Obstetric violence, birth trauma, agency, and care in Ami McKay’s The Birth House

Abstract Ami McKay’s The Birth House aptly captures how with the advent of obstetric technologies, medical interventions escalated the proportion of women who encounter obstetric violence as part of normal procedures resulting invariably in birth trauma. The novel portrays the dehumanizing experiences of birthing women under the care of a physician who represents the single-sighted perspective of obstetric care, undermining the uniqueness of each delivery experience. The paper analyzes how this narrative captures the phenomenology of obstetric violence during the early twentieth century. The paper aims to study how the novel analyzes the issues such as lack of agency, privacy, and dehumanization experienced by birth mothers in the maternity ward. This paper also aims to discover how the novel advocates for a positive birth experience emphasizing the uniqueness of each birth mother’s experiences. By employing the concepts of obstetric violence, birth trauma, agency, pain, privacy, medical colonization, and positive birth experience, this paper explores the epistemological friction in the notion of maternal care between the indigenous midwives and the traditional Western medical discourse to showcase the relationships among maternal care, obstetric violence, birth trauma, and positive birth experiences. The paper also critiques the novel for its uncritical polarized portrayal of treatments offered by the midwives and physicians.


Introduction
You just feel like you're not supposed to be challenging your doctor.You don't want to be a problem or an inconvenience, and you don't feel educated enough to really question these things that are done, but they're also not explained (Miltner, 2019, n.p.)The testimony of Caitlin Larson,22, narrates what she felt while giving birth to her boy.The articulation of her birthing experience aptly captures the invisible violence that is prevalent in obstetric wards across the globe in the contemporary world.The term obstetric violence is a very recent coinage.It was coined in the early 2000s by South American activists to sensitize the mass about the mistreatment of birth mothers in the maternity ward.Obstetric violence is defined as: the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.(D'Gregorio, 2010, p. 47) Obstetric violence conceives the imposition of unnecessary medical intervention in the name of care as a form of invasion into the private spheres of women's experiences, which thereby overrides their autonomy.Hence, the medical intrusion is defined as gender as well as race-based violence that, "consists of, but is not limited to, unconsented procedures, neglect, gaslighting, shaming, racism, and discrimination" (van der Waal et al., 2021, p. 38).Waal et al.'s study foreground the fact that since time immemorial, the tentacles of violence have been equivalently embedded in the medical practices and social fabric, and its articulation has always been followed by shaming and trivializing those women's voices.O'Brien and Rich (2022) trace the connection between social inequalities and obstetric violence from the sixteenth century onwards.Even though obstetric violence was perpetrated from the sixteenth to nineteenth century due to religious discrimination and colonialism, with the advent of medical technologies in the late nineteenth and early twentieth century, "women were subjected to needlessly aggressive interventions and routinely denied the ability to make decisions about their own bodies and health" (2183).Thus, although obstetric violence did not originate with medical interventions, these interventions escalated the proportion of women who encountered obstetric violence as part of the normal birthing procedures.World Health Organization (2015) has acknowledged the adverse impact of obstetric violence on the health and wellbeing of the mother and the child and has agreed to its presence stating, "Many women experience disrespectful and abusive treatment during childbirth in facilities worldwide" (1).Elmir et al. (2010) states that uncaring and inconsiderate birth practices lead to birth trauma (2150).The phenomenology of obstetric violence and birth trauma is complexly intertwined.The traumatic experience has long-lasting and drastic psychological effects on the mother and child (Taghizadeh et al., 2013, p. 6), which affects their holistic wellbeing.
This paper would like to study how fictional narrative portrays the incidents of obstetric violence and birth trauma.The paper would like to focus on the novel, The Birth House, by Ami McKay to encapsulate how dehumanized medical practices imposed on women lead to traumatic agentic crises.The paper would like to analyze how the fictional narrative captures the phenomenology of obstetric violence in the early twentieth century rural Canada.Roughly set before the beginning of and during World War I, this was a time when "Canadian women did not have the vote, very few married women worked in paid employment, birth control was illegal" (Mitchinson, 2002, p. 12).This was also the period when rural Canada was transitioning from the midwifery model of maternal care to medical maternity care.Wendy Mitchinson, Canadian historian, records how in the Canadian setting, there is no single history of midwives, but rather "numerous histories, many of which still need to be written.But whenever midwives existed and in whatever guise, they represented an alternative to the medical model of care" (70).The indigenous midwifery and knowledge referred to in this paper is a reference to the native Canadian midwives, who posed an alternate system of care to the Western practitioners since there is no direct reference to a particular community of midwifery in the novel.
McKay's fictional narrative revolves around the maternal care offered by the local midwives of Scots Bay, Miss.Babineau (Miss.B) and Dora Rare and the physician, Dr. Gilbert Thomas, employed by the Farmer's Assurance Company of Kings County.Dr. Thomas represents modern obstetrics innovation and medical interventions in the novel.The doctor stands as a proponent of the medical breakthroughs achieved during the nineteenth and the first half of the twentieth century and as a stark critique of midwifery birth knowledge.He introduces the treatment of twilight sleep through which he claims that the birthing mother will not feel any pain or exhaustion and that she will also have "no memory of hardship or pain" (McKay, 2006, chap. 15).In contrast, the local midwives represent the indigenous maternity knowledge and skills.
The novel is written from Dora's perspective and it dramatizes how the midwives struggle to retain their practice in order to create a space for women's resistance against medical dominance, while the physician lures women with the promise of safety, hygiene, and easy childbirth.However, the novel, through the narratives of the midwives, highlights the loopholes in the delivery and caregiving practices of Dr. Thomas.Birthing women like Ginny Jessup, Kathleen Jess' sister Ellie, and Sarah Deft's cousin who are treated by Dr. Thomas invariably experience obstetric violence in the form of unnecessary medical intervention, loss of agency, dehumanized treatment, and instrument-focused care.On the contrary, the midwifery model of care is portrayed to be humane and women-centric leading to positive birth experiences.The novel underscores how the different maternity treatments leading to obstetric violence can affect the mental and physical well-being of the mother.This paper aims to discover how the novel advocates for a positive birth experience by emphasizing the uniqueness of each birth mother's experience.The paper also aims to study how the novel analyzes the issues such as lack of agency, privacy, and dehumanization experienced by birth mothers in the maternity ward.Since obstetric violence has been disguised under the discourse of normalcy, it is imperative to return to its source to study how it has infiltrated the delivery wards.Hence the paper will analyze how in the selected fiction, The Birth House, the quintessence of obstetric violence during the early period of medicalized births in the American Continent is captured.This paper explores the epistemological friction in the notion of maternal care between the indigenous midwives and the traditional Western medical discourse to showcase the relationships among maternal care, obstetric violence, birth trauma, and positive birth experiences.In addition to acknowledging the negative outcomes of physicians' maternal treatment, Mitchinson foregrounds that the midwifery and physician model of care "polarization often compares the best of home births with the worst of hospital births" (Mitchinson, 2002, p. 167).This novel also falls into the trap of glorifying the midwives and uncritically dismisses the physicians' treatment as traumatic in nature.Thus, the paper critiques the novel's uncritical polarized portrayal of obstetric violence and birth trauma because the novel portrays that only physicians and not midwives can inflict birth trauma.The paper does not only correlate incidents of obstetric violence with its causes but also unravels how this obstetric violence is rooted in the epistemological understanding of care.This paper intends to decode how birth trauma is preempted or intensified by the birth attendants and care-providers as shown in the novel.As obstetric violence can be inflicted at any point of maternal health from pre-conception to the post-natal phase, the paper studies the various reasons for obstetric violence's prevalence during pregnancy, childbirth, and post-natal care as depicted in the novel.Taking a stand against the novel, the paper does not imply that all the medical practices and technologies are harmful and result in negative birth experiences but argues that the practices which do not consider the physical and psychological demands and needs of the parturient women should be challenged.Birth trauma need not necessarily stem from obstetric violence as perpetrated by medical professionals or midwives-although it is one of the primary causes-birth trauma can also arise due to the various maternal care provided to women based on their familial, socio-political, and economical contexts (Leap & Hunter, 2016, p. 25).However, the latter contexts for birth trauma are beyond the scope of the paper as the selected novel does not provide the contextual framing to pursue them.
The paper employs critical perspectives such as obstetric violence, birth trauma, agency, pain, privacy, medical colonization, and positive birth experience from the fields of medical anthropology, sociology, psychology, and philosophy to demonstrate the complex relationships among the parturient women, midwives, and physicians and the women's resultant birth trauma.The paper also analyzes the novel through the literary lenses of reading against the grain to underscore the limitations of the novel.The paper is divided into four sections of which the first section would briefly trace the history of obstetrical practices during the early twentieth century and provide a holistic perspective of the connection between birth care and gravid women's mental and physical health.The second section would offer a succinct literature review of how the experience of birthing is portrayed in literary narratives.This section would also make a case for critically analyzing the phenomenology of obstetric violence and birth trauma using the fictional narrative.The third section would elaborate on how midwives perceive maternal care through the characters of Miss B and Dora from the novel The Birth House while underscoring the romanticized notion of midwives' care.The novel's epistemological understanding of maternal caregiving and treatment of the physicians are critically studied through the portrayal of Dr. Thomas in the last section.Exploring how the physician's single-sighted perspective leads to obstetric violence, this section also acknowledges that Dr. Thomas' views on birthing does not reflect the entire physician community's.

A period of transition;
The scramble for control and agency Dye (1980) segregates the history of childbirth into three periods.These are (1) childbirth as a social event until the late eighteenth century, (2) the long transition of childbirth from being an exclusively female sphere to the medicalization of childbirth from the late eighteenth century to the early decades of the twentieth century, and (3) from the third decade of the twentieth century when the transformation is completed with "the medical profession consolidat(ing) its control of birth management" (98).Dye marks the introduction of new obstetric practices as the beginning of the second phase, that is, the phase of medically managed childbirth (100).Twilight sleep was one of the new obstetric practices introduced in the early decades of the twentieth century in America to assist the birthing mother (Leavitt, 1980, p. 148).DiTomassi (2019) stresses that despite the adverse effects of twilight sleep, twilight sleep stimulated "long-lasting changes in the way pain would be managed in childbirth" (326).So, using the twilight sleep method during labor was a landmark event as it played a vital role in the medicalization of birth.It was at this point in time that the tussle for power between the laboring women and the doctors originated, a period of transition in which the hold of traditional and indigenous midwives was weaning as the medical practitioners consolidated power in the laboring ward.
Until the late nineteenth century, birthing was a social event in that "Pregnant women would invite female friends, relatives, and neighbours to be present during labour and birth" (Leap & Hunter, 2016, XV).The late nineteenth century and the early twentieth century were a watershed in the history of obstetrics as childbirth, which was a social occasion until then, began to be a private and medical event (Dye, 1980, p. 98;J. Wolf, 2002, p. 372).Nancy Theriot (1996) contends that this transformation-the move from birthing in the presence of female companions and midwives for assistance to laboring in the presence of a male physician-made the process more formal, anxiety-driven, and agonizing (58-9).Childbirth was shrouded in mystery and ignorance because home births attended by female neighbors occurred less frequently (J.Wolf, 2002, p. 373) and mothers were unwilling to discuss the reproductive processes with their daughters (DiTomassi, 2019, p. 324).So, childbirth was anxiety-ridden as there was a lack of information about it among the women.
The shift in maternal care was due to various reasons, but primarily because of the early twentieth century's fascination and reverence for technology, science, and effective organizational systems by the layman (DiTomassi, 2019, p. 324;J. Wolf, 2002, p. 379) and as affluent women wanted to alleviate their labor pain to better experience their birthing (Leavitt, 1980, p. 148).To this end, women advocated twilight sleep for they believed that it eliminated the parturient women's laboring pain and thus, they could control their birthing better.Initially, when the physicians opposed the usage of these drugs in America, feminists perceived this "as a challenge to female authority" (DiTomassi, 2019, p. 325).This along with various cultural and societal factors such as the public's reverence for science and technology propelled twilight sleep (DiTomassi, 2019, p. 323).However, in reality, it did not do away with the pain (Leavitt, 1980, p. 149), but only obscured their memories of the pain by altering their consciousness; it was an amnesiac (Fannin, 2019, p. 6;Leavitt, 1980, p. 149;J. B. Thompson & Varney, 2016, p. 44).As J B Thompson and Varney (2016) rightly puts it, championing twilight sleep as inducing painless labor was a misnomer (44).While a few doctors reported that twilight sleep was extremely dangerous and so should be avoided, others passed the verdict that it was safe for both the mother and the child (Leavitt, 1980, p. 158).Nevertheless, women's choice of twilight sleep backfired as its usage did not gain them control over their childbirth, rather handed over the control to the physicians (Leavitt, 1980).
Twilight sleep, thus, was the first step to the "medicalisation and depersonalisation of the childbirth process in the 20 th century" (Thompson, 2019, p. 67).These obstetric interferences then "turned birth, normal and otherwise, into an event that always required the presence of an intensively trained, highly skilled specialist" (J.Wolf, 2002, p. 380).The introduction of obstetric technologies like drugs and instruments might have accelerated labor and reduced the intensity of labor pain but did not facilitate a better or more enjoyable labor experience (Leavitt, 1980, p. 148).The professional and medicalized routine obstetrics practices of the physicians have the potential to distress, humiliate, and embarrass the birthing women while it is assumed by the medical professionals to be "just another day at the hospital" (Beck, 2004, p. 28).Downe and Thomson (2008) argue that these acts that generate such traumatic experiences for the women are "often unconscious and unintentional" on the part of the physicians ( 270), hence making it vital to acknowledge that medical maternal care can intentionally or unintentionally result in negative outcomes of birthing.
Birth trauma has no consistent or ultimate interpretation or definition (Elmir et al., 2010(Elmir et al., , p. 2143) ) and it is a subjective experience that has different meanings for each birthing woman.Thus, Beck (2004) states that birth trauma lies "in the eye of the beholder" (32).However, the birthing experiences can result in birth trauma due to "dehumanizing, disrespectful and uncaring" maternal care provided by the birth attendants (Elmir et al., 2010(Elmir et al., , p. 2150)).Birth trauma includes the feeling of powerlessness, lack of agency, insufficient information provided, fear for the life or injury of the mother and/or child during labor, inability to voice their discomfort, feeling disconnected or disempowered, unwarranted fear of labor and its pain, the indifference of the obstetric caregiver, and so on (Beck, 2004, pp. 28-9;Downe & Thomson, 2008, p. 270).Thus, birth trauma is embedded in the dehumanized and inattentive maternal care and not in the event of childbirth itself.
Depersonalized childbirth and birth trauma have persisting deleterious impacts on the psychology and emotional states of the birthing mothers (Elmir et al., 2010(Elmir et al., , p. 2151)).The lack of women-centric care as was provided by the prevalently available model of care led to a surge in obstetric violence and birth trauma in medicalized births.The instrument-focused care brought about dissatisfaction with the women when the women's needs and voices are not paid heed to.The doctors of the transition period were primarily concerned about strengthening their control and stabilizing their hold over the birthing practices.This has led to the marginalization of the agency of laboring women (J.Wolf, 2002, p. 381).Being in a vulnerable state during birthing, the women lost their agency over their delivery (J.Wolf, 2002, p. 383).

Absence of obstetric violence and birth trauma in literary studies
Nadia Hashish's paper (Hashish, 2020) on The Birth House argues for the necessity to incorporate humanities into the field of medicine.She also elaborates on the crucial role played by midwives in early twentieth-century Western society (164).While the paper focuses on the reductionism and holism in the approaches of Western medicine and places women's lack of agency to take maternal decisions as rooted in the patriarchal society, the focus of the paper is not on the obstetric violence and its resultant birth trauma that arises due to the fundamental dissension in the understanding of the role of caregivers by midwives, physicians, and parturient women.Cosslett (1989), in a study on the consciousness and experiences of laboring women through literary narratives, discusses how the two birthing women from the selected fictional narratives attempt to align and reject the maternity practices of their contemporary times.Even though one of the women is taken care of by a midwife and another is harshly treated in the hospital setting, the paper does not divulge the obstetric violence at play and the methods of care that can bring about positive birthing experiences.
Obstetric violence has been the focal study of various disciplines like sociology, anthropology, medicine, psychology, philosophy, and media studies.Nevertheless, as Pamela Erens (2016) points out, there is a dearth of literature that primarily focuses on childbirth and its associated themes .Further, there is minimal scholarly engagement with the themes of childbirth, obstetric violence, birth trauma, and the underlying notion of care in literary texts.Therefore, a critical intervention into the literary depiction of obstetric violence and caregiving by birth attendants is crucial and novel.Pierson and Stephanson (2010) underscore the significance of amalgamating the knowledge gained from the scientific communities and humanist societies to secure a better understanding of and guide future research on human reproduction.We argue in a similar vein that it is imperative to critically study the literary discourses on childbirth because this popular discourse has immense potential to affect human's way of thinking as literature leads to discovery (Mack, 2012, p. 1).Mack (2012) argues that "Literature not so much as representational but as an experiential mode of scientific inquiry into our transforming life (. ..), could help enable legal-socio-political as well as cultural changes" (17).He argues that literature is a form of a thought experiment (4) that enables to bring out the subjects that have been silenced, "illuminate(s) the unsavoury sub-trends and subterfuges of the world we live" (18).Since dehumanized maternal care leading to obstetric violence has been successfully sidelined, analyzing obstetric care and violence through the lenses of literature is effective to locate the mismanagement of pain and care in the labor wards which has enduring detrimental effects on the mother and child.
Inquiring the source of medical mistreatment of pregnant women as depicted in the novel is relevant to the contemporary times for "Whether set in the past, present or future of its author or reader, the novel seems still to be unfolding as we read it, in a context in which its significance and evaluation have not yet been settled.The novel appears in a zone 'of proximity and contact', fragmented and incomplete" (Manderson, 2016, p. 225).The meaning-making of the plot situated in a setting that is a century ago is influenced by the readers' power of retrospection.This vantage point enables the reader to formulate arguments that will act as resistance to the hegemonic dehumanized medical discourse that has undermined the experientialities of women and foreground the shortcomings in the midwifery model of care.

Individualistic maternity care and positive birth outcomes
In McKay's novel, the midwives achieve positive birthing outcomes by enacting a model of maternal care that takes into account the individuals' needs and crises of the gravid women.Midwifery was a highly unstructured system with no professional identity and they "had no way to set standards or disseminate knowledge" (Dye, 1980, p. 103).Due to the lack of formal and professional training, they were not updated about the new obstetric instruments or drugs (Dye, 1980, p. 103).They passed on their local and traditional knowledge about pregnancy and childbirth through the apprenticeship system (Dye, 1980, p. 104).This order of the transmission of native knowledge through the apprenticeship system is replicated in the case of Miss.B who passes on her secrets, ethics, beliefs, and knowledge of pregnancy and childbirth to Dora Rare (McKay, 2006, chap. 10, 12).
In the novel, birthing through the assistance of midwives is portrayed as a social event.It operates on a local scale under the supervision of Miss.B and Dora.In Miss.B's birthing and caring model, laboring women receive support and emotional comfort from friends and dear ones.In the novel, Mabel Thorpe's birth is a time of love and care amidst the women as typical of social childbirth of the time (Dye, 1980, p. 99).During her birth, Miss.B welcomed the presence of Mabel's good neighbors and friends, Sadie Loomer and Bertine Tupper (McKay, 2006, chap. 6).Miss.B, along with the two women, works to create a comfortable environment for Mabel's delivery, where Mabel is the center of care and attention.They gossip with her, bake a cake, encourage her, and let her walk around the house to help her bear with the labor pain (McKay, 2006, chap. 6).Mitchinson (2002) observes, "Which women had control?In the case of a midwifery-directed birth, the midwife was generally in control" (168).The novel does not portray this tension for power between the midwives and the birthing mothers.It provides only the idealized version of midwives: Miss.B works along with the birthing mother to ease her pain; she does not dictate to her, but rather allows her to do what she needs to according to her body's demands thereby retaining the mother's autonomy.Miss.B's care reflects the view that the midwife "is not the most important person.(. ..)The mother is the most important person" (Leap & Hunter, 2016, XIX).The midwives in the novel are not the authoritative figures who demand complete control thereby depriving the laboring women of their agency.This cooperative approach is further embodied by Dora who follows the principle of not attending to a parturient mother without her consent.She believes that the mother should be able to choose what she wants and does not want during her birthing (McKay, 2006, chap. 47).The birthing women's choices and demands are acknowledged leading to individualized care.The birthing women's agency is not denied as is exemplified by Mabel in the novel.Mabel was able to choose whose care and presence she required during her birthing.The midwifery practice as shown in the novel is the ideal example of humanized maternal care as "A women-centered care approach in which women are respected regarding their values, beliefs, autonomy, choices, and their control over their bodies and births" (Behruzi et al., 2013, p. 1).This romanticized version of midwives is one of the possibilities in which the midwives perceive birthing as a vocation and not as a job (Mitchinson, 2002, p. 169).Otherwise, home births can also be terrifying as physician-monitored hospital births (Mitchinson, 2002, p. 189).
On the other hand, the novel carries several instances that corroborate the study of Dye (1980).The midwives possessed empirical knowledge about birthing and they "knew the stages of labor, recognized and managed a variety of difficulties such as abnormal presentations, and employed a variety of mechanical and pharmacological means to alleviate pain and speed labor" (Dye, 1980, p. 99).This is showcased in the novel when Miss.B identifies that Ginny Jessup was carrying a breech baby (McKay, 2006, chap. 13) and when Dora diagnosed Ginny with the stranger's face 1 as soon as she saw her (McKay, 2006, chap. 45).These episodes illustrate the midwives' practical knowledge and skills in dealing with abnormal pregnancies.The midwives are not only able to diagnose the complications but are also able to cure the abnormalities through their indigenous treatments.In order to bring the baby to the normal position, Miss.B suggests non-invasive treatments such as making Ginny walk on her hands and legs so that her hip is higher than her head.Miss.B then positions Ginny "with her feet above her head" on the sofa and asks Dora to sing to the fetus (McKay, 2006, chap. 13).Within two verses of Dora's singing, Ginny detects the movements of the fetus indicating that the fetus is now positioned head-down in the womb.
In a similar vein, during Iris Rose Ketch's birthing, Dora motivated her as much as possible but when Iris was about to faint from exhaustion without giving birth to her baby, Dora resorted to speeding up the labor by letting Iris smell a quill dipped in pepper (McKay, 2006, chap. 32).Likewise, during Sadie's birthing episode, Sadie was getting worn out as the baby was struck due to its enormous shoulders for Sadie's small frame of body.Dora had to intervene to ensure safe delivery by twisting the baby's shoulders and singing to the mother and child (McKay, 2006, chap. 19).Since the midwives have the ability to handle abnormal pregnancies, complicated births, and speed up the labor, their humanized care, along with their empirical knowledge system, brings a positive birth experience for the birthing women.Miss.B's empirical midwifery wisdom is evident when she is able to predict the sex of the fetus.In all her experience, she has not once been wrong about the fetus' sex (McKay, 2006, chap. 10).Thus, the novel argues that not only should medical and scientific knowledge be valued, but midwives with practical expertise and skills should also be acknowledged for the service they provide.Midwifery practices cannot be universally equated to quackery.Conversely, not all midwives possess nuanced knowledge of childbirth and its complications.However, the novel only depicts highly skilled midwives, ignoring the inexpert midwives and the negative consequences.Dora and Miss B, through their knowledge base, do not undertake to suppress the women's voices.Midwives viewed pain as a part of birthing (Mitchinson, 2002, p. 84) and this view is reflected in the novel by Dora and Miss B. They perceive labor pain as inevitable and their duty is only to "deliver women from their pain" (McKay, 2006, chap. 12) as much as it is possible.When remembering her birthing experience, Mabel smilingly says, "It was a wonderful day.Miss B. made me as comfortable as possible" (McKay, 2006, chap. 15).Mabel is not left traumatized due to her birth experience although she experienced childbirth pain, instead her birthing is an exemplar of Milli Hill's notion of positive birth.For Hill (2017), positive birth should ensure to fulfill five criteria such as the laboring woman's choice of birthing place, her choices motivated by reality and not fear, she should be listened to and respected, an experience which leaves her empowered and enriched, and her memories should be pleasant and proud (Hill, 2017, Introduction).
Mabel was at her house, her choice of birthing place, from where Miss B. sent Mabel's husband and children out to create an ambiance where Mabel did not have to worry about how her family will interpret her crying and groaning.Mabel had access to the privacy she required (McKay, 2006, chap. 6)."The best labor support will protect a woman's privacy and insure that she is not disturbed so that she can tap into her inner wisdom and dig deep to find the strength she needs to give birth" (Lothian, 2004, p. 6).Miss.B played an instrumental role in creating this privacy in which Mabel can be herself and concentrate on her birth without having to be worried about other's perceptions of her.By safeguarding her privacy, Miss.B empowers Mabel for the birthing.
Mabel also comprehends that pain is an inherent factor during childbirth and does not fear it irrationally (McKay, 2006, chap. 15).Miss.B ensures that Mabel does not feel pressurized during her birthing and states that the most essential component of any birthing is "Plenty of time to do whatever she needs, tell whatever story's on her mind, time enough to say all her prayers" (McKay, 2006, chap. 6).Miss.B does not speed up the birthing but allows Mabel to experience and express her embodied sensations and instincts.Miss.B patiently understands that every pregnancy and childbirth is unique and private and that it cannot be generalized.Even though Mabel's baby's neck is caught in the umbilical cord leading to the child's suffocation, Miss.B and Dora do not scare the mother.They positively resolve the situation with their midwifery knowledge and skills (McKay, 2006, chap. 6).
The positive birthing became feasible because the midwives in the novel perceive the labor pain as normal and they work with it as Leap and Hunter explicate.The "Working with pain" approach to childbirth is based on the belief that "Women can cope with contractions in uncomplicated labour with appropriate support" (Leap & Hunter, 2016, p. 33).Miss.B and Dora interpret the cries of the birthing women in pain as calls to "'Assist me,' 'Support me,' 'Tell me this is supposed to happen.'"(Arms, 1975, p. 160) as is seen in the case of Mabel, Iris, Ginny, and Sadie.The midwives are not unnerved by the cry of labor pain and they do understand that kindness and humanized care are the crucial needs of the laboring women-however, this might not be the case always.Exemplifying the epitomized midwifery care, Miss.B's fundamental opinion about maternal care is aptly captured when she says, "The danger's in forgettin' really in charge.Science don't know kindness.It don't know kindness from cabbage" (McKay, 2006, chap. 10).She lays stress on how kindness should be intertwined with maternal care to be of any help to the birthing women.Her midwifery model of maternal care emphasizes more on the concepts of unobtrusive assistance, care, empathy, privacy, and kindness than numbing the pain of the women during delivery.
Continuity of care is another vital aspect to bring about a positive birthing experience (Behruzi et al., 2013, p. 6).When Dora detected that Ginny has the symptoms of the stranger's face, she decides that Ginny should stay at her place, Spider Hill, until the child is born to take better care of Ginny.She brings the swelling down while strengthening Ginny for her delivery (McKay, 2006, chap. 45).Dora provides dedicated care to Ginny, which underscores the cognizance that "Caring is a transpersonal relationship that involves the conscious intention of 'doing' for another and 'being' with another in need while practicing and honoring the wholeness of mind-body-spirit in oneself and the other" (Al-Maharma et al., 2021, p. 2).By having Ginny at Spider Hill, Dora successfully plays an instrumental role in enhancing Ginny's mind-body-spirit wellness so that on the day of delivery, Ginny is in a cheerful mood and much energized.As Fahy and Hastie (2008) propound, "The integration of mind-body-spirit increases (the birthing mother's) energy, strength and power" (22).Even when Dr. Thomas' presence frustrates and disquietes Ginny on her delivery day, thereby setting off her calmness and mind-body-spirit integration, Dora brings the situation under control by physically threatening the doctor.She establishes a secure and comfortable birthing environment for Ginny (McKay, 2006, chap. 45).Dora and Miss.B bond with the birthing women on a personal level, which enforces trust, confidence, and mutual respect.When the novel concludes, Dora converts her Spider Hill into a birthing house for the women from Scots Bay.She establishes a list of rules to be followed which ensures that the birthing women have autonomy and choice and are respected and treated with dignity.The mothers would only have the visitors whom they approve of, in that, Dora assures privacy and agency.Dora provides confinement care for nine days after birth, that is, the continuity of care.She also ensures that when the mother returns home after delivery, "The mother's home must be clean and tidy, her household chores looked after, and supper enough for a week must be waiting for her" (McKay, 2006, chap. 47).Dora is concerned with the post-natal care as much as the pre-natal and during labor care.She takes comprehensive care of the birthing women when they seek her birth assistance, which is solely birthing women-centered.Thus, she establishes a sanctuary at Spider Hill convinced that "Every woman needs a sanctuary" (McKay, 2006, epilogue).
Miss.B and Dora, time and again, foreground that they will receive no payment for the maternity services they render (McKay, 2006, chap. 3, 47).Financial gain is not their ultimate motivation or goal.Their sole endeavor is to support the birthing women and help them to manage their childbirth pain as much as feasible through their traditional knowledge.They deliver "Individualized maternal care solely focusing on the birthing women's labor and childbirth (which) paves way for effective maternity services" (Al-Maharma et al., 2021, p. 1).The novel, as presented from Dora's perception, offers only the positive instances and connotations regarding midwifery practice.Nevertheless, midwifery care does not warrant positive birthing for it can also offer dehumanized care.The novel's failure to capture the wholistic picture of the midwifery practice and its outcomes indicates the partial treatment of the subject.

Maternity care and potential obstetric violence in the medical world
Elinor Cleghorn (Cleghorn, 2021a) argues that medical professionals have succeeded in integrating the gender discrimination faced by women in the socio-cultural spheres into the discourse of medical science and "construct(ed) the myth that woman was her biology; that she was ruled by it, governed by it, at the mercy of it" (Introduction).As medicine's understanding of female biology has expanded and evolved, it has constantly reflected and validated dominant social and cultural expectations about who women are; what they should think, feel and desire; and-above all else-what they can do with their own bodies.Medical myths about gender roles and behaviors, constructed as facts before medicine became an evidence-based science, have resonated perniciously.(Cleghorn, 2021b) These accounts aptly capture how medical myths have established themselves as facts before the origin of evidence-based science and how medicine from traditional times has endeavored to achieve control over its patients.During the early twentieth century, medical obstetric care was not well-developed based on sciences.For instance, there was a lack of consensus regarding the use of twilight sleep and its dangers for the mother and child in the medical world.
The unfounded speculations on which obstetric treatments were proposed are captured through the fictional explanation of Dr. Thomas' obstetric experience.He has only "observed at least a hundred or more birth" during his residency days (McKay, 2006, chap. 3;emphasis added).This was the state of obstetric medicine for "As later as 1904, many physicians received degrees verifying competence to attend births without ever having witnessed a single birth.It was not until 1920 that clinical experience in obstetrics became a requirement of medical schools' curriculum" (DiTomassi, 2019, p. 325).Although Dr. Thomas claims that science is exact leaving no scope for guesswork or superstitions (McKay, 2006, chap. 10), the treatment he prescribes-"the suggestive method", "the latest in obstetrical theory" (McKay, 2006, chap. 42)-for Ginny's morning sickness during her second pregnancy is based on the very wives' tales that he vehemently opposes.He orders Ginny to use her only valuable bowl as the sick bowl and elucidates, "morning sickness is neurotic in nature, the pregnant woman's way of gaining attention from a husband who is uncomfortable with his wife's condition" (McKay, 2006, chap. 42).He does not associate her morning sickness with the other symptoms of swollen hands and feet and the headaches.He uniformly brackets that morning sickness is a woman's way of seeking attention without providing her any individualistic or sciencebased care depending on her condition, as can be discerned from this incident.Dye (1980) argues that even though the eighteenth and nineteenth centuries witnessed scientific advancements in comprehending the childbirth process, it was not guaranteed that "the average nineteenth-century practitioner was either aware of these developments or capable of applying them clinically" (102).This is depicted in the novel when the obstetric knowledge of Dr. Thomas is in question when he does not possess the knowledge to diagnose the abnormal conditions for both of Ginny's pregnancies.When Miss.B visits Ginny's house to help her with the breech baby, Ginny informs them that since Dr. Thomas was busy with the Canning Maternity home and other work, he did not have any time to consult her (McKay, 2006, chap.13).The doctor or any caregiver should take the responsibility of the women's comfort and safety, yet Dr. Thomas does not deliver on the oath he took as an obstetric physician, to aid the "child-bearing women whenever possible" (McKay, 2006, chap. 3).He is negligent of his patients, which in turn risks the safety of the mothers and babies.
Such practices of Dr. Thomas establish that the scientific knowledge about pregnancy and childbirth that is so much revered in the early twentieth century is itself unreliable and faltering.However, these questionable treatments and dubious knowledge as practiced by many physicians were utilized to subjugate the birthing woman and alienate her from her own birthing process.This medical knowledge encourages the body/mind dualism of pregnant women.Mehta (2011) argues that disempowering patients and dehumanizing them due to the "medical care-cold, impersonal, technical style of clinical practice (is) shaped by notion that the body is a machine devoid of self" leading to patients' dissatisfaction (205).
Anne Lyerly (2006) explicates how the medical notion of mind/body dualism can be extended to pregnant bodies as: pregnant bodies are machines with technical problems, requiring practitioners to devise and deliver technical solutions, in the form of monitoring, anesthesia, and assisted delivery.Alternatively, woman's emotional needs, and the ways in which they experience labor and delivery, become secondary at best, and, at times, are viewed as hazardous when the woman's needs conflict with what the physician perceives as imperative medical care for her and, in particular, the fetus.(104) In the novel, Dr. Thomas enters against permission into Ginny's delivery room at Spider Hill to supervise his patient.He states that he has the situation under control and that if Ginny did not cooperate, he has chloroform to render her unconscious (McKay, 2006, chap. 45).He dichotomizes the birthing body and attempts to gain control over the physical body even by overpowering her mind and spirit using the various anesthesia he possesses, which is the exact opposite of birthing women's integrative power, thus resulting in obstetric violence.Dr. Thomas appropriated Ginny's first birthing with his discourse on medical knowledge, equipment, drugs, and sanitary and antiseptic conditions.He publicizes the painless and safe birthing that he can offer.While Ginny's heels are tied up in the stirrups in the labor ward, the other women in the same room curse at their husbands and weep for their mothers (McKay, 2006, chap. 13).There is no privacy for Ginny and the doctor keeps working to "extract" her child (McKay, 2006, chap. 13).After Ginny recovers her consciousness, "she's afraid to question what's just happened.There was no moment of celebration at the end.She's feeling left behind, unsure" and for the physician, this is a normal feeling, "A kind of bliss" (McKay, 2006, chap. 13).The narrator underscores the appropriation of childbirth by Dr. Thomas when Ginny "thanks him for his accomplishment" (McKay, 2006, chap. 13).The mother did not take the center stage in her childbirth experience, but rather it was her physician who should be felicitated and acknowledged for the birth.This appropriation is what Chadwick (2020) terms as "medical colonization of labouring/birthing bodies, as itself a form of obstetric violence" (31).
Ginny's pregnancies did not call for any medical intervention, but Dr. Thomas insisted on administering anesthesia and if required twilight sleep as the standard or normal procedure for any birth irrespective of the birthing women's individual cases and requirements.Mitchinson states, "A physician who adhered to the rules too rigidly could become an automaton, someone who followed procedure without thinking about what he was doing and was not sensitive to the variations among women" (Mitchinson, 2002, p. 162) and Dr. Thomas was such a physician.The underlying agenda of gaining control over the natural process is evident when the physician strives to gain control of the birthing experience resulting in maternity care that is dehumanizing and desubjectifying the women.Ginny had to wait for the doctor to deliver the news of what has happened to her, she is deprived of her embodied subjective experience in a way that Miss.B notes, "Strappin" ladies down and tyin' 'em up like hogs to have their babies" (McKay, 2006, chap. 15).Contrary to Rich's (1995) argument that childbirth "is not a drama torn from its context, a sudden crisis to be handled by others because the other is out of control of her body" (180), Dr. Thomas perceives childbirth and its related process devoid of its context.By ignoring the context, Dr. Thomas is able to render all the birthing women as a generic population with no attention to their individual needs.This is the core of the obstetric violence as portrayed in the novel.No matter who the woman is, he has a set of medical procedures to be followed during childbirth and he follows them to the letter.When a woman was taking longer than normal to give birth during her childbirth , Dr. Thomas "cut her and gave her ether" (McKay, 2006, chap. 44) even though she had to get many stitches and was sick due to the ether after her birthing.This lack of interest in birthing women as unique individuals is one of the main reasons for traumatic births (Beck, 2004, p. 32).
Allison Wolf (2013) contends that "the routinization/medicalization of birth", that is, following a standard set of procedures for all births irrespective of the birthing women's situations, needs, and desires "reduces women to objects and erases their unique subjectivity" and considering that the "women are no longer individuals, but rather are simply generic persons in labor" are instrumental in promoting violence within the delivery wards (105).What is suitable for one woman should be suitable for all women in labor.This opinion foregrounds how the birth attendant is in control of the situation and the birthing woman's body, the woman herself is deprived of agency and autonomy.As Ginny was deprived of her agency to decide whether Dr. Thomas should or not be allowed to enter her delivery room and supervise her birthing, she was passive and docile during her first delivery.She was not able to exercise her agency and control the situation she was in or what was happening to her body just like the woman who had multiple stitches due to Dr. Thomas' care.
When Dr. Thomas wants to supervise her second birthing, Ginny cries to Dora to not let him near her (McKay, 2006, chap. 42).The physician does not build a trustworthy relationship with his patients as his sole concern is the mechanical and apathetic act of delivering the baby from the mothers' bodies.He controls the situation through his dominating scientific discourse and medical knowledge.Knowledge is transformed into the battleground because the one with more knowledge would be the one who has the power to make the decisions (Mazzoni, 2002, p. 9).This is only possible for Dr. Thomas by advocating the advantages of his practice, instilling fear in the women of the negative consequences they will face without his knowledge, and quoting the legal obligation of the citizens to consult a physician during pregnancy and childbirth (McKay, 2006, chap. 3, 5, 10, 15, 45).
The maternity home's delivery room has ten beds with just a sheet hanging from the ceiling to divide the neighboring beds.Ironically, Dr. Thomas takes pride in this facility and states, "we have both privacy and efficiency.Up to ten women can labour at once and still have the best in obstetrical care" (McKay, 2006, chap. 5).Although Dr. Thomas advocates that his care provides "privacy", it is not so as observed in Ginny's first birthing scene when the cries and shouting of other women penetrate the filmy sheets."Lack of privacy in medical centers will reduce the quality of care and (does) irreparable harm to the patient" (Valizadeh et al., 2021, p. 187).Compromising privacy during birthing leads to dissatisfaction with the maternity care provided as proven by Bohren et al. (2015).This study terms the lack of privacy at a vulnerable time for the birthing women to be "undignified, inhumane, and shameful" (13), which essentially furthers or intensifies obstetric violence.The birthing women are dehumanized with no regard for their privacy in the Canning maternity home.Dr. Thomas' notion of privacy does not take into account the dismaying cries and curses and hence, he does not offer a wholistic sense of privacy for the women.
Dr. Thomas uncritically believes in the process of modern obstetric care and states that "the surgical knives, the scissors, the needles, the bottles of ergot and ether (. ..) hasten childbirth and put the labour process in the doctor's hands.He has complete control" (McKay, 2006, chap. 5).These instruments and procedure contribute to what Fahy (2008a) terms as the medical surveillance which would consolidate the medical power over the patient's body (5).The description of the maternity home's delivery room exactly resembles Fahy's surveillance room in that it "is a clinical-looking room where the equipment the staff may need is on display and the bed dominates", an "environment designed to facilitate surveillance of the women and to optimize the ease and comfort of the staff" (Fahy, 2008b, 18).She also argues how this type of surveillance would only result in the birthing women's reduced sense of self and emotional welfare, inhibition of her physiological functioning, and cause psychological distress (18), in other words, birth trauma.The physician's genuine care for his patient is lacking in Dr. Thomas' medical model of care.His understanding of maternal care is rather based on his own economic and social status for he states to his friend regarding the women of Scots Bay, "If I could avoid (going to Scots Bay), I would.Except for a chosen few, there's not much sense of civility to be found in that place.Too many marriages with too few names" (McKay, 2006, chap. 29).He is not concerned for his patients on a personal level, but rather considers his work only as a job which earns him his living.His commodified care in the capitalistic world is aptly depicted during Sadie's birth when he refuses to provide maternal care to her because her birthing took place in her house and not his maternity home despite the fact that her family had already paid his fees (McKay,chap. 19).Even after receiving the payment for his services, he is oblivious to his patient's health status.He "relies on books and charts more than he relies on his heart" (McKay, 2006, chap. 42).His concern for the women is not based on the practical needs of women, but stems from his economic concerns and acquired medical knowledge, which ultimately numbs him to the women's voices and ensuing obstetric violence.Dr. Thomas, thus, epitomizes how physicians "become professionals in the medicalisation of childbirth, instead of in caring for people in childbirth physically and emotionally" (van der Waal et al., 2021, p. 37).We highlight that Dr. Thomas cannot be the sole representation of all physicians for several physicians also preempt birth trauma with their timely intervention during complicated deliveries.We foreground the novel's shortcoming in providing a unidimensional representation of the medical practitioners and argue that Dr. Thomas is to be read as representing only a strand of the medical obstetric caregivers who (un)intentional provide dehumanizing and instrument-oriented care.The novel, thus, polarizes the midwives' care who conceive of their work as their vocation with Dr. Thomas who perceives this as a job, which earns him a living.Thus, the novel fails to depict the other possibilities of the spectrum in maternal caregiving including the midwives who are primarily guided by financial gains and physicians whose sole concern is their patients' wellbeing.

Conclusion
Since pain is inevitably linked to an underlying pathology in modern Western medicine (Duncan, 2000, p. 493) and the pain was inherent in childbirth, "pain became the issue used by obstetricians to justify the strict medical control and monitoring of even the low-risk births that prevail" (J.Wolf, 2002, p. 381).This led to maternity treatments that were solely aimed at numbing the labor pain beginning from the period of transition and medicalized births like the twilight sleep.The novel highlights the shift from midwives' primarily humanistic maternity care, which began to be slowly replaced by the technology-driven, instrument-focused medical care in which the birthing women were marginalized by the physicians who supposedly knew the best course of action and implemented a uniform set of maternal procedures.Primarily due to the women's general lack of (technical) knowledge regarding maternity among other factors, the physician's authority went unchallenged in most instances leading to obstetric violence and birth trauma.
While the novel rightly portrays an instance-arguably the predominant scenario-of maternal care at the turn of the twentieth century, the novel's clear demarcation that the midwifery model of care is superior beyond faults and that Dr. Thomas' treatment invariably results in birth trauma does not encapsulate the entire reality.While the novel depicts the physicians' preference for instruments and pathologizing childbirth, it overlooks their successful treatments and the positive outcomes of their obstetric interventions.With Dora as the narrator, the novel is partial to the treatment of the subject and the instances are portrayed such that the readers sympathize and empathize only with the midwives and the pregnant women who have suffered due to Dr. Thomas' care.Even though the novel's implications regarding the maternal care models cannot be extrapolated or generalized, the novel is significant in addressing what constitutes birth trauma and positive birthing experiences.Thus, while rendering a polarized perspective on the midwifery and physician models of care, the novel also highlights the treatments and factors that constitute obstetric violence and otherwise.
Technological maternity services are an inevitable part of the contemporary world and they should be tailored to suit the individual woman's needs.The socio-cultural and economic context of the women should also be taken into consideration.In The Birth House, juxtaposing the personalized and dehumanized care highlights the impact these models of maternal care can have on the birthing women's lives either positively or negatively.By changing the approach of maternal care, positive birthing is feasible and can improve the quality of life for the mother and child.Thus, with its limitations, the novel is pertinent because it draws our attention to this prevalent birth trauma crisis and urges us to reflect on the same.