendants, even though they promote distance between lay and professional understanding of the situation.
Potential Inconsistency with Patient Welfare Thus, throughout a typical course of labor, neither staff members nor patients learn much about the other's very different concerns. While there may be some reciprocal exchange of information, the staff seek only minimal information as to the woman's experience of labor, and the patients obtain only bare knowledge of the prognostic evaluation of labor. Neither party requests large amounts of patient input into the decision-making process. Basically, the patient's perception of the situation remains unexplored, irrelevant to the course of labor. It is as if the woman's views have no effect upon the physiological events. At least, this is the modus operandi of the staff as long as her perceptions are not verbalized by her or her partner. And, as is evidenced in the above examples, patients frequently refrain from expressing their views or questioning the staff. Only expressions of pain or pain tolerance are recognized or dealt with throughout the labor. Undoubtedly, contractions are the primary concern of the women: enduring each one and getting through the seemingly unending series. However, it is possible that by dealing with other ramifications of the pain, the quality of the pain and thereby one's coping capacity could be modified. Some women might cope more easily with the sensations by talking about their intensity, while others might find relief through expression of altered mood states or emotional duress. Some might interpret their sensations in terms of the baby's activity in utero and/or the uterine changes that bring about his/her emergence into the external world. Some might monitor their own ability to cope and have their opinions of the situation, of themselves, and of their coping behaviors validated by others throughout the labor. Some of the literature on pregnancy lends support to the notion that women may exhibit a heightened sense of vulnerability and dependence on others while undergoing these vast biological changes.23-25 Miller, in a sociological study of the social meanings people attach to pregnancy, finds that women rely on their doctors' assessments of well-being to validate their own feelings and confidence.ttt In my study, general, nonspecific assessments to this effect were automatically given by labor attendants, regardless of patient cues. I was not able to systematically investigate the effects of this nonvarying feedback. However, the restrictive potential of the limited range of interaction between women and those who in some sense tttRita S. Miller, unpublished PhD dissertation, "Pregnancy: The Social Meaning of a Physiological Event," New York University, 1972. 899
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control the birth process poses the question of an outcome effect on the transition to motherhood and on the health and well-being of both mother and baby. The general issue of the erects of staff-patient transactions in birth has to do with the complex set of factors of environmental stress, emotional or psychological distress, and onset or aggravation of illness. My suggestion is that future studies attempt to measure actual effects of providers' actions and interventions on the individuals under their care and separate out the various effects of structures of communication and other environmental factors on the outcomes of well-being. This data base was not large enough to examine, for example, what variations in initial contact behavior and in mothers' evaluations of childbirth were associated with different patterns of interaction with birth attendants.
Implications for Family Beginnings By describing one stage in the childbearing process in terms of the types of responses to the woman from staff members, I have characterized one factor that shapes the birth experience and indirectly influences the initial contact experience. What happens when a woman is handed her child for the first time may have tremendous consequences for the child's development, for family relationships, etc. What happens in the entire birth event-from how a woman experiences pain to how she is treated by others to how she feels about her baby-may affect the woman's psychological status: her self-esteem, her attitudes toward role performance in various spheres, her marital relationship, etc. If all women are routinely processed in the particular fashion I described, the results for birth experience are likely to depend upon the woman's expectations for birth. Shereshefsky found these expectations to be highly variable and important for adaption.26 While some women in her study looked forward to labor and delivery with a sense of completion and discovery, others expressed fears of bodily intactness and viewed it as a personal assault. For some women, the restrictive and normalizing feedback (coupled with a lack of physiological complications) might conform to their preconceived views of their births. They could feel quite gratified and their first attempts at parenting could be colored by the feeling of comfort and satisfaction. The opposite could be posited for women whose expectations leave them ill-prepared for the limited set of behaviors they are encouraged to display. Thus, staff communication may serve as a mediating influence upon the woman's assessment of childbirth and thereby her initial parenting experience. The woman's reactions, however, have not been analyzed in the manner in which I have treated the content and style of providerpatient interaction. Naturalistic understanding of women's attitudes would be an important extension of this study. Recently, the options available for maternity care have increased.27 Alternative types of birth settings and arrangements for postpartum/neonatal care have proliferated in the 1970s. The findings presented here imply the necessity for greater flexibility in the interpersonal treatment of women during labor. Another study on the importance of support 900
during labor for reducing pain and increasing enjoyment suggests the clinical benefits of more personal attention.28 In conclusion, it should be emphasized that communication with hospital staff is only one of many important influences on one's childbearing experience and on initial parenting. I have examined staff-patient interaction during childbirth, and interpreted the findings in terms of the routinization of work and the inhibition of patient behavior. The facts that (a) obstetric practices have been modified since the data were collected in 1976, and that (b) the associations suggested here have not been statistically tested do not affect the questions raised. Because the findings of restrictive treatment of women are representative of the environments in which this sample was drawn, they demonstrate that restraint on patient behavior may well occur without reference to individual patient welfare. In fact, such restrictions perpetrated by staff members and adhered to by patients appear to stem from the preconceived, untested, stereotypical models that doctors and nurses have of "'manageable" patients. Reassuring interactions and the imposition of behavioral norms are based on assumptions about what patients need, even though their effects on women and families are unknown.
REFERENCES 1. Bowden D, Winter P, and Ploog D: Pregnancy and delivery in the squirrel monkey (Saimiri sciureus) and other primates. Folia Primatologia 5:1-42, 1967. 2. Rosenblatt JS: Prepartum and Postpartum Regulation of Maternal Behavior in the Rat. In M Hofer (Ed): Mother-Infant Interaction. New York: Elsevier, 1975. 3. Hinde RA: Mothers' and Infants' Roles: Distinguishing the Questions to be Asked. In M Hofer (Ed): Mother-Infant Interaction. New York: Elsevier, 1975. 4. Hinde RA and Simpson MJA: Qualities of Mother-Infant Relationships in Monkeys. In M Hofer (Ed): Mother-Infant Interaction. New York: Elsevier, 1975. 5. Mead M and Newton N: Cultural Patterning of Perinatal Behavior. In S Richardson and A Guttmacher (Eds): ChildbearingIts Social and Psychological Aspects. Baltimore: Williams and Wilkins, 1967. 6. Rosengren W: Some social psychological aspects of delivery room difficulties. J Nerv Mental Disease 132:515-521, 1961. 7. Nuckolls KB, Cassel J, and Kaplan BH: Psychological assets, life crises, and the prognosis of pregnancy. Amer J Epidemiol 95:431-441, 1972. 8. Yang RK, Zweig AR, Douthitt TC, et al: Successive relationships between maternal attitudes during pregnancy, analgesic medication during labor and delivery, and newborn behavior. Dev Psych 12:6-14, 1976. 9. Zax M, SameroffAJ, and Farnum JE: Childbirth education, maternal attitudes, and delivery. Am J Obstet Gynecol 123:185190, 1975. 10. Davenport-Slack MS and Boylan CH: Psychological correlates of childbirth pain. Psychosom Med 36:215-223, 1974. 11. Newton N and Newton M: Mothers' reactions to their newborn babies. JAMA 181:206-210, 1962. 12. Klaus MH and Kennell JH: Maternal-Infant Bonding. St. Louis: Mosby, 1976. 13. Klaus MH, Leger T, and Trause MA (Eds): Maternal Disorders: A Round Table. Sausalito: Johnson and Johnson, 1974. 14. Werts CE, Gardiner SH, Mitchell K, et al: Factors related to behavior in labor. J Health Hum Behav 6:238-242, 1965. 15. Arnold DO: Dimensional sampling: An approach for studying a small number of cases. Amer Sociologist 5:147-150, 1970. 16. Danziger SK: On doctor watching: fieldwork in medical settings. Urban Life 7:513-532, 1979.
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TREATMENT OF WOMEN IN CHILDBIRTH 17. Bogdan R and Taylor SJ: Introduction to Qualitative Research Methods. New York: John Wiley, 1975. 18. Goffman E: The Presentation of Self in Everyday Life. Garden City, NY: Doubleday, 1959. 19. Becker HS: Problems of Inference and Proof in Participant Observation. In GJ McCall and JL Simmons (Eds): Issues in Participant Observation. Reading, MA: Addison-Wesley, 1969. 20. Denzin N: The logic of naturalistic inquiry. Social Forces 50:166-182, 1971. 21. Lofland J: Analyzing Social Settings. Belmont, CA: Wadsworth, 1971. 22. Danziger SK: Uses of expertise in doctor-patient encounters during pregnancy. Social Sci and Med 12:359-367, 1978. 23. McKinlay JB: The sick role-illness and pregnancy. Social Sci and Med 6:561-572, 1972. 24. Bardwick JM: Readings on the Psychology of Women. New York: Harper, 1972. 25. Anthony EJ and Benedek T: Parenthood-Its Psychology and Psychopathology. Boston: Little, Brown, 1970.
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26. Shereshefsky PM and Yarrow LJ (Eds): Psychological Aspects of a First Pregnancy and Early Postnatal Adaptation. New York: Raven, 1973. 27. Mehl LE: Options in maternity care. Women and Health 2:2942, 1977. 28. Norr KL, Block CR, Charles A. et al: Explaining pain and enjoyment in childbirth. J of Health Social Behav 18:260-275, 1977.
ACKNOWLEDGMENTS The research for this paper, based on data collected in 19751976, was sponsored through a predoctoral Health Services Research Traineeship, NIH, directed by George Psathas, Boston University, and a postdoctoral traineeship from NIMH, directed by David Mechanic, University of Wisconsin-Madison. I am indebted to Patricia MacCorquodale, Lewis Leavitt, and anonymous reviewers for their comments on earlier drafts.
Nursing Research Colloquium at Adelphia University Nov. 1-2
The Project for Research in Nursing (PRN), Adelphi University, School of Nursing, Garden City, LI, NY, will present its fourth research colloquium on November 1 and 2, 1979. Carol Lindemann, PhD, Dean of the School of Nursing and Associate Director of Nursing Service, Health Sciences Center, University of Oregon, is the featured speaker. On Thursday evening, November 1, she will present her extensive research on measuring quality of nursing care, and Friday morning, November 2, she will report on multiple studies investigating nurse-patient interactions. Dr. Lindemann will also be available by appointment for individual and small group research consultation during her two-day stay. The conference is free of charge and is open to the health-care community by reservation. For further information and/or reservations, contact the project co-directors, Dr. Jacqueline Rose Hott or Dr. Pierre Woog, (516) 294-8700, ext. 7674, or write to Adelphi University, School of Nursing, Garden City, Long Island, NY 11530.
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