Authoritative knowledge

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The contours of the cultural scripts available to women in different

cultures are premised on forms of ‘authoritative knowledge’ (Jordan,

1997 ). In differe nt cultu res the form s of autho ritative know ledge that

count in relation to pregnancy and childbearing, whether hierarchical

as in the UK and North America, or more horizontal as in Bangladesh,

will shape individuals’ expectations and experiences and ultimately how

sense is made of them. The concept of ‘authoritative knowledge’ derives

from Brigitte Jordan’s innovative work from the 1970s in which she

took a biosocial approach in order to explore birth practices in four

different cultures (1993). Up until this time, and reflecting a wider

lack of academic interest in the private sphere and women’s lives,

reproduction and childbirth had largely remained outside the scope of

many research agendas. In her work, Jordan explored the ways in which

authoritative knowledge contextualised and shaped women’s expectations

and experiences of birth. According to Jordan, ‘the power of authoritative

knowledge is not that it is correct but that it counts’ (1997:58) and so

in different cultures, different forms of authoritative knowledge are

discernible. In much of the Western world the medicalisation of reproduction

and childbearing has led to highly technological practices around

childbirth. In contrast, much more low-tech or no-tech practices contribute

to authoritative knowledge in many developing countries.

Authoritative knowledge is not, then, premised on ‘highly developed

technology’ but rather on recognisable and accepted practices that are

continually reinforced, and through their practice given legitimacy

(Sargent and Bascope, 1997:203). In some contexts authoritative knowledge

is consensual and shared, based on a horizontal model of knowing

and practices. In others one kind of authoritative knowledge dominates, is

hierarchically organised and regarded as most powerful. Most importantly,

authoritative knowledge is ‘socially sanctioned’ and requires that

‘people actively engage in (its) production and reproduction . . . thus

continually reinforcing its validity’ (Sargent and Bascope, 1997:183).

The ways in which authoritative knowledge is produced, reinforced

and maintained will differ from culture to culture. The determinants and

display of authoritative knowledge will also be varied. But clearly they

relate to the ways in which women and their bodies are viewed within a

soci ety and, in turn , the practic es that exist arou nd childb earing. In the

follow ing se ction these area s will be expl ored. Exam ples from res earch

and pers onal obse rvations from the fie ld in Banglade sh an d the Solomon

Islan ds, where I lived and work ed duri ng the 1980s and, latt erly the UK,

will be used (Mi ller, 1995 ). In consideri ng cul tural constru ctions of

wome n and their bodies, Szurek has made the obse rvation that ‘the

ways in which a society defines wome n and values the ir reprod uctive

capa bility are refl ected and displayed in the cultu ral treatme nt of birt h’

(19 97:287). In the UK, pregna ncy and birt h are large ly regard ed as

medicalised processes that require expert management and supervision.

As Usshe r has comme nted, ‘pregn ancy, childb irth and the postn atal

period have been pathologised . . . positioning women’s experiences as

an illness in need of int erventio n’ (19 92:47). As a result, the vast m ajority

of birt hs take place in hospita l (98 per cent), wh ich has become regard ed

by many as the ‘natural’ place to give birth. In most cases women do not

resist this highly technological and medicalised approach to birth, but

rather collaborate in its maintenance and perpetuation: although retrospectively

they may come to resist and challenge aspects of it (Miller,

2003). Feminists and others have regarded the medicalisation of childbirth

as indicative of the wider social structures that differentially shape

women’s lives in patriarchal societies. In a Western context, the shifts that

have occurred around reproduction and childbearing can be explored

and explained through an analysis of the interwoven themes of knowledge

production, power, medicalisation and patriarchy (see chapter 3).

In the UK, authoritative knowledge in relation to reproduction and

childbearing is based on biomedicine and technology, in the context of

heightened perceptions of risks, which are themselves cultural constructions

(Lupton, 1999; see chapter 3 in this volume). The result of this is

that ‘cultural authority’ is seen to reside in the medical and health

professionals who manage pregnancy and childbirth (Sargent and

Bascope, 1997:183). The ways in which this authoritative knowledge

translates into practices and in turn shapes women’s expectations and

experiences is displayed through the development of highly formalised

services around pregnancy and childbirth. Regular monitoring and

screening form part of the process of antenatal preparation for childbirth

in the UK. Women are expected to make routine visits to either a midwife,

general practitioner (GP), and/or obstetrician during their pregnancy.

As already mentioned, for the vast majority of women, childbirth

takes place in hospital and is professionally managed by highly trained

health professionals. Following the birth of a baby, postnatal care in the

UK is less structured. It is based on home visits made by midwives and

health visitors, with the number of visits made related to professional

perceptions of coping and need (Miller, 2002). The models of practice

that exist around childbearing in the UK, as in many Western societies,

are based on one form of authoritative knowledge being more powerful

than other ways of knowing. This is also the case in the USA, where

Jordan notes that ‘medical knowledge supersedes and delegitimizes other

potentially relevant sources of knowledge such as women’s prior experience

and the knowledge she has of the state of her body’ (1997:73). Such

dominance leaves little opportunity for other ways of thinking about

pregnancy and childbirth, whilst at the same time reinforcing ‘pre-existing

patterns of authority’ (Sargent and Bascope, 1997:192).

In many Western contexts, then, authoritative ways of knowing are

hierarchical and have led to distinctions being made between those who

are regarded as ‘expert’ – the medical and health professionals, and those

who are not – childbearing women (Miller, 2000, 2003). Authoritative

knowledge is displayed through constructions of expert knowledge. Yet

these are rarely resisted but instead interactionally constructed ‘in such a

way that all participants come to see the current social order as a natural

order, that is, the way things (obviously) are’ (Davis-Floyd and Sargent,

1997:56). The findings from research focusing on women’s experiences

of transition to first-time motherhood, which is detailed in the previous

chapter, demonstrate this. They show the ways in which the dominance

of expert knowledge is not rejected or even particularly resisted, but

rather engaged with and thereby reinforced. An overarching theme in

the interviews with women during the antenatal period was that there

were culturally appropriate, morally underpinned and socially acceptable

ways of preparing for childbirth and motherhood. Antenatal preparation

involved engaging with or, in some cases, wanting to hand over to, others

who were perceived to be ‘experts’, those who were perceived to possess

authoritative knowledge and cultural authority and were located within

the medical and health services (see chapter 4). This appears in stark

contrast to the findings from other research that both supports a critique

of medical ised childbirth (Oakle y, 1979, 1980 ; Rothman , 1989) and has

shown the ways in which individuals have resisted and challenged

medical discourses (Cornwell, 1984; Martin, 1990; Blaxter, 1990).

However, such findings may be a feature of women’s shifting relationships

with ways of knowing, especially in relation to reproduction and

childbirth in late modern Western societies. It may also be a feature of

their age, social class and status as first-time mothers. Certainly the

findings are supported by more recent research from North America,

which claims that ‘although some women are alienated by their experience

of medicalised birth, many women across social classes welcome

medical intervention, if not management, and are quite satisfied with

hospital deliveries’ (Fox and Worts, 1999:328). These findings also point

to the dynamic nature of cultural scripts which are not static but rather

shift over time (see chapter 7).