Thesis Proposal

People vs. Policy: A Comparative Discourse Analysis of Childbirth Caregivers in America

In order to fully understand childbirth care options in the United States, and to look ahead

at how women will view these options America¶s changing health care environment, we as

health care consumers need to understand the two distinct discourse communities speaking to

expectant mothers: midwives (the natural childbirth community) and obstetricians (the medical

community). To identify and analyze those discourse communities, I propose performing a

comparative discourse analysis of the Codes of Ethics of the Midwives Alliance of North

America (MANA) and the American Congress of Obstetricians and Gynecologists (ACOG),

which should reveal the values most important to each group and the language used to express

those values.

My interest in this topic is indeed personal. Inspired by a women¶s studies class I took in

college, I began researching childbirth options when I was pregnant with my first child. I read

books and online forums, met with a midwife and an obstetrician, and made my decision: I chose

to give birth at a free-standing birth center staffed by three direct-entry midwives. When the time

came, I labored in a tub of warm water, received no drugs or other interventions, and delivered a

healthy baby girl. I am thankful that I had the ability to choose this type of care. I gave birth in

South Carolina, one of only 26 states in the U.S. where direct-entry midwives are legal and

regulated (³Direct-Entry Midwifery State-by-State Legal Status´).

After having such a positive experience with my own birth, and after having had

countless conversations with other women who did not understand my choice, blamed me for

putting myself and my child ³in danger,´ or confessed that they had no idea that there were even

options in childbirth care, I decided to research the topic further. There are many key issues in

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the discussion of childbirth care in the U.S., ranging from the current state of the health care

industry, to insurance companies and malpractice suits, to a society motivated to medicalize and

treat with prescription drugs anything perceived to be an abnormality; however, I plan to analyze

the subject from a rhetorical point of view. The language and rhetorical strategies used by

midwives and obstetricians are markedly different, forming two distinct discourse communities.

One could say that the two groups, even as they serve the same patients, aren¶t even speaking the

same language. If we can understand this language, we can better understand the type of care

available for expectant mothers.

LITERATURE REVIEW

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To understand the current rhetorical situation, we need to first understand the history of

childbirth care in America. Until modern times, childbirth history was the story of one central

character: the midwife. The term 

 comes from the Old English word meaning ³with

woman,´ but she is also known as ³grandmother´ or ³granny´ in languages around the globe

(Cassidy). Today, there are two main types of midwives: the direct-entry midwife (also known as

a lay, independent or traditional midwife), who is trained mainly by apprenticeship but also often

in a school of midwifery and usually delivers at home or in free-standing birth centers; and the

nurse-midwife, who is trained in nursing school and usually works in hospitals, reporting to

physicians (Lay). For this proposal, I will use the term ³midwives´ to refer only to direct-entry

midwives.

For centuries, midwives were the primary ± and usually only ± option to assist a mother

in childbirth. Starting in the early 1800s, doctors began pitching their services to deliver children,

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campaigning that their medical educations set them apart from ³ignorant´ midwives (Cassidy).

By the turn of the 20th Century in America, doctors:

«launched public education campaigns promoting the ideas that birth was painful and

should be treated like a disease, and that male attendants were best qualified to handle

deliveries. These early campaigns were brutally effective. By and large, midwives were

left to care for those who could not afford ± or did not live near ± a doctor. (Cassidy 39)

Thus, after being the dominant option for childbirth care for centuries, midwives delivered only

half of all babies in the U.S. by 1910 (Cassidy). As concerns about infection and disease grew,

and as the U.S. government began to forbid midwifery education, the medical community

became the dominant choice for expectant mothers. By 1930, midwives delivered 30% of

American babies, and those were mostly in the rural South to poor women. By 1973, direct-entry

midwives delivered only 1% of vaginal births (Cassidy).

The midwife was saved from obscurity by the women¶s liberation movement of the late

1970s. Turned off by the isolation of delivery rooms, the routine treatments (like enemas and

shaving) and the clinical approach of doctors and hospitals, women began requesting more

natural methods of childbirth, often choosing to deliver at home, even in states where it was

illegal. By 2006, midwives delivered 10% of vaginal births in the U.S., a number believed to be

on the rise (Cassidy).

As the favor of doctors and midwives has risen and fallen, other factors have influenced

women¶s options. Politics have come into play, as states regulate midwives differently, with

some offering education and licensing for midwives while others strictly forbid the practice all

together. Insurance, specifically malpractice insurance, has become such a burdensome cost that

many midwifery practices and free-standing birth centers have had to close (Cassidy). The

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medical community has been split on the health and safety of midwives, offering plenty of

studies that show that home births attended by midwives are ³as safe as´ or sometimes even safer

than hospital births (Cassidy), but also continuing to assert that hospital births are the safer

choice for mothers and babies (³Position Paper on Midwifery Licensure´). Clearly, the

discussion of childbirth care in America has become passionate, often leading to heated, divisive

rhetoric.

þ 


` 


The history of and present-day situation of midwives and obstetricians puts these two

camps at opposite ends of a long spectrum. The medical option of childbirth is clearly dominant,

but the natural childbirth camp is slowly gaining attention. As the groups wrestle with their

current status, and as expectant mothers make choices (if they are aware of having a choice) for

their childbirth care, it is important to understand the values and ethics of each organization.

Midwives may not identify themselves as medical practitioners, but they are caregivers

and likely have a similar set of values to medical caregivers. To better understand the ethics used

by all caregivers of expectant mothers, I will explore the general values of medical ethics and

how they are followed and interpreted by midwives and obstetricians. According to Steinberg

and others (so many others that this is considered common knowledge on Wikipedia), there are

six key values generally associated with medical ethics:

1.c Autonomy (È

 
  ± the patient may choose or refuse

treatment

2.c Beneficence (ë 
  ) ± caregivers should act in the best interest of

the patient

3.c Nonmaleficence (




  ) ± ³first, do no harm´

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 4.c †ustice ± values concerning how to distribute resources and choose fairly which

patients to help first

5.c Dignity ± patients and caregivers have a right to be treated with dignity

6.c Truthfulness/honesty ± caregivers must be honest about treatment, especially

concerning informed consent.

I plan to further explain each value so that in my discourse analysis, I can discuss how the

professional codes of ethics written by the leading associations for midwives and obstetricians

reflect, accept and/or project general medical ethics.

Both the Midwives Alliance of North America (MANA) and the American Congress of

Obstetricians and Gynecologists (ACOG) spell out their ethics clearly in their organizational

Codes of Ethics. Most businesses today have written codes of ethics that function to ³influence

the decisions which individuals make so that the resulting behaviour [
Ë is acceptable to the

organisation [
Ë´ (Farrell and Farrell 588). Codes of ethics are their own unique genre. They

mostly operate the same way: to identify the values important to the associations and their

members by setting company standards, outlining their principles or summarizing company

values (Farrell and Farrell). I¶ll review how a code of ethics reflects the values of an organization

incorporating research from Davis, Frankel, Farrell and Farrell, and Tucker et al on the

importance of codes of ethics and the role they play in professional organizations.

 
 


  `




In ³The Discourse on Language,´ Foucault argues that groups are formed and divided

through language and discourse. The truth and collective knowledge of a group can be found

through its discourse²by what the members say, as well as by the discourse they exclude.

Foucault even uses a medical example to illustrate how the power of language and discourse

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within the medical community can create Truth about how the body works (even if that idea is

later proven false). This concept directly applies to the language used by midwives and doctors

and the ³truths´ about childbirth and maternal care created by such rhetoric. Therefore, if I can

provide a better understanding of the language and rhetoric used by MANA and ACOG in a

document like the Code of Ethics, I can better understand what defines and differentiates these

two groups and can perhaps even uncover an underlying truth to which they both subscribe.

To identify the discourse communities of midwives and obstetricians, I will need to

employ a discourse analysis of text, in this case, specifically interpreting the language and

phrases employed in their Codes of Ethics. Discourse analysis is, according to Kinneavy,

the study of the situational uses of the potentials of the language. [ «Ë The particular

province of discourse study « excludes, on the one hand, merely linguistic or semantic

analyses and, on the other, aspects of the situational context and cultural context. But

whenever either the linguistic or the metapragmatic considerations can throw light on text

as such, they become subordinately relevant to discourse analysis (22-24, qtd. in Kaplan

and Grabe 193).

Per Kinneavy¶s suggestion, studying the specific language used in a written document

can help us understand the full meaning of a text. Farrell and Farrell performed a discourse

analysis of corporate codes of ethics, revealing that writers of codes of ethics tend to employ five

specific linguistic features, which display the power of the organization and prevent the reader

from making independent decisions. Following their method, a discourse analysis of MANA¶s

and ACOG¶s Codes of Ethics should reveal the power dynamic of each group over their

membership. Furthermore, a discourse analysis of the specific words chosen will likely reveal

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important information about the values of each organization and the type of care they offer when

implementing those values.

My discourse analysis would not be complete without also employing the works of Bitzer

and Burke. Clearly, the two Codes of Ethics were composed in different rhetorical situations

(Bitzer); the documents have very different audiences and were written within different

exigencies, and these differences should help shed light on the underlying values of each

organization. Furthermore, the language used by each group helps create a terministic screen

through which they interpret the world (Burke). Midwives and obstetricians view a laboring

mother differently ± either as a natural process or a medical situation ± and that screen affects

how they react to the mother. An analysis of Burke¶s application to these discourse communities

should help to further illuminate how they developed their ethics and values, and why each group

chose particular language to express their ethics.

PRO†ECT PLAN

þ  

In order to analyze and discuss the differing rhetoric of these two groups and better

understand their values, I will write a thesis employing a comparative discourse analysis of the

Codes of Ethics for the Midwives Alliance of North America (MANA) and the American

Congress of Obstetricians and Gynecologists (ACOG), the two leading professional

organizations representing natural and medical childbirth options. I will begin by analyzing the

type of ethical appeals that each Code is making. I expect to find that both groups appeal to the

same major values of medical ethics, but use different rhetorical strategies to make those appeals.

I will try to find specific mentions of the six values of medical ethics and discuss how explicitly

(or not) they are defined. This analysis will help reveal the import that each organization places

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in each major tenet of medical ethics. I may find that both groups make similar appeals, and thus

share the same ethics²or that they are divided by something as essential as their ethics.

I will then compare the rhetorical strategies employed in MANA and ACOG¶s Codes of

Ethics, specifically analyzing the audience and goals of each piece. The audience chosen by each

group reflects whom they want to persuade ± an expectant mother or a fellow in the profession.

This choice illustrates differences in the goals that each group may have had in publishing their

Codes; in other words, appeals to the audience indicate how each group seeks validation and/or

works to persuade new clients (or, in the case of the dominant community, there may not be a

need to persuade potential clients).

Finally, I will identify, analyze and compare the language used by both organizations. I

plan to identify key words used by each group and discuss those words that appear most often.

For example, the ACOG Code of Ethics always refers to the ³patient,´ while MANA uses the

term ³woman´ or ³woman and child.´ This choice of words reflects the type of care each group

offers: ACOG views an expectant woman as a medical case (as is expected of their medical

school training), while MANA stresses the value of personal relationships between midwives,

women and their children. I will also identify the linguistic features displayed in each code,

following the work of Farrell and Farrell, and how these features empower (or not) their

members to make individual choices.

By analyzing the ethical claims, rhetorical strategies and language utilized in MANA and

ACOG¶s Codes of Ethics, I hope to clearly identify the two discourse communities involved in

American childbirth. I then hope to be able to expand on this knowledge by reflecting on how

these groups are participating (and will continue to contribute to) the current healthcare debate in

the U.S. As more women become insured, money will not be as much of decisive factor for

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future mothers. How might this affect how women review their childbirth options? I may also be

able to make recommendations to MANA and ACOG to alter their rhetoric (co-opting some of

the opposing group¶s language, perhaps) to appeal to the growing number of women, armed with

insurance and education about their options, who will be having children in the future.


 


 
  

With a goal of graduating in December 2011 but completing most of my work by the end of

summer 2011, I propose the following schedule for the development of my thesis:

uc Assemble my committee and gain full topic approval in early Fall 2010

uc Submit my GS2 form by February 2011

uc Take my oral comprehensive exams in late April/early May 2011

uc Submit my first draft of the thesis by August 1, 2011

uc Defend in September 2011

Because of my later graduation date, I can be flexible to work within my committee members¶

schedules. Even though I plan to do most of my writing during the summer, I will not expect my

committee members to be available to work with me during that time.

CONCLUSION

By performing a comparative discourse analysis of the Codes of Ethics of the Midwives

Alliance of North America and the American Congress of Obstetricians and Gynecologists, I

hope to reveal the values most important to each group and the language used to express those

values. By uncovering the rhetoric and values of each group, we can better understand what

defines the two discourse communities and how they are communicating to their audiences. I

plan to employ and contribute to research in the fields of medical ethics, rhetoric, health

communication, organizational communication and gender studies. I believe my research will

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contribute to a greater understanding of the choices women have in childbirth care, and equip

women to make more educated choices in America¶s changing health care environment.

I look forward to the opportunity to research and write a thesis analyzing these issues

important to professional communication. I have a passion for this research and hope to share

that excitement with a dedicated committee chair. Though I am delaying my graduation until

December 2011, I am eager to begin working together. I will contact you in late August to set up

a meeting to discuss this thesis proposal and your interest in chairing it. Thank you for your

consideration.

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 BIBLIOGRAPHY

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