A review of Debates on Gender and Technology: Cesarean Births in Taiwan, by Chen-I Kuan.
Through examining the conduct of cesarean sections in Taiwan Chen-I Kuan’s doctoral thesis contributes to bioethical debates surrounding gender and technology. Chapter 1 situates her thesis as being concerned with women’s “limited autonomy” in childbirth choices. She seeks to tread a middle ground between understanding women responses to modern medical childbirth as structurally determined or as expressions of unfettered decision-making. The theoretical hinterland of the project is the medicalization of childbirth (and, particularly, feminist critiques of that medicalization) and recent sociological conceptions of risk found in the work of Ulrich Beck, Anthony Giddens and Mary Douglas and Aaron Wildavsky.
Chapter 2 explores the Taiwanese context, specifically the political and economic landscape. Kuan presents an effective analysis of media, professional and scientific discourses around childbirth and, specifically, cesarean section conducting her analysis in terms of “risk”. Drawing on a range of sources she explores the diversity and conflicting aspects of the messages Taiwanese women are presented with regarding the “best” “option” for childbirth. Various discourses present vaginal birth as ideal while also presenting cesareans as less dangerous, less risky, and, furthermore, reinforcing the women’s (notional) right to choose. The cesarean section is presented as normalized, creating the idea that there are two modes of childbirth and, while one is understood to be replete with potential complications, the invasive surgical aspect of the other is rendered neutral in cost-benefit analysis. It is only the unintended complications of cesarean sections that are understood negatively. In the case of vaginal births all consequences are obstetrically unintended. Kuan shows the risk analysis of childbirth discourses to be skewed by the social organization of childbirth in Taiwan, a country which has almost no midwives.
In Chapter 3 Kuan analyses a range of materials that define the debate surrounding Taiwan’s high levels of cesarean sections. She shows how the technology is presented as “good” while women are presented as “bad” for their supposed choice to use this good technology. Kuan argues that the information mothers-to-be are given about childbirth constructs them as scientifically illiterate. This is reinforced by the semi-urban myth that women seek to schedule cesarean sections such that their child will be born at an auspicious time, according to the traditional “Bazi” belief system. Kuan argues that it is not the case that women have sufficient control over the decision-making to schedule cesarean sections and select “lucky birthing days”. Women are also presented as choosing cesareans in order to avoid the pain of vaginal childbirth. Kuan demonstrates that this assumes that having a cesarean section is a painless mode of delivery and certainly less painful than a vaginal delivery. However if one accounts for the relative difference in post birth pain experienced by women this assumption is overturned. In the concluding discussion of this chapter Kuan shows precisely what little power women have in choosing between vaginal and cesarean birth by focusing on the scarcity of Vaginal Birth After Cesarean (VBAC). Despite this being a safe option the professional approach remains “once a cesarean always a cesarean” and women who actively pursue a vaginal delivery following a cesarean are, more often than not, unsuccessful.
The uses of monitoring technologies to assess risk is the predominant focus of Chapters 4 and 5 which explore how the size and position of the fetus, as well as the size of the pregnant women’s pelvis, are used by obstetricians to estimate the chance of a successful vaginal delivery. Even a slightly larger than average fetus can prompt an obstetrician to induce labor, an intervention that can increase the chances of childbirth ending in a cesarean. Furthermore, induction is also used as a response to relatively minimal amounts of suffering in the latter stages of pregnancy and for the purposes of scheduling childbirth. The natural schedule of pregnancy and childbirth forms a timetable that medical technology is used to “risk” assess and control according to the predominate values of Taiwanese biomedicine. It is also clear that rather than being a standard expectation a vaginal delivery is considered merely a possibility, an outcome that may or may not be achieved depending on favorable circumstances. Thus in cases where the circumstances are read as unfavorable this rapidly results in vaginal delivery being considered unlikely and therefore not worth attempting. Monitoring technologies “manufacture risks” that require responses. Such medical activity makes a normal, vaginal birth less, not more, likely.
Chapter 6 continues discussion of the structural aspects that contribute to obstetricians electing to perform cesarean sections. The theme of risk management is again central. It is evident that Taiwanese obstetricians increasingly attempt to protect themselves against real and imagined risks of childbirth, and potential lawsuits, through recourse to cesarean sections. Certainly Taiwanese obstetricians possess some of the greatest skill in the world at performing cesarean sections. Nevertheless, those who actively promote vaginal birth do so as a moral commitment. Despite these structural imperatives as well as the media and professional discourses that push women towards surgical birth Kuan finds that women tend to actively prefer a vaginal birth. This is predominantly based on the idea that, despite the attendant pain, it is the natural way to give birth. Despite the effects of surgical births being under emphasized by obstetricians women are aware of the potential consequences, including the extended stay in hospital. Nevertheless, cesarean sections are widely perceived as safe and some women do pre-emptively request them so as to avoid pain and potential harm to their sexual lives, something that occasionally also concerns their husbands. Women were also concerned for the health of their child and how they could best ensure their well-being. In seeking to control the mode of their delivery Taiwanese women are caught between various priorities that alternately nudge them towards vaginal and cesarean childbirth.
The final Chapter 7 addresses Taiwanese women’s requests for cesarean sections and the idea of women as pragmatic actors. The first section concerns the idea of “suffering twice” a term used to refer to women who labor for a vaginal birth but, nevertheless, end up having a cesarean section. Some women also request cesareans as a way to avoid the dehumanizing aspects of the organization of childbirth. In the second part the focus is on women as reflexive actors who, like their obstetricians, attempt to evaluate and pragmatically negotiate the risks of childbirth.
In her conclusion Kuan offers an excellent overview of the forgoing analysis. She drives home her conclusion that, in contrast to feminist models, Taiwanese women collude with the medicalization of childbirth as a way to pursue, rather than relinquish, control. With the absence of midwifes and the different discourses of natural child birth the Taiwanese landscape differs significantly to that found in extant studies of Western countries. Nevertheless the sociology of risk remains a relevant theoretical basis for analysis and, on this basis, Kuan’s study offers significant insight into the Taiwanese context.
Dr Nathan Emmerich
School of Sociology, Social Policy and Social Work
Queen’s University Belfast
Primary and Intellectual Sources
Fieldwork in Taiwanese hospitals
Official childbirth literature made available to Taiwanese women
Material drawn from the Taiwanese media
Feminist studies of childbirth conducted in America and Brazil
Syracuse University. 2011. 334pp. Primary Advisor: Cecilia Van Hollen.
Image: “Cesarean Delivery, Lateral Cut-away View – Medical Illustration, Human Anatomy Drawing”, Nucleus Medical Media.