Authority and authoritative knowledge in American birth.

WTi he questions "What is authoritative knowledge in the obstetric setting?"; "Who possesses the information on which action is based?"; and, more importantly, "Who should make the decisions in the birth place?" are the topic of this remarkable series of articles. It is commonly accepted that, as a practicing obstetrician in the United States, I am an authority in the realm of birth. I have training in science and technology that allows me to manipulate the tools of modem medicine. This ability has come to be the accepted standard for bringing new human life into the world here in the United States and increasingly in the rest of the world. I, along with my colleagues, create the "standards of care" that become the basis of legal actions that control physicians and midwives, profoundly affect women in birth, and have trapped us in a model of childbirth that is unhealthy and destructive. An undercurrent of distrust for biomedical authority, whose hegemony is spreading worldwide, runs through all these articles. I share this distrust. I also know that I am often asked to apply biomedical technology when less invasive techniques would produce a better outcome. The key question to be considered here is, "If science and technology are not the best sources of authoritative knowledge, who then should be in control and what knowledge should be considered authoritative in decisions made in the birthplace?" Trevathan proposes that physiological changes in the birth canal, brought about by bipedalism, caused rotation of the infant's body to face away from the mother's reach, a change that necessitated the presence of a birth attendant. The introduction of a need for a birth attendant, I believe, also created the basis for the current power of the technomedical model in childbirth. When it became necessary to have an attendant, it also became necessary to have some way to signal the mother that birth was near and that she should seek out safety and help. The signal had to be something no woman could ignore. That signal is pain. No other normal body function is accompanied by pain. Only when there is pathology does the body signal us with pain: "Stop walking on your foot! There is a piece of glass in it." "Stop running! You are about to have a heart attack." Pain in labor is different. It exists primarily to signal the mother that she needs to …