The anthropology of obstetrics and obstetricians: The practice, maintenance, and reproduction of a biomedical profession By RobbieDavis‐Floyd and AshishPremkumar (Eds.), New York: Berghahn Series. Three volume series.Volume 1 – Obstetricians speak: On training, practice, fear, and transformation. 2023. 345 pp.Volume 2 – Cognition, risk, and responsibility in obstetrics: Anthropological analyses and critiques of obstetricians’ practices. 2023. 334 pp.Volume 3 – Obstetric violence and systemic disparities: Can obstetrics be humanized and decolonized?2023. 376 pp.

Through their comprehensive three-volume series, Robbie Davis-Floyd and Ashish Premkumar build upon prior research on the Anthropology of Obstetrics and Obstetricians to formalize it as a subfield within and yet distinct from the Anthropology of Reproduction. While the latter has frequently shed critical light on the practice of obstetrics by foregrounding experiences of pregnancy and childbirth, the new proposed subfield takes on the experiences and perspectives of obstetricians themselves as its direct object of study. Entitled, The Anthropology of Obstetrics and Obstetricians: The Practice, Maintenance, and Reproduction of a Biomedical Profession, the series emphasizes collaborative scholarship that aims to integrate social science analytics and ethnographic sensibilities with biomedical perspectives. In doing so, the editors bring a novel lens to topics that have long been central to the anthropology of reproduction: interrogating the technocratic model of childbirth, examining the factors that contribute to maternal health disparities among racialized groups, and deconstructing how biomedical categories of risk are mapped onto birthing bodies within specific social and historical contexts. At the same time, these three volumes also speak to wider questions in medical anthropology concerning the “hidden curriculum” of medical training, authoritative knowledge, and the possibility of humanizing—or even decolonizing—the practice of biomedicine on a larger scale. The three volumes include contributions from anthropologists, practicing obstetricians, perinatologists, and physician-scholars in the social sciences like Premkumar (whose thoughtful autoethnography is a highlight of the series). While the majority of authors do draw upon data and observations from the US context, the editors make a commendable effort to situate the Anthropology of Obstetrics within a larger global context and include contributions from 19 countries: Nigeria, South Africa, Russia, Hungary, Switzerland, Ireland, the United Kingdom, Greece, Turkey, India, Chile, Brazil, Peru, the Dominican Republic, Mexico, the United States, Canada, New Zealand, and Australia. While many chapters allude to the influence of “American-style” biomedicine in international contexts and consider how its hegemonic practices are remade by local actors, Eugenia Georges' chapter “Becoming an Obstetrician in Greece: Medical Training, Informal Scripts, and the Routinization of Cesarean Birth” is especially noteworthy for drawing attention to the material conditions and structures that facilitate this historical process. For example, she expands on the role of US efforts to counter Soviet influence in Greece through programs funded under the umbrella of the Truman Doctrine which offered stipends to Greek healthcare workers to finance their medical training in the United States provided that they agreed to return to practice clinically in Greece after graduating. The volumes are organized thematically. The first, “Obstetricians Speak: On Training, Practice, Fear, and Transformation,” consists entirely of obstetricians' own firsthand accounts of their experiences as clinical practitioners paired with their more general reflections on the field at large. While highly thoughtful and informative, these accounts achieve the theoretical richness and critical reflexivity implied by their classification as “auto-ethnographies” with varying degrees of success. Across the three-volume series, Premkumar's chapter on his own training as a perinatologist (Volume 1) and Smith-Oka and Marshalla's contribution on how bodily and social boundaries in medical training intersect with social hierarchies in the Mexican context (Volume 2) both provide exceptionally strong illustrations of what ethnography has to offer to the anthropology of obstetricians as a specific mode of analysis that remains methodologically distinct from the practice of contextually informed self-reflection. Though they examine quite disparate topics, these authors all demonstrate an expert ability to wield the bifocal analytic lens that is characteristic of the best ethnographies as they skillfully weave together detailed observations of everyday clinical practice in ways that directly speak to more abstract theoretical questions. The second volume, “Cognition, Risk, and Responsibility in Obstetrics: Anthropological Analyses and Critiques of Obstetricians’ Practices,” seeks to understand the well-documented, persistent gap between evidence (what statistically rigorous biomedical studies suggest clinicians should do), discourse (what clinicians say they do), and practice (what clinicians actually do). The first chapter offers an overarching framework that attempts to provide a generalizable model to characterize obstetricians’ cognitive processes and categorize obstetricians themselves into one of four distinct “stages.” These represent a spectrum that spans from “Stage 1 Thinking,” which is characterized by “naive realism,” “fundamentalism,” and/or “fanaticism,” “State 2 Thinking: Ethnocentrism,” “Stage 3 Thinking: Cultural Relativism,” and “Stage 4 Thinking: Global Humanism.” According to the model, Stage 1 thinking represents the most extreme attachment to the ideals of technocratic obstetrics, namely, an approach that pathologizes birth and incorporates a high level of biomedical intervention while Stage 4 thinking encompasses the other end of the spectrum, that is, a commitment to the values of “deep humanism” in clinical practice. One of the model's strengths is its recognition that individual clinicians may shift between different cognitive stages in various contexts. Stressful circumstances or cognitive overload are proposed to trigger a “regression” to a version of Stage 1 thinking referred to as “Substage,” which, the author suggests, is characterized by tunnel-vision, an “inability to process information; [a] lack or loss of compassion for others,” and a reliance on ritual to establish a sense of control (23, Vol. 2). This recognition highlights an important and likely generative area for future research on obstetricians: an ethnographic examination of decision-making in “high-risk” situations. Overall, the framework proposed in the first chapter of Volume 2 is constructed up against the hypothetical actions and perspectives of a “straw man” obstetrician whose positions reflect the most extreme, egregious examples of the technocratic and patriarchal ideologies that inform biomedical obstetrics—while understating the role of structural elements in shaping individual clinicians' thinking. For instance, the author suggests obstetricians could “more easily process” studies comparing epidurals to other pain medications and incorporate their recommendations into clinical practice in comparison to studies demonstrating the benefit of doulas, massage, or laboring in water. She argues that obstetricians would be more “likely to discount” the evidence presented in the latter study, given that it does not fit neatly within “their pre-existing knowledge system” (31, Vol. 2). While her critique captures a very prevalent technocratic bias, it fails to account for the crucial and central role that the everyday structures of clinical care play in shaping physicians' cognition. In contexts where more holistic interventions are unavailable or against hospital-wide regulations, these structural constraints play an equally significant role in how information is processed and incorporated into clinical practice. This point is illustrated by an excellent, detailed study of how one specific policy structure—the Maternal Fetal Medicine Units Network Vaginal Birth After Cesarean Calculator (MFMU VBAC) calculator—shapes individual clinicians' decisions. Nicholas Rubashkin's chapter expertly traces the dynamic processes through which this particular tool came to incorporate the structures and biases of technocratic obstetrics in concrete ways. Overall, the four-stage framework's tendency to foreground individual intention leads naturally into the chapter's conclusion: that solutions to the complex problems in obstetrical practice identified by series' contributors can be found in the principles of global humanism and its recognition that “there can be many right ways as long as everyone's individual rights are preserved” (25, Vol. 2). The third volume, “Obstetric Violence and Systemic Disparities: Can Obstetrics Be Humanized and Decolonized?” is divided into three parts. Part 1 examines obstetric violence through contributions that develop a systematic typology of its many forms, examine how it is differentially distributed along axes of race and indigeneity, and reflect on its relation to longstanding gendered tropes and ideologies within biomedical obstetrics. Part 2 discusses efforts to reform contemporary obstetric training and practice through the larger movement to decolonize medical education in the United Kingdom as well as attempts to humanize childbirth in Russia, Brazil, New Zealand, and the United States. Part 3 contains only one chapter, which reflects on some of the practical challenges the series' contributors encountered while attempting to conduct ethnographic research on obstetricians. Lokugamage, Ahillian, and Pathberiya's chapter on Decolonizing Biomedical Education in the United Kingdom elaborates on modern obstetrics as a practice that was not merely shaped by but developed within social orders that were rooted in the racial violence of colonization and slavery and functioned according to their corresponding racializing logics. The authors go on to identify relevant inequities in medicine and global health, ranging from Western bias in research methodologies to “the growth of the arms trade” to “the emergence of sweatshops” (144, Vol. 3). However, by conceiving of these forms of violence primarily as legacies of a past history of colonization, the interventions described by the authors may not be preparing participants to recognize the ways in which the contemporary practice of biomedicine in the United Kingdom and worldwide remains deeply intertwined with violent, extractive colonial structures that are alive and well today—not mere remnants of a historic phenomenon. The implications of a chronology that locates colonialism in the past rather than the present are further apparent in the concluding emphasis on “the importance of adopting a decolonizing attitude” in lieu of systemic change to the global systems of injustice in which biomedicine is complicit (152, Vol. 3). The tendency to center individual attitudes as a primary target for interventions that seek to humanize childbirth (or medicine more generally) appears throughout the final volume which could be strengthened by including an intervention that more directly addresses structural and/or policy factors (like those that are outlined by Sadler and Leiva in their exceptional analysis of the financial incentives for the performance of cesareans in Chile). The three-volume series includes contributions on the Anthropology of Obstetrics and Obstetricians from a diverse collection of geographic regions. Volume 2 would be especially useful for courses in medical anthropology or the anthropology of reproduction. The series as a whole is useful for social scientists, researchers, and clinical practitioners focused on understanding the practice of obstetrics from a critical perspective.

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