REFLECTING ON PRACTICE TO THEORISE EMPOWERMENT FOR WOMEN: USING FOUCAULT'S CONCEPTS

/ ! i Dr Kathleen Fahy RN EM BN MEd PhD, Professor of Midwifery, Head School of Nursing

and Midwifery, University Drive, The University of Newcastle, Ca[[aghan NSW 2308

Email: kathleen, fahy@newcast[e.edu.au

ABSTRACT

The aim of this research is to understand how power

operates in the medical encounter with the

childbearing woman and to theorise ways in which

midwives can empower women to experience contro(

over what happens to them.

Thirty-three Australian pregnant young women and the

researcher participated in this study.

A post-modern, feminist praxis approach was the

research method used. Data was collected using

participant observation, in-depth interviewing and

reflective journaling. Data was ana(ysed using Miche[

Foucau[t's theoretical concepts concerning disciplinary

power/knowledge.

Key theoretical findings are: knowing how power

operates allows midwives to predict what wi l l happen

i f the woman is intending to resist standardised

medical birthing practices. When disciplinary medical

power is used the purpose is to coerce patients to do

what the doctor wants. Power and knowledge are

inseparab[e, as each strengthens the other, thus

Foucau[t writes of a single concept - Power/

Knowledge. Medical power operates most effectively

with the co-operation of the midwife and the

submission of the childbearing woman. Medical power

is normal[y invisible; i t on[y becomes visib(e when

resistance is encountered, whereupon rewards, threats

and punishments are used in an attempt to gain

submission. Women can be more empowered i f the

midwife shares knowledge, not just about pregnancy,

[abour and birth, but also about the woman's legal

rights and what might happen i f she decides to refuse

standardised medical care. In this way women's

empowerment can be facil itated so that they are more

likely to experience the type of childbirth they desire.

INTRODUCTION

This paper presents one aspect of a research project

concerning teenage childbearing. The data presented

was gathered as part of a large, critical, feminist praxis

research project. Two cases are described and they are

exemplars of the kind of experiences that occurred

during the study. The use of the first person throughout

this paper and the inclusion of my own experiences as

part of the data are consistent with best practice in

feminist research (Fonow ~t Cook, 1991; Lather, 1991;

Reinharz, 1992; Stanley ~ Wise, 1993).

The focus of this paper is on ways to work with women

to facilitate their empowerment. Given that much of

what happens to women during the childbearing year is

under the control of obstetricians, the question is:

How can midwives help women to experience control

over what happens to them? In attempting to answer

this question research data is analysed using some of

Michel Foucau[t's theoretical concepts, including

'disciplinary power'; ' power/knowledge';

'panopticonism'; ' the gaze'; 'docile bodies' and

'dominant vs. subjugated discourses'. His concepts are

firstly explained and then applied and extended in the

interpretation of two separate clinical situations

between two young women (Beth and Lisa), two

doctors, and myself as researcher. Finally, specific

strategies are discussed for facilitating the

empowerment of childbearing women. This theorising

gives guidance to midwives who work within

mainstream health services and want to enable woman

to experience more control over what happens to

them.

VOL 15 NO 1 MARCH 2002 5

METHODOLOGY

Context and Participants

The primary research site was a women's health centre

(WHC). The study had institutional ethical approval

from both the university and the health authority and

the approval of the management committee of the

WHC.

At the WHC I formed partnerships with young women

across their childbearing year. My rote was that of

community midwife during the antenatal and post-

natal periods. I conducted this rote in close

collaboration with the antenatal clinic at the hospital.

When the young women attended hospital I was a

researcher and a support person for them. I was

present during a number of their labours.

The 33 participants were mostly marginatised young

women (Fahy, 1996a). Their demographic profile was

consistent with the literature on teenage childbearing,

in that their backgrounds were characterised by

poverty and poor educational attainment (Upchurch Et

McCarthy, 1990).

Praxis Research Design

Like action research, praxis research proceeds as an

ongoing spiral of practice, self-reflection, scholarly

inquiry and theorising which leads to changes in the

practitioner/researcher's practice (Lather, 1991;

Stanley Et Wise, 1993). Praxis methodology is designed

for individual practitioners who are working with

individual clients (Fahy, 1996b).

Data for the study was derived from all aspects of my

midwifery research praxis, including multiple in-depth

interviews, participant observations at the WHC and the hospital, and my own reflective journating

(Reinharz, 1992). Some interviews were fully tape-

recorded. In the clinical incidents presented here I

carried a tape recorder and spoke into it immediately

after the events. At[ data concerning the young

women was given to them to validate before it was

used for analysis and theorising.

Analysis and interpretation

The analysis and interpretation of the critical incidents

demonstrates a post-structural, feminist account. In this

form of data analysis the focus is on the process of how

meaning is constructed. Such an account emphasises

reflexivity and emotion. The data and its interpretation,

therefore, are both personal and political (Lather, 1991;

StanLey Et Wise, 1993; Fonow Et Cook 1991).

The theoretical formulations, which are derived from

data analysis, have their concrete groundings in the

immediacy of the clinical situations. The analysis of

data presented here follows Attheide's and Johnson's

(1994) notion of "Validity-as-Reflexive-Accounting",

which places the researcher, the topic, and the sense-

making process in interaction. This means that the

reader can evaluate the validity of the theoretical

claims being made by reading the actual data from

which the theory is being generated (Denzin, 1994).

Like all qualitative results, no claim to generalisabitity

is being made. The reader, however, is invited to make

decisions about the transferability of theoretical

formulations to their own practice setting (Dickson,

1995).

LITERATURE REVIEW

In this section Michel FoucauJt's concepts in relation to

disciplinary power are first outlined and then applied

to maternity service provision. FoucauJt was an

historian and a philosopher. It needs to be

acknowledged that Foucautt wrote over a number of

years and his own ideas developed over time, thus

there is no single correct reading of Foucautt. No

attempt is being made to cover the scope of his

writings, as only selected concepts are addressed here.

D i s c i p l i n a r y Power

Foucautt traced the historical transition from the

exercise of the sovereign's (or Legal) power to modern

forms of disciplinary powers. Legal power, he

demonstrated, operates openly, in public view and can

be very effective even if the subject resists, e.g.

arrest, public trial and imprisonment can at[ happen

against profound resistance from the subject (1980).

In the hospital this is the kind of formal power that

managers sometimes use (e.g. disciplinary

procedures).

Unlike legal power, disciplinary power seeks invisibility

and is difficult to detect, usually not becoming visible

until resistance is encountered (Foucautt, 1982). Also

in contrast to legal power, disciplinary power requires

the co-operation of the subject. The way the subject's

co-operation is gained was one of Foucautt's central

concerns. The disciplines he was concerned about

were the practice professions and the corresponding

institutions in which they exercise their powers, e.g.

the army, prison, the asylum, the factory and the

hospital (Foucautt, 1979). Disciplinary power, Foucault

argues, operates concurrently with, and may subvert,

the subject's legal power.

6 AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

' P a n o p t i c o n ' , ' T h e G a z e ' and ' D o c i l e S u b j e c t s '

HistoricaLLy, Legal power was visible and often

rituaLised, e.g. public floggings and executions where

the agents of power are cLearLy identified as judge or

executioner. In contrast to Legal power, the disciplines

derive much of their power from putting the subjects

on display, while those who are controLLing the

situation remain unseen (or reLativeLy so). Foucau[t

(1979) used the Panopticon (observational tower in

jails) as a concept and a mode[ to facil i tate

understanding of how surveiLLance is central to the

operation of power. When jails were first constructed

each inmate was kept in a ceLL with two Large windows,

one window facing the panopticon tower and the other

window directly behind the first window. This had the

effect of Lighting the inmate's ceLL so that the inmate

could be seen at aLL times from the panopticon. This

surveiLLance Foucau[t caLLed 'the gaze'. The person

who is subjected to this kind of 'gaze' cannot know

when they are being observed and when they are not.

In order to avoid punishments (e.g. solitary

confinement) and/or to gain rewards (e.g. parole),

subjects generaLLy behave in ways that their observers

desire.

Foucau[t argues that once subjects interna[ise the

understanding that they may be observed at any time,

they become their own observers, turning themselves

into 'dociLe' subjects. HistoricaLLy 'gazing' is a

relatively new phenomenon. It is the basis for

disciplinary power, so much so that without 'gazing'

disciplinary power cannot operate. An increase in

surveiLLance Leads to an increase in disciplinary power

and decreasing surveiLLance decreases disciplinary

power (Foucau[t, 1980).

P a n o p t i c o n i s m and M a t e r n i t y Care

Foucau[t's concept of the Panopticon has wide

appLicabiLity for understanding medical power. In the

hospita[s the 'NightingaLe wards' were designed to

facilitate surveiLLance of both patients and nurses by

putting them under the 'gaze' of senior nurses, who in

turn were governed by the matron, who uLtimateLy was

LargeLy controLLed by invisible medical power. Medicine

as a discipline has been, and continues to be, almost

entirely administered upon patients (aLive and dead) to

gain knowLedge. It is through gazing, including the

invasive technoLogicaL and surgical gazing, that doctors

[earn medical knowledge, which is the basis of medical

power. Thus Foucau[t's (1980) concept of knowledge/

power shows that the concepts of power and knowledge

are inseparable (discussed in more detail below).

Medical surveiLLance of childbearing women during

pregnancy has been termed 'nataL-panopticonism'

(Terry, 1989). In maternity services Medical

Panopticonism occurs, for example, when women come

to hospital for antenatal care and are subjected to the

medical gaze of antenatal assessment. The

surveiLLance is intensified and made more powerful by

technoLogicaL gazing, e.g the use of routine screening

tests Like u[trasounds and admission cardiotocographs.

In the birthing suite one way in which medical power is

intensified is by doctors being able to walk into any

Labouring woman's room at any time. An

empowerment strategy is to aLLow (even suggest) that

the door be closed and anyone wishing to enter must

first knock and ask permission.

P o w e r / K n o w l e d g e and D o m i n a n t D i s c o u r s e s

Foucau[t argued that the disciplines borrowed the

disciplinary techniques of the CathoLic Church

(FoucauLt, 1984). This was most cLearLy seen in the

cloistered orders of nuns and monks, where men and

women actively participated in turning themselves into

submissive subjects of the church hierarchy. Monks

and nuns (and to a Lesser extent the whole society) did

this, he argues, because of their belief that

compliance would be rewarded and disobedience

would be punished in the after-Life. My reading of

Foucau[t is that, historicaLLy, the church's basis for

power over the people was that people believed the

clergy's claim that God would punish and reward

church members depending upon their submission to

church doctrine. HistoricalLy, the church's power has

Lessened as people have Lost faith in the clergy's claims

to know the mind of God. This suggests that a strategy

of pubLicLy chaLLenging medical knowLedge claims that

are not evidence-based - and not in women's best

interest - may be a useful strategy in reducing medical

dominance in birth.

Power and knowledge are, for Foucau[t, synonymous

terms (Foucautt, 1980). He (1980) argued that power

and knowledge are seLf-referentiaL, meaning that

having the public accept the disciptine's knowLedge

claims has the effect of increasing the power of the

discipline, and having power aLLocated by society

increases the standing of one's knowledge claims. It is

critica[ to be aware that i t is society that decides

which knowLedge and authority i t wilt accept and

which i t wiLL margina[ise. Thus, society, via its

representatives (governments and bureaucrats), aLLows

certain groups e.g. obstetricians; to have power, whilst

simuLtaneousLy Limiting the attempts of others e.g.

midwives, to increase their power over birth. Thus

VOL 15 NO I MARCH 2002 7

there are dominant knowtedges (or discourses) such as

medicine, and subjugated discourses such as

midwifery.

weeks of my study. My involvement is worthy of special

consideration because of the impact that i t had on the

outcome of the power struggle that is described.

M i d w i v e s and C h i l d b e a r i n g W o m e n as D o c i l e S u b j e c t s

Midwives and women have their own sources of power

and are in turn the subjects of medical and managerial

discipLinary power. This paper focuses on the

inappropriate use of medical power, but i t must be

remembered that midwives have considerable

disciplinary power in relation to clients, and

sometimes use their power inappropriately (Fahy Et

Smith, 1999). Modern disciplines, FoucauLt (1984)

says, induce submission by promising people rewards

for compliance and punishments for non-compliance;

this is normally done implicitly. As the data wit[ show,

when this idea is applied to medicine, the promises

that medicine offers are ' l i fe ' , 'health' and 'pain

relief', while the punishments are fears of 'pain',

'death' or 'disabil ity'. Childbearing woman are

implicit ly offered a safe and relatively pain-free birth

as the reward for submitting to medical surveillance

and control during their pregnancy and birth.

Why are midwives so often 'docile subjects' in relation

to disciplinary power? There are many rewards and

punishments built into the training of nurses and

midwives, which ensure that, for the most part, they

become submissive subjects. The punishments for not

behaving as 'docile' subjects within the health care

system are welt known and include being shunned,

criticised and ostracised by one's colleagues, in

addition to being subject to format administrative

sanctions (Huard Et Fahy, 1999). At the same time, one

of the most potent pLeasures is to Let go of

responsibility, handing over decision-making to the

powerful other. This frees us from the worry and

anxiety of takin~ control of the situation and being

hew responsible (Foucauit, 1980). Thus, some

midwives actively resist the introduction of midwifery

models of care and support the medical model of care

for well childbearing women as a way of avoiding

taking more personal responsibility.

These ideas wilL now be used to guide analysis and

interpretation in the incidents concerning Beth and

Lisa.

KEY THEORETICAL FINDINGS

In order to help the reader differentiate the raw data

and the tater interpretation, raw data is presented in

bold. The following incident occurred in the earLy

C l i n i c a l I n c i d e n t One

Beth is an 18-year-old woman who tires with her

boyfriend Mick. She is tat[ and very slim. Although she

denies anorexia I think i t likely. In her interactions she

is defensive, easily startled, non-trusting and dif f icult

to get to know. She has no trust for teachers, doctors,

nurses or the police, whom she sees as agents of

control. Beth has repeatedly refused to attend the

hospital for antenatal care after two early visits

because she doesn't Like the way she was treated. I

have been conducting antenatal care at the WHC and

sending my assessment data to the hospital At her

37th week by date I expressed concern at Beth's Lack

of weight gain and the apparent small size of the baby.

I strongly urged her to go for an antenatal check up at

the hospital. She would only do this i f I went with her

because she feared being bullied or embarrassed. On

the day of the incident, as I drove her to the hospital,

Beth told me that she had vomited after breakfast.

Apparently she had stomach pains after dinner last

night and she stilt fel t very nauseated.

Beth (B) was seen by Dr T (consultant), whom she had

not met before. He sat at the desk, facing the wall,

and B sat beside the desk, facing toward him. I (R for

Researcher) sat at the other end of the desk; his back

was toward me most of the time. There are no

preliminaries and no assessment is conducted at any

stage during the incident. What follows is the totaL

extent of the interaction.

Dr -I:. Well, we have hardly seen you. How are

you 9oing? (J:lickin~ through B's notes).

B. Not well, I feel really sick, like I 'm ~oin~ to

throw up all the time.

Dr T. (i~noring her expressed concern) You are

overdue by three weeks. Why haven't you

been to see us? (accusfngly).

He is angry that Beth has not attended the clinic as she

is 'supposed to': she has not submitted herself to nataL

panopticonism, thus depriving medicine of both

knowledge and power.

B. I 'm not overdue, I 'm thirty-seven weeks

(assertively, confidently).

Beth is sure of herself and wi l l not take on a submissive

rote. She is using her own power to attempt to counter

medical power.

8 AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

Dr. T. The ultrasound shows that you are three

weeks overdue.

He wants her to agree that her dates must be wrong.

Here is the crucial [ink between power and knowledge.

The knowledge derived from the ultrasound is being

used to support disciplinary power.

B. Well, it's wrong, I 'm not due for three

weeks yet (strong and sure).

This is Beth's legal power and she is resisting medical

power.

Dr. T. Look, this ultrasound was done at 18

weeks' gestation. At that time they are

very accurate. You must have your dates

wrong. You have to be admitted straight

away, today, now!

Without checking how it could be that there is a six-

week discrepancy in dates that hadn't been noted at

the time of the ultrasound, the doctor is increasing the

pressure by becoming more authoritative and

demanding. This suggests that getting Beth 'under

control' is more important than careful assessment in

order to determine the 'truth' of the situation. The

power that we see operating is disciplinary power, as

the doctor seeks to regulate and subdue Beth's

rebe[lious refusal to comply with medical

panopticonism. It is as if he takes her refusal to

accept medical advice as a persona[ insult.

B. No, I can't be. I'm not due, I'm not ready,

I've got nothing ready. I'm not going to

hospital (said defiantly).

Beth continues to assert her legal power and to

intensify her resistance.

Dr T. Look, this is serious; the baby's life is in

danger. Your life is in danger. If you don't

have this baby very soon you might get a

clotting disorder and die (said with cold,

controlled anger).

What he had said before this hasn' t worked; she is still

resisting, thus he has resorted to threatening her with

the death ei ther of the baby or herself. By so

blatantly threatening her it becomes obvious now that

he is using power. This is consistent with Foucault's

notion that disciplinary power is not normally visible,

but it becomes visible when resistance is

encountered.16 The doctor cannot use any legal power

to make her be admitted, so the only power he has

available is disciplinary power.

That the doctor would ultimately resort to threatening

death for Beth and/or her baby is predictable from

Foucau[t's theory that the disciplines need both

rewards and punishments to induce docility. My

interpretation of how obstetrics uses rewards and

punishments to gain compliance from childbearing

women is that i t portrays itself as providing the safest

way to have a baby (a reward). Further, through the

use of drugs obstetrics also promises that woman can

have a relatively pain-free birth. These rewards are

generally sufficient for most women to submit to

medical power. If, however, women choose not to

submit, then the punishments can include being

treated rudely, being relatively neglected, and/or

being threatened with death or bodily damage of self

or baby. By comparison, women who submit to

medical power are not generally threatened with

death; rather they are sometimes inappropriately

reassured when in fact their life or the life of their

baby is really at risk (Douglas, Fahy ~ Robinson, 2001).

How real was the risk that Beth's baby's life, or hers

for that matter, were really urgently at risk as the

doctor said? On reviewing the literature later I found

that a large study of term and post-term infants

suggest that per[natal death is lowest at 40 weeks'

gestation, i.e. 2.3 babies per 1000 births at 40 weeks

compared with four babies per 1000 births at 43 weeks

gestation. This evidence does not support the doctor's

assertion that a life-threatening emergency exists

which requires immediate admission. Assuming, as I

do, that this obstetrician was not i l l informed, then the

evidence indicates that he knew that the situation was

not urgent. It seems to me that he was primarily

concerned with having this rebellious young woman

comply with his wishes, and he was prepared to use

serious threats to ensure it.

R. Beth, the doctor is right. Ultrasounds ore

very accurate in early pregnancy. We both

know your baby is small [or dates and going

over-term by three weeks is dangerous [or

the baby. I agree with the doctor - you

should be admitted today. I can let Mick

know what is happening and bring in some

clothes for you.

(PAUSE)

B. Oh, (pause) O.K.

I'm embarrassed to read this now and to know that I

failed Beth as both an advocate and a support person.

Further, I actually backed up the use of medical power.

At the t ime I didn ' t question the obstetrician's

competence or truth telling; I believed both the doctor

and the ultrasound report. I made myself docile and

subjugated my own knowledge to that of obstetrics.

This was in spite of the fact that I had spent many

hours with Beth and conducted a number of antenatal

VOL 15 NO I MARCH 2002 9

assessments, when her fundus had always been

consistent with her dates. By comparison, the doctor

had never met Beth before and spent only a few

seconds before deciding, on the basis of the ultrasound

alone, that she was overdue and that is was a life-

threatening emergency. It is amazing to me now that

at that time I did not question or challenge the doctor.

I immediately doubted myself and believed that he was

right. As the data indicates, my role in supporting

medical power was crucial in helping to bring about

Beth's submission.

In order to understand my behaviour I interpreted i t

within the context of all my experiences of nursing and

midwifery, in fact, not just my own experiences but

what I had observed of the behaviour of other nurses

and midwives. The pivotal role that nurses and

midwives play in ensuring patient submission to

medical power can be seen in a number of other

incidents in this study. The role nurses and midwives

play is not unlike that which mothers generally play

when they take a child to the doctor; agreeing with

the doctor and encouraging the patient-child to do

what the doctor wants.

Foucau[t [ends support to this interpretation because

he wrote about the crit ical role served by Non

Commissioned Officers (NCOs) in marshalling the

troops in wars and getting them to fol low orders from

officers (who because of class and education were

quite alienated from the foot soldiers). He [inks this to

the way in which nursing helps medicine gain patient

compliance and he says that we function in the role of

NCOs in the medical army (1982). Thus, supporting

medical power - either covertly (by silence) or overtly

(by directly saying things to support the doctor) - is

'normal' behaviour for nurses and midwives, while

overtly supporting the woman is ' abnormal' (meaning

uncommon).

Midwives often claim that they assume the role of the

woman's advocate but in fact I believe i t to be a

relatively uncommon activity. As discussed in the

literature review (above) and in Huard ~ Fahy (1999),

advocacy is very di f f icul t for nurses and midwives who

work in the system (or who need the patronage of the

system). I did not allow myself to be conscious of my

own needs at the time, but now I ask, what might have

happened i f I had supported Beth? I suspect my right to

conduct research in the hospital would have been

revoked and possibly I was unconsciously motivated to

protect my own interests.

I took Beth straight up to the birthing suite and

identified myself as her support person. The staff was

waiting for her and they seemed angry with her,

probably because she had not attended regularly for

antenatal care. Within ten minutes a different doctor

(registrar) introduced himself to both of us and said

that he was going to attempt to induce labour

immediately because, in agreement with the

consultant, he was concerned that the pregnancy was

three weeks overdue. He did a vagina[ examination on

Beth and inserted Prostin. About five minutes later the

registrar returned to the room to tel l Beth that her

dates were correct after all, there was a 'typo' in the

ultrasound report.

I doubt this; I think i t more likely that the original

doctor made a calculation error which was compounded

by his failure to do any kind of check or physical

assessment. I think that the younger doctor was

covering for him, probably out of fear of being subject

to punishment from the consultant i f he did not.

Beth was in labour within one hour of being induced.

She birthed a baby that was three weeks early (37

weeks) and was intrauterine growth-restricted. Baby

Tina spent her first five days of l ife in the nursery,

which is possibly implicated in the bonding problems

and breastfeeding failure that Beth experienced.

C l i n i c a l I n c i d e n t T w o

By the time the following incident occurred I had

proceeded around the praxis research-learning spiral

quite a few times. I [earned from observing and

listening to the experiences of young women and

reflecting upon my own experiences related to this

study. Based on my increasing consciousness that

power and knowledge are so [inked and that legal

power is an antidote to attempts to use disciplinary

power, I now had a strategy for working with young

pregnant women and their partners, and that was to

provide them with knowledge and prepare them for

what birth may involve. The use of a birth plan was a

specific strategy to help young women to focus on

their own power to control what happened to their

bodies.

Lisa is a 14-year-old who had been living in the care of

the Department of Family Services (DFS). The incident

that is about to be described took place when Lisa was

39 weeks pregnant. I had known Lisa, and seen her

regularly, since she was ten weeks pregnant. I had

spent at least 15 hours with Lisa (and her partner

David) helping them to [earn about what labour would

require of Lisa and what the standard medical

practices were. We discussed in detail all aspects of

cephalic presentation births and commonly occurring

medical interventions. We had also discussed

commonly occurring complications and what options

10 AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

they may be offered at each stage. This knowledge

was translated into a birth plan that represented Lisa's

Legal power

Lisa and David asked me to accompany them on their

visit to the doctor because they wanted to present the

birth plan that we had been working on for a few

months. Lisa was seen by Dr C (a junior registrar), who

sat at a desk, facing the wall. David and Lisa took

chairs at e i ther end of the table, facing the doctor. I

took up a position standing in the corner behind the

doctor, as there was nowhere for me to sit.

Dr C. Lisa, how are you going?

L. Good: (She handed him the birth plan).

Essentially Lisa's birth plan states that she wants an

unmedicated Labour and that she hopes for early

discharge.

Dr C. Oh, this doesn't look like there's any

problem.

However, he Looked confused, which I interpreted as

meaning he didn't know what to do with it. Birth plans

were unusual in this hospital and I thought he probably

hadn't seen one before.

R. Dr C, Last time we gave a birth plan to (I

named obstetrician in charEe), and he

si~ned it and attached it to the woman's

notes.

Here I am using a tact ic of power to indicate that his

boss accepts a birth plan and gives it more power by

signing it and including it in the notes for all to see.

Dr C. Oh, okay. (Pause). Have you seen the

standard hospital birth plan? (authoritative

tone).

I interpret that the doctor feels unsettled about the

change in the balance of power that a birth plan

implies, but being relatively junior is unsure of why he

feels uncomfortable. His reference to the standard

hospital birth plan may be an a t tempt to undermine

the validity of Lisa's plan.

L. No. (looking at me, confused and perhaps

frightened).

The doctor seems to be empowered by Lisa's silence

and apparent confusion, and seeing this he intensifies

his use of fear.

Dr C. All of this is fine of course if everything

goes well, but things often don't go well in

first labours; I mean you're more likely to

get out of a second or third labour in one

piece than you are with a first labour

When you haven't done it before, your body

hasn't experienced it before and things

tend to go wrong.

L. How would you know, you haven't had a

baby, you're a man (feisty).

Lisa is resisting medical power and is using her power

as a woman who is able to bear children. She is

actually taunting him.

Dr C. Well how would you know, you haven't

had one either..

The doctor 's childish retort indicates he has been

unsettled by her taunting, but he recovers himself and

moves, as Foucault would predict, into inducing fear

and promising rewards for compliance with medical

power.

Dr C. If you go back 150 years women and

babies were dying in childbirth. But

because of modern medicine childbirth's

much safer now, but even so, things can go

wrong and we have to intervene (Lisa was

squirming and looking uncomfortable).

R. Dr C, Lisa's young and strong and healthy.

She's stopped smoking, she doesn't drink,

she doesn't have any health problems. I

think it's reasonable to expect she'll have a

normal birth. We have discussed forceps,

vacuum extraction and caesarean section.

We're very hopeful that none of those will

be necessary. (This was said in an easy,

friendly kind of way, but inside I felt angry

that he was trying to make Lisa doubt

herself and trust medicine).

Here I am using my midwifery knowledge against his

medical knowledge. I am also clearly identifying

myself as the woman's ' f r iend' and advocate. I'm on

her ' s ide ' . It is important to note that I was not

aggressive or threatening, which made it easier for the

doctor to accept what I said without feeling attacked.

Dr C. Don't get me wrong, so are we. (He

backs down).

This younger doctor does not want conflict and he

doesn ' t want to be seen as trying to frighten her

(which he was). I don ' t believe my challenge would

have had the same effect if the doctor had been a

specialist obstetrician who would see my challenge to

him as an a t tempt to usurp his authority (which it

was).

[SHORT SILENCE]

Dr C then palpated her abdomen and said that

she looked like about 38 weeks and that the

head was engaged.

VOL 15 NO 1 MARCH 2002

We walked outside and I asked her how she fel t about

the things the doctor had said to her.

L. I thought he was trying to scare me.

R. I thought so too. Did he scare you?

L. No, no, I'm going to be positive ubout this.

Lisa went on to have the type of labour that she had

wished for. She was mobile throughout labour, did not

ask for any pain relief except nitrous oxide and birthed

her baby naturally with the assistance of two gentle

and patient midwives.

CONCLUSIONS

This paper has presented a number of FoucauJdian

ideas about how disciplinary power operates. These

ideas have been used to analyse two clinical incidents

where young women were attempting to resist the

coercive use of medical power. The main ideas are

given below in summary form.

When a power struggle occurs between a doctor and a

patient i t is a struggle between the patient's Legal

power to self-determination and medicine's

disciplinary power, aimed at subverting the patient's

expressed desire and gaining compliance with medical

'orders'. Obstetric discourses are dominant because

they have the sanction of society, which in turn is

closely tied to society's trust in techno-science upon

which obstetrics claims to base its treatments.

Obstetrics uses talk of rewards (safe, pain-free birth)

and punishments (death or damage to the body of self

and/or baby) to gain compliance. This is usuaUy subtle

because disciplinary power works most easily when i t is

hidden. The use of power only becomes visible when

the patient uses their legal power (of self-

determination) to resist attempts to gain their

compliance.

The normal role for a hospital-empLoyed nurse or

midwife is that of NCO in the medical army; i.e.

gaining the woman's compliance with medical orders.

If a midwife wants to empower a woman she has to

plan carefully and prepare the woman well for the

medical encounter. Midwives are not normally

advocates for women during the medical encounter.

This is probably because confronting medical power

directly is a risky strategy because i t is likely to anger

the doctor. When the doctor feels his/her power

threatened, my theorising (based on FoucauJt) predicts

that the doctor wi l l probably counter with an

escalation of disciplinary power. This may involve, as

i t did for Beth, threatening the woman with physical

damage or death to either herself and/or baby.

The data from this study suggests that direct

confrontation from the subjects of medical power,

regardless of whether i t is the midwife or the client

who does the resisting, has mixed and unpredictable

effects. I theorise that confrontation is much more

Likely to be successful when the woman is least

physically vulnerable (i.e. healthy and not in labour).

The more physically vulnerable she becomes the Jess

chance she has of being successful in subverting the

use of coercive disciplinary power. It is important to

recognise that i f an attempt by the client to assert

their legal power is not successful then the incident

may result in an increased sense of disempowerment

for both the client and the midwife.

Analysis of the second clinical incident shows that

there were two, inter-related strategies that were

successfully used to counter the coercive use of

disciplinary power, and they were both related to

empowerment, rather than advocacy. The first was to

help Lisa to develop knowledge because, as Foucault

(1980) showed, more knowledge means more power.

The related strategy was to support Lisa to use her

legal power by writ ing down her wishes in a birth plan.

A birth plan asserts the woman's sovereign rights and

acts as a disincentive for the coercive use of

disciplinary power. Finally, I think Lisa's self-assertion

was successful in part because her timing was good

(she was not physicaUy vulnerable) and also partly

because the personality and junior status of the

registrar meant that he didn't want to take on a

confrontation. My own role, in the background, gave

moral support to Lisa. When I did speak i t was as an

advocate, but a relatively non-threatening one.

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