Confessions of a Dissident

-by Marsden Wagner MD, MSPH

Following is Chapter 14 from "Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives", eds. Robbie Davis-Floyd and Carolyn Sargent. University of California Press. In press. Reprinted with permission.

One evening in the mid-1980s I found myself, a medical doctor, sitting in a small bar at a Swiss resort with three other speakers for a conference to begin the next morning: Rick Carlson, a lawyer, John McKnight, a sociologist, and Ivan Illich, a sociologist. While we came from different professions, we had in common that our recent writings were challenging the authoritative knowledge (AK) in medical care.

Recognizing this, we began to chat about how we came to challenge that AK, and what the roots of such behavior might be. Although we found no common denominator in childhood, we came to see that by the time we reached graduate school, each of us was disenchanted with the system and looking for ways to avoid getting sucked too deeply into it. We found that after finishing graduate school, all four of us went through some kind of gestation period during which we quietly worked our way up through the system. Only after we had some experience in our field and had achieved some measure of professional success did we begin to challenge medical AK.

Challenging an established body of authoritative knowledge--especially one which, as in medicine, is perpetrated by "the authorities"--involves at least two steps: recognizing its deficiences, and then wanting to correct those deficiencies strongly enough to be willing to speak out against the authority of the group. Here my father taught me well. He was a Protestant preacher who questioned from the pulpit the validity of literal translations of Bibilical passages and challenged conventional wisdom by, for example, placing a bench at the bus stop in front of his small church saying "Millions for armaments, how much for peace?" He put up that bench in early 1941 when everyone was preparing for war.

After medical school I marched through an orthodox speciality training in pediatrics and neonatology, eventually serving as chief resident in pediatrics at the UCLA hospital. Following several years of active pediatric and neonatology practice, I was dissatisfied and restless, feeling that I was just practicing rescue medicine, not solving the child health problems of the community. So I returned to UCLA for two years of postgraduate study in the science of medicine and public health.

The single most important thing that happened to me during those two years was being exposed to a different paradigm. While the medical paradigm focuses on the individual who comes for help, on sickness, on curing, and for the most part uses the biological approach, the public health paradigm focuses on populations, on health, on prevention, and uses a bio-psycho-social approach. Once that paradigm shift happens, there is no turning back (see for example Konner 1987:401).

Taking a job as Assistant Professor of Pediatrics and Public Health at UCLA, I found myself in two schools with two different paradigms. My attempts to merge the two were naive and ineffective. I was quickly marginalized in the Department of Pediatrics and the medical school. The only reason I was tolerated was because of my credentials as a clinician.

During this period I had an important experience. I went on a medical anthropology expedition to a settlement of preliterate Indians living in the Sierra Madre mountains of Mexico. The group consisted of a faculty person from the medical school (me), a faculty person from the Department of Anthropology, several medical students and several anthropology graduate students. At that time, medical anthropology was a relatively new discipline having difficulty bridging the gap between biomedicine and the healing systems of indigenous cultures. The idea behind the expedition was to teach students, hopefully before they were too engrained in their discipline, true cross-disciplinary collaboration.

In our camp one day there appeared a young Indian family- mother, father, daughter about six years old and a baby of perhaps six months. The family had walked for several days to come to where we were camped and where an Indian healer also camped, because the baby was sick. They presented themselves first to us, and I got out my stethoscope and found a severe bilateral pneumonia. But before I could prepare the syringe of long-acting penicillin, the family left and went to the healer. After seeing the healer, they prepared to leave the camp and return home. Through an interpreter we learned that they thought that my use of the stethoscope was in fact our treatment. When we explained that we were not finished, they were adamant that they wanted no more treatment, as the healing was finished.

What to do? The students asked my opinion on what would happen if the baby did not receive the shot of penicillin. I honestly replied that the baby would almost surely die. An argument ensued as to our course of action, sadly split along disciplinary lines. The medical students said that we must save the baby's life with the shot, even against the parents' wishes. The anthropology students said that such a course of action would be yet another step in destroying this culture and this family, without which neither this baby nor any other baby could survive. The clash of the paradigms, even at graduate student level, did not bode well for our original idea of influencing students while they were still young.

Our solution was a compromise which left no one happy. As the baby was being carried on the back of the six-year old sister, we seduced her into our camp with candy and while her attention was diverted by a student, I snuck up behind and quickly injected the baby without the sister's- or the parent's- knowledge. This whole experience pushed me further along towards a fuller understanding of the limits of the medical model and its inability, in its headlong pursuit of curing and saving lives, to solve the health problems of the community.

During this time, my work in academic public health was not going where I wanted it to. While using what was for me the better paradigm, my public health colleagues were for the most part unwilling to confront real issues which might bring them into conflict with the medical world they both admired and feared. Furthermore, public health academia was removed from the real world of health policy and public health practice, and academicians had little wish to bridge the gaps between research, policy, and practice. So after eight years on the faculty, I elected to stay in public health rather than pediatrics, but to get out of the University setting and into public health practice.

My years in the Department of Maternal and Child Health of the California State Department of Public Health provided me with a whole different set of frustrations. My colleagues now feared both doctors and politicians. The politicians used the public health services as a sop to the poor and as a way of keeping the poor in their place. The doctors saw to it that our public health services used the one-on-one (doctor-patient) clinical model and blamed the victims, poor families, who failed to "comply" with us. Public health practice turned out to be a confusing mix of the medical model and the public health model with no room to maneuver, and no possibility for innovation.

It was when I started working as Responsible Officer for Maternal and Child Health for the World Health Organization that, at last, I felt I had the right job. I was working in the European Regional Office, which meant that I worked with health systems in industrialized countries- my real interest. I still had the right paradigm, and although I was still surrounded by colleagues who were mostly afraid of change, at least now I did have the opportunity of developing my own program, which I quickly set about doing.

Shortly after I started at WHO in 1979, at an annual meeting the 32 countries in the European Region complained that their perinatal services were costing more and more with not much evidence of improved benefits and little evaluation of efficacy. They suggested that our Regional Office evaluate birth services and report back to them. Since perinatal services were part of my responsibility, I was told to do such an evaluation.

I was less than enthusiastic because I had not been involved previously in maternity services. I had been imbued with obstetrical AK (authoritative knowledge) during my years of medical training, and never had any reason to doubt its validity. On the other hand, when I worked in the U.S. I had not been blind to some of the evils of the system- nurses doing most of the work and obstetricians getting most of the glory and the money; a double standard of care, one for private and another for publically funded hospitals.

While in California I had heard of an amazing experiment in a rural town which recruited two midwives (at that time such midwifery was illegal in California) to work in the public hospital. During the three years in which they handled most of the births, the incidence of prematurity dropped almost by half, and neonatal mortality dropped from 23.9 per thousand to 10.3 per thousand- less than half of what it had been before the midwives arrived. This success was followed, nonetheless, by a medical backlash- the program was discontinued, and the perinatal mortality rates returned to its previously high levels (Levy et al. 1971). But, as an American, I knew essentially nothing about midwifery and, while curious about this experiment, I had failed to see its importance.

I had also experienced the births of my own four children. The obstetricians were so nice to me that it was not until the fourth birth that I realized that I had been patronized and denied the opportunity to be present at the births. So I asked the obstetrician at the UCLA hospital where I was on staff to allow me to be present, and he said no. To my everlasting chagrin, I complied. While I had questioned some of the workings of the maternity system, I had not questioned its fundamental authority.

Since I had no experience with maternity care systems, I decided to form a perinatal study group to work with me in evaluating maternity and neonatal services in Europe. In retrospect, the fact that I did not personally identify with obstetrics may have made me more open to what the group was soon to uncover. I started by including only obstetrics and neonatology in the study group, but as we worked I realized we needed other viewpoints, and so I gradually added nursing, midwifery, social science, and finally consumers. We started by reviewing the scientific literature and soon came across the gap between science and practice. To confirm this observation, we recruited a scientist not in the group to survey routine obstetrical procedures. We were shocked when the report from this scientist concluded that only approximately 10% of all routine obstetrical procedures had an adequate scientific basis (Fraser 1983).

The group decided to do cross-national surveys of present maternity care practices. We found that not only had this never been done cross-nationally, it also had never been done at a national or local level in many countries. In other words, there was little or no monitoring of maternity services. Our surveys showed great variation in obstetrical practices with little or no relationship to perinatal outcome (Bergsjo et al. 1983). The variation was among countries, within countries, within districts, between hospitals. In other words, obstetrics reflected the opinions and wishes of the Chief of Obstetrics in a given hospital. The variations also reflected custom: every continental European country preferred the vacuum extractor, while Britain and every former British colony preferred forceps. Such findings went a long way to disenchant me not only with "authoritative" knowledge but with authoritative practice (AP) as well.

At this time I began to make acquaintances and connections in the Danish midwifery community. Primary among them was a midwife, Susanne Houd. She played an instrumental role in exposing me to a system of knowledge radically different from obstetrical AK. These two systems in many ways complemented each other, but what was noteworthy was that I had never heard about midwifery knowledge from the obstetrical literature or from obstetricians. I began to study midwifery, and learned how it was a key profession in birthing in every country in the world outside of North America. I visited midwives in many settings in many countries to learn more about their work.

Susanne worked in a hospital (as do most European midwives) but also did some homebirth. She asked me if I would like to accompany her to a homebirth and I agreed. After asking the pregnant woman for permission, she took me along to a prenatal visit so I would not be a stranger at the time of birth. Already I was beginning to see that this was very different from the obstetrical approach, that the medical and social models of birth were completely distinct. It would be impossible for me to exaggerate the influence of my experience with homebirth on my opinion of obstetrical authoritative knowledge and practice. Home birth is as different from hospital birth as night is from day. Trying to describe home birth is like trying to describe sexual intercourse- you can give the outlines, but you can never adequately describe the personal dynamics, feelings, ambience.

I went to homebirths in a number of countries to try to learn what I could about this way of birthing. I began to look at the scientific literature on home birth, and soon discovered that home birth had been a pivotal issue in the formation of obstetrical AK. It became clear that obstetrics had taken a completely irrational approach to homebirth which was most curious. The scientific data showed it to be as safe as hospital birth for a woman with an uncomplicated pregnancy, and yet obstetricians roundly condemned it. For example, Dr. Keith Russell, former President of ACOG (American College of Obstetrics and Gynecology), publically declared in the Los Angeles Times (1992) that "home birth is child abuse in its earliest form." The fact that the Netherlands has never had a home birth rate under 30% and has birth outcomes equivalent to or better than neighboring countries is a huge thorn in the side of obstetrical AK.

In my travels, I began to bring up the subject of homebirth with obstetricians, inevitably getting only angry reactions. When speaking to roomfuls of obstetricians, I began to ask all those who had ever been present at a homebirth to raise their hands. No one ever did.

Eventually it became clear to the Group that there were two central issues in the debate over maternity services. The first issue concerned who was to control maternity services. Home birth was a sub-issue, since the hospital is doctor territory, where physicians have control, whereas they are not in control in the family territory of the home. A much larger and more central issue of control was the place of midwifery in maternity care. We gradually realized that the midwife-obstetrician controversy had been going on for at least two centuries. All over Europe, the obstetricians were succeeding in marginalizing midwives and gaining rather complete control of maternity services, in spite of clear evidence of benefit from midwifery.

The second issue was appropriate use of technology. The Group soon uncovered the large gap between the scientific evidence and the widespread use of obstetrical technology. Generally speaking, governments were willing to go along with the "expert" opinions of the obstetricians regarding the use of technology, even in the face of scientific evidence to the contrary. Consequently, the Group saw this issue as absolutely key to the evolution of maternity care, and it eventually became the focus of the activities which followed on the work of the Group. We soon learned that when it came to questions about control (including home birth and midwifery) and technology, obstetricians were adamant and unwilling to consider change, even in the face of compelling evidence.

I became aware that our Perinatal Study Group had forgotten alternative services. Wherever I went, I sought out alternative birth practitioners and observed alternative birth practices, including such unorthodox innovations as underwater birth at the Black Sea in the former Soviet Union, and the training of native Inuit women in the northern part of Quebec in Canada to be midwives in their own villages (Stonier 1988; Daviss, this volume). I observed a Cesarean section birth in China with one acupuncture needle in an earlobe as the only anesthesia and the woman wide awake throughout. (After the operation was concluded, the Western doctors present studied an acupuncture chart and said that since the lines on the chart did not follow nerve pathways, they could not accept what they had just seen with their own eyes- a paradigm clash).

The Study Group decided to do a cross-national survey of these alternative services, and recruited a midwife and a medical sociologist to do the study. The midwife, although fully accredited after orthodox training and practice, had also been involved in some alternative practices, and the sociologist had extensive experience with research in reproductive health. To our knowledge, such a survey of alternative birth had never been done, and the findings made it apparent that there was a vast knowledge completely outside of obstetrical AK. The findings became a chapter in the report of the Study Group (WHO 1985).

From 1979 to 1985, our Perinatal Study Group met regularly to look at all of our literature summaries and research results and to debate, argue, and- yes fight- over what it all meant. There were too many unanswered questions regarding obstetrical knowledge and practice: why did it reject homebirth out of hand? why did practices vary so widely? why did it not incorporate midwifery knowledge? why did it reject alternative knowledge? All of us in the Group went through a long and painful process of confronting ourselves and each other and re-evaluating our thinking.

We agreed at the beginning that scientific evidence would be the basis on which we must work. We met once a year for five days. The first day, some group members presented scientific reviews of agreed-upon subjects, and others presented surveys of services the group had asked them to conduct. The rest of the week was open discussion and debate, in an attempt to reach consensus on the issues the group had agreed to address. Ultimately, we did reach consensus on all these issues. We became friends and came more and more to respect each other, and this made it more and more difficult to hang on to our old beliefs. We were, of course, going through a paradigm shift of considerable magnitude that, in most cases, would affect our daily professional lives. No one in the Group, most especially myself, was left unmoved or unchanged.

At the end of the Perinatal Study Group's five years of work, it was my responsibility to pull it all together into a report. I decided to write it without the usual WHO jargon, and to write it so that anybody could understand it. The result was a WHO book, Having a Baby in Europe (WHO 1985). I had many insights as I wrote because the process of writing forced me to organize all of the scientific literature, surveys, discussions, and experiences of the Group. The result was a body of knowledge about maternity care very different from obstetrical AK, as the former is based on the public health paradigm, while the latter is based on the medical paradigm. And this body of knowledge based on the public health paradigm would be hard to discredit, as it carried the heavy authority of the WHO.

By medicalizing birth, i.e. separating a woman from her own environment and surrounding her with strange people using strange machines to do strange things to her in an effort to assist her (and much or all of this may sometimes be necessary), the woman's state of mind and body is so altered that her way of carrying through this intimate act must equally be altered. The result is that it is no longer possible to know what births must have been like before these manipulations. Most health care providers no longer know what non-medicalized birth is. This is an overwhelmingly important issue.

Almost all women in most developed countries in Europe give birth in hospital, leaving the providers of the birth services with no genuine yardstick against which to measure their care. What is the range for length of safe labor? What is the true [i.e. non-iatrogenic] incidence of respiratory distress syndrome in newborn babies? What is the incidence of tears of the tissues surrounding the vaginal opening if the tissues are not first cut? What is the incidence of depression in women after "non-medicalized" birth? The answer to all these, and many more, questions is the same: no one knows. The entire modern obstetric and neonatological literature is essentially based on observations of medicalized birth. [WHO 1985:85]

During a WHO visit to China, I realized that the developing world was- and is- in serious jeopardy of unquestioningly importing the orthodox obstetrical model. So I decided to try to export something else- the experience and newfound knowledge of the European Perinatal Study Group. Through WHO we organized a meeting in Beijing so that the Group could spend a week in discussion with perinatal experts from all over China.

The meeting was such a success that I, together with the Deputy Director of the WHO Regional Office of the Americas, who was also at the meeting, was able to convince the European Regional Office of WHO to organize a series of three Consensus Conferences in collaboration with the Regional Office of the Americas. The purpose of the conferences would be to use the experience and knowledge of the Perinatal Study Group, together with thorough review of the scientific literature, as a basis for formulating recommendations for the appropriate use of technology before, during, and following birth. The way in which these meetings were organized, the recommendations generated, and their impact has been described in detail in a book, Pursuing the Birth Machine (Wagner 1994).

In each Consensus Conference, we again lived through the clash of the orthodox obstetrical and neonatal AKs with the new AK emergent from the Perinatal Study Group and from the scientific literature, and the painful struggle of the participants to resolve the differences and reach consensus. The result was an extraordinary set of consensus recommendations for appropriate perinatal technology which, when published in The Lancet (WHO 1985, 1986), started a deluge of angry protest from the obstetrical establishment.

Important lessons can be learned from the way in which the medical establishment has attempted to discredit Having a Baby in Europe and the consensus recommendations. With regard to the knowledge in these publications, I do not know of any attempt to directly challenge their validity or "truth": there are no articles that take on specific recommendations to show why they were not scientifically justified, no requests to debate the specifics. Rather, other strategies were employed. One was saying that the recommendations were relevant only to the Third World (i.e., maybe the knowledge is valid but it doesn't apply to us). But by far the most common approach has been to attack the authority, rather than the knowledge.

Many times, I have witnessed how, if a midwife, nurse, or lay person (including social scientists) makes statements supporting the public health model of maternity services, the advocates of obstetrical AK assume a condescending posture and dismiss this person as ignorant, not worthy of attention. But because of my credentials as medical specialty practitioner, my earlier academic appointments, and my position with WHO (and also perhaps the fact that I am a man), this approach was obviously not appropriate for me. Something different was required. So the strategy in my case was to attempt to isolate me from the Study Group and from WHO and take away my authority by discrediting me. Most of the attempts at discrediting were carried out behind my back, so that I would have no chance to respond.

The one chance I was given to confront my critics in public was a most interesting experience. I had begun to collaborate with Patricia St. Clair, a health service researcher interested in women's health issues, and we had been writing and speaking about the low efficacy, high risk, and high cost of in-vitro fertilization (IVF) (Wagner and St. Clair 1989). To my surprise, I was invited to debate IVF at the next international meeting of IVF clinicians. On arriving at the conference hall, I accidentally stumbled into the small room where all those involved in the debate except me had been invited for briefing. The organizers were embarrased and pretended to have invited me. The debate was held in a large hall. Present were over 1000 IVF clinicians from many countries.

Following the debate, members from the audience could ask questions. When I was asked if it was not true that everything I said was my personal opinion and had nothing to do with WHO, the audience cheered. It was clear that I had been set up. Fortunately, we had already held an official WHO meeting in Copenhagen on IVF and had generated WHO consensus recommendations (WHO 1990). So I replied that everything I had said was included in an official WHO report and pointed to a large pile of WHO reports in several langauges lying at the front edge of the stage, suggesting that the audience was welcome to take copies. Most of the audience immediately queued up to get a copy of the WHO report. Their attempt to disassociate me from WHO in public (there were many journalists in the audience) had backfired. Such an experience might discourage direct confrontation.

Similar skepticism was evident in the orthodox obstetric establishment in Germany. When the German Obstetrical Association wrote to their Ministry of Health demanding that homebirth be outlawed, I wrote to the same Ministry of Health suggesting that we organize a meeting in Germany to discuss the scientific information on homebirth. The Obstetrical Association replied that they would never meet with me because I was "subjective and incapable of rational discussion on home birth."
In the opening speech to over 2000 obstetricians at a recent annual meeting of the European Congress of Perinatal Medicine (at which I was not present), Professor Saling, an obstetrician from Berlin, spent several minutes attacking me by name. I was "against the health of mother and child," I was "against modern obstetrics," and did not understand that the negative effects of obstetrics that I was pointing out were due to the few individual doctors who do not follow modern obstetrics: "As an epidemiologist and non-obstetrician he doesn't understand the difference between good and bad obstetricians." And of course, "he cannot be taken seriously as a scientist."

Attempts to personally discredit me are usually of three types. First, I am not an obstetrian, and only obstetricians have the necessary expertise. My answer to this is to use an analogy that is easily understood by my (sports-oriented) critics. Maternity care is a football game and the obstetricians are the players running up and down the field. But every good team has a coach (reproductive scientist) who does not play but is on the sideline carefully watching the overall patterns of play. The best play is the result of combining the observations of players and coach (Wagner 1989). It is extraordinary how the use of the analogy quickly neutralizes this objection.

The second common accusation is that I am not objective. Doctors have been saying this to women, patients, and politicians for a long time. Such a strategy backfires, however, when it is identified as part of a discredited paradigm- the classical Cartesian model (Wagner 1982). It is extraordinary that medical education still fails to teach the scientific realities that there is no such thing as objectivity, and that every doctor is as subjective as his patient.

How often I have heard that I am against progress. To criticize technology is tantamount to criticizing science and progress. The misunderstanding that technology = science = progress is widespread in medicine. A strange dichotomy exists in which, if I am not in favor of all technology, I am against all technology- you are with us or against us. I find it necessary to repeat often that the technology is not bad but can be misused, that doctors are not bad but can make mistakes.

Attempts to discredit me have sometimes gone to extremes. A group of Australian doctors wrote to the General Director of WHO demanding that I be fired. A group of doctors in England started a rumor that I had indeed been fired and reported this to a journalist who, fortunately, checked the story first by calling me before he printed it. Such attempts are more understandable when one realizes that, if a doctor steps out of line, his colleagues are usually able to reel in the dissident through local sanctions. The first sanction usually applied to a local physician is to take away hospital privileges. This is easy, since the decision to do so rests in the hands of other local doctors who can do this in secret. But there are usually other hospitals in the community that the dissident doctor can use. A much tougher sanction is to bring the doctor before some medical tribunal which may decide to suspend or take away a license to practice. While the overt purpose of such tribunals is to protect the community from doctors clearly unable to practice due to alcohol, drug abuse, etc., they can and have been used to discredit doctors who do not follow the rules of the "club" (see below) and of orthodox medical AK.

Wendy Savage is an obstetrician practicing in London who refused to follow all the edicts of the local old boys' obstetrical network. She consistently offered her patients unconventional choices and options, and worked to train residents to treat patients humanistically, as well. Displeased with her innovations, her department chairman took the opportunity of a baby's death to suspend Savage's license to practice and institute a formal inquiry. The mother, a Bangladeshi, had requested a trial of labour after a previous Cesarean, which Savage allowed, but which was not standard practice at the time. The baby was ultimately delivered by Cesarean, and seemed healthy at birth, but died two days later. Because she went public with the case and received extensive media coverage and popular support, and because her lawyer was able to force the tribunal to open its sessions to the public, she was acquitted (Savage 1986). (It is noteworthy that the old rule, "once a Cesarean, always a Cesarean" is gradually being thrown out of obstetrical AK and a "trial of labor" is now standard practice in some countries, although not, for example, in Australia.)

Peter Lucas, a general practioner in Melbourne, Australia, was not so lucky. Because he attends some home births and backs up home birth midwives, he was brought before a closed-door tribunal and suspended for four months. His case typifies many others. It is important to remember that only medical doctors sit on these tribunals, so such "peer review" can all too easily become a mechanism for protecting orthodoxy. In the U.S., a typical means of forestalling physicians who try to back up homebirth midwives is that they are denied insurance by the physicians who sit on the boards of the insurance companies in their communities.

As a WHO staff person, not a practicing MD, I was immune from the usual sanctions, and new avenues of attack had to be found. Getting me fired would accomplish two purposes- discrediting me and separating me from WHO. Having WHO's name on the books and recommendations that I helped to write gives such authority to the knowledge that it obviously has made problems. So there have been many attempts at this kind of separation. In his speech, Saling said, "These are his opinions and have no relation to the official policies of WHO."

Many similar experiences over the past few years have forced me once again to reconsider my assumptions about the medical profession. When I speak in public, as I often do, about the gaps between science and medical practice, I am always met with the reasonable question, but why? Why would intelligent doctors continue practices which science has shown to be wrong? The public finds this difficult to believe, much less accept, and in the beginning so did I. But as the power of the profession was turned against me I came gradually to realize that I had misconstrued the medical profession. Doctors are not bad individuals, but they are human and members of their community and have all the biases and motivations that entails.

Furthermore, as a group they often focus on concerns irrelevant to people's health. I remember being somewhat taken aback when I first realized as a young doctor that the American Academy of Pediatrics, of which I was a member, had two goals: to advance the health of children, and to advance the wellbeing of pediatricians. In this second role, the Academy functioned like a labor union, and if the two goals came into conflict, as sometimes happened, the second goal almost always took precedence. It became more and more clear that there were many determinants of medical practice, some having nothing at all to do with health. This realization about the nature of doctors and what makes them tick was another revelation for me that became part of the paradigm shift I was making. Eventually my insights into the nature of doctors led to another paper, "Birth and Power" (Wagner 1989).

The list of non-health determinants of medical practice is long; a few illustrations from maternity care will suffice to show where my thinking and observations were leading me. I saw that commercial pressures are ever-present. For example, the International Federation of Obstetrics and Gynecology organized a meeting to make recommendations for the use of the electronic fetal monitor. The travel and local costs of the participants were paid for by the industries making the monitors, and in order to get into the room, it was necessary to pass through a large commercial display of monitors. When I wrote to the obstetrician who had organized the meeting, expressing my concern for possible conflict of interest, he wrote back, indignantly assuring me that he was at all times "objective." My concern remained, since the meeting recommended routine electronic monitoring of all births, although the scientific literature did not and does not justify such a recommendation (Leveno et al. 1986, Prentice and Lind 1987; see Goer 1995:131-153 for summaries of 39 medical studies relevant to EFM).

Custom and habits are determinants of practice; how else to explain that for operative vaginal birth, forceps are used in Britain and her former colonies while the rest of the world uses the vacuum extractor? Convenience is the best explanation for the fact that induction of labor is so common in many countries that there are statistically significantly fewer births on weekends and at night. Willingness to change involves willingness to admit that you have been doing it wrong. This may help to explain why most obstetricians still prefer the woman to deliver on her back with her legs up during birth even though we have known for decades that, scientifically speaking, that is the worst possible position.

Territory, power, and control are certainly involved in the way obstetrics has tried for a long time to suppress midwifery practice (see Arney 1982). Most recently, studies by medical anthropologists have shown me how many obstetrical routines have cultural rather than medical determinants (Kitzinger 1978, Rothman 1982, 1989; Martin 1987; Konner 1987). Davis-Floyd, for example, notes that the routine use of the electronic monitor conveys to birthing women the message that their bodies are defective machines dependent on these man-made machines and the authoritative knowledge vested in the technical experts who can manipulate and interpret them (1992:104-111). She suggests that these and other routine obstetric practices make not scientific, but ritual and symbolic sense as transmitters of technocratic core values. From my perspective, such insights are valid and useful, but they would be rejected out of hand by orthodox adherents.

When I speak about such non-medical determinants of practice, I am told I am "doctor-bashing." Any criticism whatsoever of physicans is called "doctor-bashing." Whence comes this term? I can criticize my auto mechanic and I am not "bashing." I can tell a joke about lawyers and I am not accused of lawyer-bashing. (Note the paucity of doctor jokes, most of which are about how godlike doctors are.) As part of my paradigm shift, I came to realize that the medical profession has a set of mechanisms meant to set them apart from the rest of society, to protect them from any outside interference and to make their AK and AP sacrosanct. To not be able to say something negative about doctors without being labeled a doctor-basher is just such a mechanism. Another is obvious- to insist that one cannot possibly understand the obstetrical paradigm unless one is an obstetrician.

The trappings of doctors are another mechanism to set us apart. Why do doctors wear white coats? There are certainly no hygienic reasons for it- white material is no cleaner than any other color of material, and darker colors would certainly be more practical. Yet I can go to any country in the world, visit any hospital, and there, without fail, are the white coats. When I was an intern at UCLA hospital there was even a strict hierarchy of white coats- one type for interns, another for residents, another for attending physicians.

Of course, white is on top of the color scale in many countries, especially Western ones. It symbolizes refinement and purity, as in white flour, white rice, and white sugar (all of which have had their nutrients stripped away). It is the color of priestly vestments- as Robert Mendelsohn so aptly pointed out in Confessions of a Medical Heretic (1981), the hospital has become the cathedral of the 21st century.

Why do we put "Doctor" in front of physicians' names in everyday conversation? We don't say "Lawyer Jones." The only other profession with such an honorary title in everyday language, not surprisingly, is the priesthood. So often I have heard a doctor who is addressed as "Mister Brown" correct the speaker and say "It is Doctor Brown." From long personal experience I can assure the reader that being called Doctor morning, noon, and night has a profound effect on one's self-image. For some years now I have carried out an interesting experiment. I have tried to excise "Doctor" from my name- from everyday conversation, from letters, from participant labels at meetings, etc. It is difficult to do so. If I say to someone, "Please don't call me Doctor, as that is not what my mother named me," they are confused and embarrassed, and often I get the impression they think I am a crackpot.

But the most difficult problem, sad to say, has been with myself. Normally I find it a relief not to be called Doctor, but from time to time I am sorely tempted. When I am trying to get action from someone, all I have to do is use "Doctor" and things happen. This is especially true if I am dealing with a hospital or physician's office where the use of "Doctor" immediately creates an atmosphere of subservience around me. Small wonder that "Doctors" soon come to believe that they and their AK and AP are beyond reproach.

Why do doctors have "patients"? Other professionals have "clients," something very different. Clients hire professionals to perform services for them- they call the shots. But turning a person into a "patient" redefines that person as someone who is sick and under a doctor's supervision- automatically a dependent position. Because pregnancy and birth are not illnesses, I have worked hard the past ten years not to use the word "patient" in maternity care. For example, in Having a Baby in Europe, the word "patient" never appears. When speaking or writing about maternity care, health professionals often use "mother," again an unfortunate term since it refers only to the woman in her role as a mother and not to the whole person. So I try to use "woman."Several years ago I finally convinced WHO in Europe to change "Maternal and Child Health" (used everywhere in the world) to "Women's and Children's Health."

Another mechanism to protect medical authoritative knowledge and practice is, as we have seen, for all doctors to join together into an extremely powerful private club known as the medical profession. I have been a member of this club since I took the Hippocratic oath on the day of my graduation from medical school. One central rule of this club is never to criticize other doctors or medical AK or AP in public. As early as medical school, we were told that the doctor who does so is a traitor to the profession.

One day about ten years ago I received a call from a criminal lawyer in Toronto, Canada. She was desperate because, for the first time in her career, she had a case involving health professionals and was having great difficulty finding any doctor willing to testify in court. Her clients were two midwives who had attended a homebirth after which the baby died. Midwifery had been illegal for the last 100 years in every Canadian province and, with this death, the local obstetricians went to the coroner demanding an inquest. Several obstetricians had agreed to testify for the prosecution at the inquest but, although the lawyer had found several doctors who told her, "off the record," that the midwives had done nothing wrong and were not culpable, they would not testify to this in a coutroom open to the public.

I went to Toronto and in my testimony at the coroner's inquest talked about midwifery. The members of the jury knew nothing about midwifery but were open, and listened while I talked about the central role of midwives in maternity care in the rest of the world. I was simply giving the midwifery AK, as well as the AK developed by our WHO Study Group. At the end of the trial the jury wrote a ten-page report demanding that the government investigate making midwifery legal. The government eventually did so- in 1992, midwifery became legal in Ontario Province.

Shortly thereafter, I testified in another case involving two midwives in Vancouver. Again a leading obstetrician testified for the prosecution. In this case, there was no jury, only a judge. It should not have surprised me that the judge decided against the midwives. Judges, of course, are like doctors- members of the power elite in the community and much more likely to believe in the authority of the local doctor, whom they most likely know socially.

Since then I have testified in court in a number of countries and in every case involving a jury the midwife (or doctor practicing an alternative approach) has won while in every case involving only a judge, she has lost.

As noted above, doctors are quite willing to see litigation against midwives or dissident doctors but strongly object to the use of the public courts for litigation against doctors. But as long as the complaint system (for those feeing they have been poorly treated by doctors) is physician-controlled, the public has no choice but to use the public courts if they are to prevent the possibility of conspiratorial cover-up and get a fair hearing of their complaint. The medical profession believes that systems of knowledge and practice differing in any respect from orthodox medical AK should be judged only by themselves, behind closed doors.

The paradigm shift which helped me to better understand the medical profession also helped me to better understand the public health profession. Public health practitioners are also human and the determinants of their practice often have little to do with the health of the public. Many public health practitioners are also doctors and members of the club, and not about to go against the rules. But even those who are not have two real problems which seriously interfere with their job. In general, they have less power than the medical profession and live in fear of their jobs. And they are confronted by the dilemma that in order to carry out their primary role- protect the health of the public- they may be called upon to take actions which will not make the doctors happy. I have had countless arguments with public health practitioners who insist that the best strategy is always to keep the doctors happy and quietly bring them along. But sooner or later, a case will come along in which they must take a stand to support either the public or the doctors. Their allegiance to the medical club is so strong that most often they cannot go against the club, and the public is the loser.

A simple example will illustrate how public health practitioners acquiesce to the power of medical practitioners. In many countries it is fortunately becoming more common to collect data from hospitals and clinics on their practices. This data is collated at the central level by public health authorities who feed it back to the practitioners. So far so good. But how about giving this data to the public so they can make informed choices about which hospital, clinic, or physician to choose? Needless to say, the doctors are against this: they don't want information about their individual practices available to the public ("who can't understand it anyway"), as they are concerned about unfavorable comparisons with other doctors. The result is that in many places this data is still not available to the general public, or, if it is available, it does not identify the hospital, clinic, or doctor. I have argued without success against this latter strategy with public health practitioners in Denmark, France, Luxembourg, Australia, and the U.S.

Several years ago I went to Leipzig to an annual meeting of a European perinatal organization attended by hundreds of obstetricians. A leading obstetrician gave a lecture on the history of maternity care which covered all the outstanding medical breakthroughs and advances of the past century, and the high level of current obstetrical knowledge. The presentation was so unbalanced that, during the ensuing discussion, I (naively) tried to bring some better balance by noting that some important history was left out, such as the DES (diethylstilbestorol) and thalidomide disasters. Immediately the speaker and audience became quite hostile to me. Gradually, I have come to realize that the central purpose of medical meetings is not the presentation of balanced reports but rather to provide a reconfirmation of the correctness of the obstetrical AK (authoritative knowledge).

Such medical meetings, of course, also serve to confirm the correctness of current obstetrical AP (authoritative practice). The most common type of paper at such meetings is a case series from a doctor or clinic demonstrating the efficacy of a particular procedure (a scientific methodology with low validity). Several times in discussions at meetings I have pointed out that our practice and judgment are not infallible. Death is the great enemy, and, according to the medical club, we must carefully hide our failures. Maternal mortality audits and perinatal audits, in which the deaths of women and babies are analyzed, are always done in secret committee. The fact that these committees find a significant proportion of deaths to have been preventable and to have resulted from mistakes in clinical judgment does not usually reach public awareness. In Pursuing the Birth Machine I wrote,

Orthodox obstetrical AK does not allow sufficient attention to death or to public discussions of deficiencies in knowledge and practice.
After learning that medical meetings are not good forums for balanced debate, I gradually turned more and more to the scientific journals as better places to discuss critical issues. At least in the journals one can argue substance, and in a few of the best journals, hope to get a balanced approach. In The Lancet, for example, it was even possible to get a paper published which discusses the pros and cons of medical AK versus public health AK (Stephenson and Wagner 1993a).

I gradually learned also to turn to the public for debate on maternity care. Not only is this the appropriate audience (it is they who are having babies, not us), but strategically it is much more effective because, although doctors may have vast expertise behind closed doors, they usually flounder when addressing the public- a result of their condescending attitudes and patronizing approach. I started by accepting requests for interviews for newspapers, television, and popular magazines. Later, I became more proactive about publicity, and would myself call a journalist if something important came along.

I also collaborated more and more with consumer groups such as Foraeldre og Fodsel (Parents and Birth) in Denmark, the Active Birth Movement in Italy, the Association for the Improvement of Maternity Services in Britain, Femme-Sage-Femme (Women and Midwives) in France. These groups and many others have played key roles in opening up the debate and providing more options in maternity services. My knowledge base has been broadened greatly by my association with such groups. Whenever there have been real confrontations between consumer groups and the medical club over maternity services, the consumer groups prevail (see Szurek, this volume).

The most effective collaboration seems to combine three elements: a few doctors and scientists who are knowledgeable about obstetrical AK, midwifery AK, public health AK, and the current scientific literature, and who are willing to go public; interested journalists not intimidated by doctors; and consumer groups not controlled by health professionals and not afraid to aggressively go public.
Just after the publication of Having a Baby in Europe, a Danish midwife and I were discussing how to promote this new knowledge. She suggested we start with Denmark, and organize a "Birth Conference."

We approached the Danish consumer group Foraeldre og Fodsel and they were enthusiastic to collaborate. The Danish organization of obstetricians and gynecologists and the Danish organization of midwives also agreed to participate. The conference was held in the WHO building in Copenhagen and was a big success.

The Birth Conference was an idea whose time had come. In the past eight years there have been over 50 similar conferences in over 20 countries. They have varied from country to country- for example, in Eastern Europe there are no consumer groups as yet and the local organizer is usually a public health authority, while in Western Europe the initial local organizer often is a consumer group or a midwife organization. But they all have WHO input, and involve bringing together what we call "all interested parties," by which we mean any groups or disciplines or individuals in the community with interest in or responsibility for maternity services.

While we at WHO initiated most of them in the beginning, by now they are all locally initiated and continue to pop up everywhere. The central purpose of the birth conferences is to legitimate and confirm the midwifery AK and public health AK found in the WHO publications, and to use this knowledge to stimulate change in maternity services. As such, these conferences are the mirror opposite of obstetrical meetings whose central purpose is to reaffirm the obstetrical AK and the status quo.

The atmosphere of the two types of conference is equally different. It is not unfair to describe the ambience of obstetrical meetings as serious self-importance. The participants are mostly men who have exchanged their white coats for dark suits and ties. The ambience of the birth conferences is earnest joyfulness. Participants are mostly women- it is difficult to get too serious and stuffy with crying babies and breastfeeding mothers everywhere to remind us what this work is really all about.

The methodology of the birth conferences is also different from medical meetings. They are open to the public, and every attempt is made to involve "all interested parties," including midwives, physicians, epidemiologists, social scientists, health administrators, consumer groups, and, very importantly, the media. Presentations on the present status of local birth services are followed by presentations on the WHO recommendations and the latest scientific findings. The discussions that follow focus on bringing the local services closer to what WHO and the science suggest. These discussions constitute confrontations between obstetrical AK and midwife and public health AK, or, put another way, a struggle between the medical paradigm and the public health/midwifery paradigms. Finally, an attempt is made to generate consensus recommendations for changes in local maternity services. There is usually considerable media coverage afterward.

The birth conferences can bring surprises to some of the participants, especially physicians only familiar with medical meetings. I remember that during the first birth conference in Denmark, the doctor who was head of the ultrasound department at the University Hospital gave a glowing account of the wonders of obstetrical ultrasound. There followed a discussion in which participants brought forward the lack of scientific documentation for his assertions and the fact that not one experimental trial had yet shown efficacy for routine scanning during pregnancy. The physician in question was most dismayed with what for him was clearly an unusual reaction to his standard speech.

Similarly, at one of the most recent birth conferences, organized by the Midwives' Association of Luxembourg in 1993, I presented data on how the use of obstetrical interventions in Luxembourg far exceeds the WHO recommendations, following which there was a heated debate between the obstetricians and the midwives over these practices. At the end of the conference a local obstetrician told me he was shocked, as the doctors had agreed to come because "we expected to have a friendly chat with the girls."

The birth conferences have had a variety of impacts, some planned and some not. There is no question that they have served to raise the awareness of the public health paradigm's approach to maternity care, and to legitimize it. They have also raised awareness about the gap between science and obstetrical AK, and about the need for change.

And the birth conferences have started a process of building in midwives and consumers the capacity to read, understand, and use the scientific literature. These conferences serve as opportunities to identify those in the community really interested in changing maternity services. Here there may also be surprises. While it is common to invite the more liberal doctors in a given community, they are often exposed during the discussions as being interested only in minor changes around the edges of obstetrical AK, but not at all in giving up the core obstetrical AK and the power that goes with it. Such physicians are often upset during the conference because they are used to being seen as progressive, and to attacks from the right, but they are not used to attacks from the left.

On the other hand, allies for the public health approach may, surprisingly, be found among conservatives. Conservative politicians may see choice at birth as a way to promote conservative values such as individuality and a strong family. Conservative older physicians, trained before the high-technology takeover of obstetrics, may prefer a more cautious and humanistic approach to health care.

Birth conferences have also served to jump-start or accelerate the process of change in maternity care. One of the reasons we pushed ahead with promoting these conferences was because of what happened after the first birth conference in Denmark. Shortly before the conference, the Danish Minister of the Interior (responsible for health), a woman and conservative politician, had decided that the present guidelines for maternity services, over ten years old, needed revision. She asked the National Board of Health to carry this out. The National Board, in turn, asked a leading professor of obstetrics to revise the guidelines, which he was happy to do. The revised guidelines were passed on to the Minister, who did not like what she saw but was not sure why, and felt insecure about criticizing a physician and professor.

Then the next morning in the daily newspaper the Minister read a long article about the just-finished birth conference. She recognized that many of her concerns about the revised guidelines parallelled the issues discussed at the conference. She wrote to WHO, enclosing a copy of the revised guidelines, and asking that we meet with her. The Danish midwife and I wrote a short critique of the guidelines and met with the Minister, urging her to get opinions from "all interested parties" in Denmark. She did just that, and the result was a new set of guidelines completely different from the first revision. Instead of being based only on obstetrical AK, they were based much more on midwifery and public health knowledge. This was an easily visible direct impact of the birth conference. Usually the impact is slower, less direct, and less visible, although from time to time, such as in Italy, Austria, Britain, and Russia, the impact has been clear.

The reaction of the higher-ups at the World Health Organization has been quite ambivalent. The good news is that, when Having a Baby in Europe became the bestseller among WHO publications, the management in the European Regional Office was most pleased and proud. The usual standard operating procedure in WHO is to organize "expert" meetings, publish a report, and move on to something else. There was no precedent for going out into the real world to promote the reports or recommendations through collaboration with professional and lay groups. Nevertheless, our efforts to promote appropriate perinatal technology were well-received by a small but critical mass within the European office. There were a few key WHO staff people who understood the public health paradigm and let us know that they believed in our work, most importantly the Director General in Geneva and the Regional Director in Copenhagen in the early 1980s. Without their support we could never have succeeded in our tradition-breaking efforts.

The bad news is that the great majority of WHO staff have come to the organization straight from the medical world and brought with them the medical AK and allegiance to the medical club. These staff people truly did not understand what my efforts were all about, except that I was breaking the rules of the club and making doctors angry. I was seen by these staff members as a real troublemaker, and could cite countless examples of their efforts to stop me. For one, my immediate Director in Copenhagen blocked my plans for the three Consensus Conferences until I went over his head to the Regional Director and the General Director. When another Director told me to stop and I refused, he said that if it were up to him, he would fire me, but for some reason, the Regional Director would not allow him to do it (see below). This same Director threatened to take away the funding for my program if I didn't conform to his notion of what I should be doing. When I refused, he took away most of my funding, leaving the Women's and Children's Health Program with, for example, fewer funds than a very medically oriented program for the management of diabetes.

But because of all the support I had generated in the countries in my Region, I was able to proceeed with my program. Financial sanctions are a typical way for the medical club to force conformity to the obstetrical AK. In Germany many insurance companies will not reimburse a family for a birth if it takes place in an alternative birth clinic. In Australia and other countries, government health insurance will not reimburse midwives for a home birth.

Many attempts were made to stop or change my writings. When I began to publish scientific articles running counter to the medical AK, I was told that all of my writings must be approved by management before I submit them to journals. I told them this was scientific censorship and I would quit first, and they backed off. The management in the European Office in Copenhagen originally was in favor of my writing a sequel to Having a Baby in Europe. However, by this time there was a new Regional Director in Copenhagen and a new Director General in Geneva, and when this new management saw the drafts of The Birth Machine, they wanted to make such substantial changes that the result would be a watered-down and confusing compromise between the medical and public health paradigms. It was necessary to have this second book published outside WHO.

When my article appeared comparing the medical approach used at WHO headquarters in Geneva with the public health approach used in the WHO Regional Office in Copenhagen (Stepehnson and Wagner 1993a), the response of the relevant Director in Geneva was not to debate the issue but to attack me for going public.

WHO has an extraordinary means of operation. As I mentioned earlier, a great deal of time and resources go into organizing "expert committee" meetings to consider particular issues in health services. When the committee's final report is published, it contains the disclaimer, "The views expressed in this publication are those of the participants and do not necessarily represent the decisions or stated policy of WHO." When our recommendations on in-vitro fertilization were published in a leading medical journal, WHO headquarters in Geneva was angry and wrote a letter to the editor (never published) with the above disclaimer.

When the recommendations from Having a Baby in Europe or the three Consensus Conferences (all can be found in official WHO publications) are included in my speeches or interviews, and a reader or listener writes to WHO with a complaint, they are sent the disclaimer instead of an explanation that I am making recommendations from a WHO report. The paradox that WHO makes recommendations and then refuses to take responsibility for them must be the result of wanting to be involved in improving the health of the world while, at the same time, never making doctors angry.

Some of WHO's work, for example, the report on Primary Health Care from Alma Ata (WHO 1978) and the Regional Targets for Health for All (WHO 1986) from Copenhagen are based on the public health approach and are outstanding, but the organization has not been able to promote these publications aggressively enough because they contain ideas counter to medical orthodoxy and therefore might displease Ministries of Health and/or physicians. Both of these WHO documents emphasize the important role of non-physician health workers such as the midwife and the traditional birth attendant (TBA). Yet for many years there was no midwife on the regular staff in WHO headquarters in Geneva or WHO European Regional Office in Copenhagen.

There is very little possibility for WHO headquarters to influence the Regional Offices or vice-versa. The WHO headquarters’ programs for TBAs always tended to emphasize how we might train them, never honoring their indigenous knowledge nor trying to empower them in an egalitarian way as primary health care workers. Attempts by the European Perinatal Study Group and the subsequent WHO Consensus Conference recommendations to empower midwives and bring back their central role in maternity care in the industrialized countries met with resistance from doctors both within and outside of WHO.

The considerable media coverage I have received makes the WHO management nervous. They must agree with me that our primary responsibility is to the people but they say, again and again, that our credibility depends on our being seen as a serious, scientific organization. Similarly, when the Danish midwife and I received a prize from the Danish consumer organization Foraeldre og Fodsel for our contribution to improving birth care in Denmark, WHO didn't know how to react. No WHO staff person had ever received a prize from consumers- was this good or bad?

Three strategies evolved in my attempt to coexist with WHO.

(1.) Whatever I say or write must have a solid scientific base. This has saved me countless times. For one example, in a speech in Edinburgh I said that birth in Scotland was at least in part based on the convenience of doctors, since there were fewer births at night and on weekends. This comment made the front page of the Sunday paper there, and precipitated an angry phone call from the Director of Health for Scotland to my Regional Director. I suspect the Regional Director heaved a sigh as he picked up the phone to call me yet again and ask what this was all about. I was able to give him the exact reference from the scientific literature for a Scottish study showing that the excessive use of artificial induction resulted in a statistically significant decrease in births at night and on the weekends. My Regional Director was able to call Scotland back with scientific justification for my remarks, and thus support me in my work.

(2.) Another important strategy was, whenever possible, to have recommendations made by a "group of experts" rather than by me personally. Recently I made a mistake which shows the value of the group approach. I had done a survey of the scientific literature on in-vitro fertilization (IVF) and drafted a paper which was highly critical of present services. I sent a copy of the draft to someone in WHO headquarters asking for a personal critique. To my shock and without asking me, he sent the draft to a number of IVF clinicians all over the world. A deluge of angry letters to WHO followed.

Learning about this, my Regional Director suggested that I bring together a group of "experts" to consider the issue. I did just that (although the "experts" included all interested parties) and the result was a WHO report saying pretty much what my first draft had said. Now, however, it has the authority to go along with the knowledge.

(3.) Perhaps the most important strategy was an unwitting one. From the beginning of my tenure at WHO I spent a good deal of my time "in the field" and developed good relationships with my official public health and medical counterparts in governmental and non-governmental orqanizations in many countries. Then, when I began to promote the new birth recommendations, I came into frequent contact with many unofficial counterparts including midwifery organizations, consumer groups, social scientists, and health service researchers in many countries. Later, when efforts were in process to have me fired, my Regional Director mentioned my "broad power base in many countries" and I suddenly realized that there were a lot of people "out there" who would support me. This was the reason, as mentioned earlier, that one of the directors told me that he couldn't fire me because the Regional Director found it politically impossible.
It is important to point out that, when all was said and done, WHO did support my work and all the recommendations in their publications based on the public health paradigm.

Brigitte Jordan (1993) defines authoritative knowledge as legitimate, consequential, and worthy of discussion, as the knowledge on the basis of which, in a given community, decisions are made and actions taken. In effect, all of my efforts at WHO, as well as the efforts of many other dedicated individuals, have been directed at expanding the body of knowledge recognized as authoritative in obstetrics, at opening it up to include the authority of birthing women, midwives, scientific researchers, and public health advocates and professionals.

These efforts are part of the global struggle for control of maternity services, which in turn is part of the much larger struggles for (1) control of women in patriarchial cultures; and (2) control of all health services. In another paper, Patricia Stephenson, a health service researcher, and I describe how the medical profession is used by society to control women's reproductive health (Stephenson and Wagner 1993b). And in Pursuing the Birth Machine I describe in much more detail how the struggle for maternity services as part of all health services plays itself out in different parts of the world. I also point out a number of outstanding examples of people, including doctors, midwives, and scientists, who have broken out of the obstetrical orthodoxy and made important contributions to broadening both the authority and the knowledge on the basis of which decisions about birth can be made, and actions taken.

At the present time there seems to be a cross-disciplinary coming together of understandings about the paradigms influencing contemporary maternity care. In Pursuing the Birth Machine, I compare the "medical" model of birth with the "social" model of birth. In In Labor: Women and Power in the Birthplace, Rothman (1982) describes the "medical" and the "midwifery" models of birth, which Davis-Floyd (1992) re-names "technocratic" and "holistic." In another paper Stephenson and I (1993a) contrast the "medical" and the "public health" approaches to determining the proper management of infertility services. An economist compares a "professional" with "societal" or "state" models of health care systems (Light 1993).

There is, not surprisingly, considerable overlap among the alternative (social, midwifery, holistic, public health, and societal) paradigms, indicating a convergence of insights from a variety of viewpoints and disciplines. In other words, the limitations of orthodox medical authoritative knowledge are being challenged from many quarters. This convergence is sure to facilitate the ongoing struggle to transcend these limitations in the interests of improving health care.

NOTES

1. In Becoming a Doctor: Medical School as Initiation, Melvin Konner describes a conversation with a physician who was an expert on public health that casts light on my own experience. This physician had held an important administrative position in internal medicine, and had a strong reputation in research, but had given all that up to take a leadership role in public health:

"People were puzzled, and I, like many others before, gave voice to that puzzlement. He was forthright, even adamant. Public health measures, not medical care, were responsible for all the important reductions of morbidity and mortality in modern times, he said. This was not news to me and I had little trouble with it, but [his] vehemence was surprising.

"Another physician who joined in the conversation was the designer and implementer of a program for screening newborn infants for hypothyroidism, which if undetected can easily cause profound mental retardation. The two of them insisted not only that public health measures were much more important than medicine, but that medicine had accomplished nothing at all. I protested. Coronary artery bypass surgery? Appendectomy? Antibiotics? Nothing I mentioned impressed them in the least. The treatments were overrated, the numbers of people saved were trivial compared with the numbers, past and future, saved by preventive measures.

I felt like an idiot. Here I was, taking my first steps in clinical work, defending the whole enterprise of clinical medicine in an argument with two men who had spent decades practicing medicine at its best and who had abandoned it and insisted that it was useless. There was no getting around the irony of this exchange, nor its implications for the journey on which I had embarked (1987:40)."

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CONFESSIONS OF A DISSIDENT
Marsden Wagner

A chapter in Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives, eds. Robbie Davis-Floyd and Carolyn Sargent. University of California Press. In press.