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CONCLUSION
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441 Conclusion Robbie Davis-Floyd, Lesley Barclay, Betty-Anne Daviss, and Jan Tritten In developed countries it has been demonstrated that the development of a nationwide system of integrated midwives is the single most important factor in reducing maternal mortality. jerker liljestrand, Co-chair, Safe Motherhood Program, FIGO (Presentation at the Meetings of the International Federation of Latin American and Caribbean Obstetricians and Gynecologists, May 2005) The “medical model” shows us pregnancy and birth through the perspective of technological society, and from men’s eyes. Birthing women are thus objects upon whom certain procedures must be done. The alternative model . . . which I will call “the midwifery model” . . . is a woman’s perspective on birth, in which women are the subjects, the doers, the givers of birth. barbara katz rothman, In Labor: Women and Power in the Birthplace (1982: 34) THE IMPORTANCE OF IDEOLOGY: WHAT’S IN A NAME? In 2002 Ellen Hodnett carried out a systematic review of 137 reports on factors influencing women’s evaluations of their childbirth experiences. Her objective was to summarize what was known about satisfaction with childbirth, with particular attention to the roles of pain and pain relief. The reports included in Hodnett’s review included descriptive studies, randomized controlled trials, and reviews of intrapartum interventions. The results were as follows: “Four factors—personal expectations, the amount of support from caregivers, the quality of the caregiver-patient relationship, and involvement in decision making—appear to be so important that they override the influences of age, socioeconomic status, ethnicity, childbirth preparation, the physical birth environment, pain, immobility, medical interventions, and continuity of care, when women evaluate their childbirth experiences.” The review’s conclusion is that “the influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction are neither as obvious, as direct, nor as powerful as the influences of the attitudes and behaviors of the caregivers” (Hodnett 2002: 171–172). Attitudes and behaviors stem from particular philosophies, or paradigms, that form the template for the caregiver’s beliefs about birth. In other 442 conclusion words, it’s the model behind the “model that works” that most determines the kind of care a practitioner will provide. In this volume, we have taken an educated tour of birth models that work whose practitioners are providing optimal maternity care. It is readily apparent that all of the models that work presented here share a common ideology based on the fundamental notions that birth is normal and that women are its protagonists. What should we call this shared ideology? It has received various names over time. It was first described in print by sociologist Barbara Katz Rothman (1982) as the “midwifery model of care”—this label has since become internationally recognized as a useful signature by which to differentiate the philosophy and ideology of midwifery from that of obstetrics. Recognition of the difference between the two professions—midwives focus on normalcy, obstetricians on pathology—goes back centuries; serious discussions about the implications of those differences have been taking place since that time. Because midwives are the most numerous primary maternity care practitioners and have long engaged in discussion and reflection with each other and with social scientists about what it is that they do that works and doesn’t work, they have continued to articulate and refine “the midwifery model of care” (e.g., Rooks 1999). In many midwifery educational programs around the world, this model is held out as an ideal for midwifery practice; in others, it is actively taught as the standard for midwifery care. Others have suggested other names for this model, in part to avoid identifying it with a particular profession and to acknowledge that many midwives over-medicalize their treatment of birth even as some physicians work very hard to practice “the midwifery model.” To date there is no international consensus on the most appropriate name for the ideology and practice of supporting normal birth. In Birth as an American Rite of Passage (2004), Robbie Davis-Floyd expanded on Rothman’s discussion of the differences between the “medical” and “midwifery” models of care, using the labels “the technocratic model of birth” and “the holistic model of birth” to name these contrasting paradigms (see Appendix C.1). Some years later, Davis-Floyd expanded her understanding of the dominant paradigms operative in global maternity care to include a third paradigm, the humanistic model, which stretches across the divide between the technocratic and holistic models (see Appendix C.2). As...