Maternity, Medicine and Power: Reproductive Decisions in Urban Benin. Carolyn Fishel Sargent. Comparative Studies of Health Systems and Medical Care, Vol. 22 (John M. Janzen, series ed.). Berkeley: University of California Press, 1989. 256 pp. $36.00 (cloth).
This book constitutes a major step forward in the understanding of a process that is affecting every Third World nation: the wholesale adoption of an imported Western model of birth. The deplorable lack in the ethnographic literature of good cross-cultural studies of women and reproduction will soon be eliminated if more studies like this one are forthcoming.
Sargent's study primarily concerns the factors that influence birth decisions made by the women of one particular ethnic group in northern Benin, the Bariba. Much of the value of this research lies in her skillful comparison of urban Bariba women in the city of Parakou with their rural counterparts and predecessors in the town of Pehunko, where Sargent conducted an earlier project in 1976-77. The understanding of "pure" Bariba culture she gained in this earlier research gave Sargent a baseline for comparison of the changes that have accompanied the urbanization and modernization of Benin, and most especially of the significance of these changes for women's reproductive choices.
Two cultural idiosyncracies characterized the birthing styles of rural Bariba women, both reflections of core values and beliefs of the wider Bariba culture. Stalwart stoicism in the face of pain is one of these. Bariba men found many opportunities for gaining honor and prestige by not showing pain; birth provided the only such avenue for most Bariba women. The ideal pattern for birth had the woman going about normal activities around the house without any indication to her husband that she was in labor (other women present seemed usually to have known), then, when she could no longer stand, retiring alone to a room and giving birth without making a sound. Ideally, the husband would know of his offspring's birth only when the baby's own cry was heard; at that point, maternal relatives and friends would enter to offer assistance and support.
According to the author's painstaking survey work, most rural Pehunko women did succeed in living up to or approximating this ideal, thereby gaining considerable and lasting prestige and community respect. Moreover, the indigenous midwives whose skills were often called upon in complicated deliveries also often gained high community status. Unfortunately, no statistics are available on the outcomes of these births, nor is Sargent explicit in detailing traditional procedures. But many modern studies have established the efficacy of walking during labor as opposed to lying down, and the kneeling position Bariba women apparently used for delivery is certainly physiologically more effective for pushing than the flat-on-the-back position of the American hospital. I was frustrated by the lack of specific detail about birth position, manner of delivery, and indigenous midwifery techniques, as this sort of information might prove useful in working out practical alternatives to standard hospital routines. I also wished for inclusion of personal narratives describing women's thoughts, emotions, and actions during these private deliveries. But since pain is a taboo topic among the Bariba, privacy highly valued, and shame an ever-present danger, perhaps such stories are simply never narrated.
The other basic tenet of Bariba culture reflected in rural birth patterns is a strong belief in the reality of witch babies. Being born in certain positions or with certain physical characteristics categorizes a child as a witch who, if allowed to live, will grow up to do harm to his or her family. Delivering alone or with only other women present often enabled the mother to determine the fate of her child, as she (in consultation with any female attendants) could choose whether or not to disclose significant information that could lead to the baby's execution by a ritual specialist. (A fascinating question that arises here is the degree to which women may have used this power to control the number and spacing of children that they would have to raise.)
So we see among rural Bariba a picture of birth as exclusively women's domain, and as an important source of personal power and community prestige for women-a situation which has suffered a frontal attack in recent years from government harassment (through fines, difficulty of obtaining birth certificates, and explicit deprecation) of those women who continue to strive for the Bariba ideal by giving birth at home.
Although city women who used to give birth at home and now do so in the hospital say that the pain is the same (anesthetics are not widely available) and often complain of the increased sense of shame and lack of privacy, fewer and fewer exercise their option of home delivery. The reasons for this reproductive choice are very closely analyzed in the body of the book. In keeping with her stated intent to demonstrate that "the complexity of factors determining health care choices should not be underestimated" (p. 21), Sargent identifies four agendas which urban Bariba women must "juggle": the proverbial Bariba virtues of courage, and stoicism, the religious belief in the necessity of witchcraft control, status aspirations, and a desire for competent medical care. Achievement of the first two, neatly accomplished in solitary home birth, appears antithetical to achievement of the latter two, which (urban Bariba believe) can best be accomplished in hospital delivery.
Resolution of this conflict results, not from abandonment of traditional ethnic beliefs and values as Sargent had originally expected, but from their adaptation to the reality of the modern urban context, in which hospital birth is almost a cultural requirement. Stoicism, still held as a value, is adhered to in the hospital although privacy is sacrificed; and witch babies, still firmly believed in, are ritually neutralized instead of killed. This "juggling" process allows traditional values to be satisfied in modified form, at the same time as the (now perceived as) higher goods of status advancement and medical safety for mother and child are achieved. Thus the modern Bariba woman both maintains her ethnic identity and expresses herself as a full participant in the "civilized" world.
Highest status among urban Bariba is held by civil servants, who are perceived as representing the most "civilized" state of alignment with European modes and mores. Those women who have achieved this status for themselves would do nothing to jeopardize it; those whose husbands (or other family members) have achieved it are constrained to maintain it as they give birth. Home birth was widely perceived among civil servants and their equivalents as uncivilized, embarrassing, and possibly even a "career risk" (p. 141). (Most of the city women interviewed by Sargent who did choose to deliver at home were the daughters or wives of peasants.) Even those women who did not share their husband's agenda of status aspirations and would have preferred home delivery almost always subordinated their personal desires to this perceived higher good. Said one woman, "I'm not illiterate so how could I deliver at home?" (p. 113).
The valuation of hospital birth as more civilized is linked to government-fostered perceptions of its safety. This mythos accompanies the exportation of the Western technological model of birth wherever it goes, although comparisons of midwife-attended home birth with hospital birth statistics in many countries do not support this claim of greater safety. (Although statistics on birth outcome in Benin are largely nonexistent, Sargent herself was able to compare maternal mortality rates between one government hospital and one village community, and found no significant difference between hospital and home deliveries (p. 95).) Sargent notes that in Benin in particular, the government-promoted notion of hospital birth as safer is questionable: hospitals are generally understaffed, undercleaned, and underequipped with the technology upon which personnel schooled in Europe were trained to rely. Yet "they will save you if you suffer" was a primary motivation for the women who chose hospitals for birth.
New cultural notions of safety and "civilization" are combining in Benin to limit health care options. At present in Parakou, and in Benin as a whole, a wide array of indigenous healers, some of whom have been organized into a national association, coexist and even occasionally work with the expanding medical profession. But the indigenous midwives, not officially classified as healers but as "birth attendants," are not given the governmental status that would allow them to integrate their services with those provided in the hospital, in spite of WHO recommendations to the contrary. Sargent's study highlights the increasingly limited role that midwifery, previously an important avenue to prestige and respect, plays in the lives of modern pregnant women.
Although the lack of specific data on indigenous delivery methods may limit its usefulness to those interested in cross-cultural birthing techniques, this very readable (except for occasionally annoying minor errors that escaped the copy editor's eye) and ethnographically outstanding book is a must for anyone interested in the interplay between cultural trends and women's reproductive choices in any society. Current trends all over the Third World encourage increasing reliance on Western technology at the expense of indigenous healing systems. As technological interventions rise, Sargent predicts "decreased family participation at delivery, bed confinement for the woman in labor, greater reliance on drugs" and a diminishing of Bariba women's traditional sense of control over the birth process (p. 180). To adopt the Western technological model is ultimately to adopt the core value and belief system that underlies it. The transformation of birth from women's private domain to public event is paralleled in Bariba society by the decreasing autonomy of both the household and indigenous political and healing systems, and increasing state intervention in all of these domains.
Accompanying this paradigm shift from traditional to modern values, in Benin as in the United States, has been a dramatic expansion in social role options for women. Increasing numbers of urban women hold civil service and other prestigious positions unavailable to their mothers or to their rural counterparts. At the same time, just as in the U.S., domains such as childcare and reproduction, once exclusively the province of women, become increasingly subject to institutional control. As women around the world move into their power in men's domain, must they give it up in their own?
Robbie Davis-Floyd, Ph.D.