February 2004


De-Medicalizing and Re-Humanizing Childbirth in America

by Jennifer Ayers, B.A., L.P.N., I.C.C.E.

 

I have been ingesting the culture and practice of childbirth in our country for many years now.  As a young girl, I read everything I could about birth and wanted to continually learn more.  But, it wasn't until my first pregnancy in 1992 that ended in miscarriage that I began to fully nourish my desire to satiate my hunger for learning all I could about the mystery of birth.  Now, after having had time to digest the information I have accumulated (and continue to consume) I have come to definite conclusions about childbirth and what we have done in our American culture to both hinder and nurture the process.

Primitive cultures viewed childbirth as a rite of passage and whole communities celebrated the event.  The pregnant woman was educated and nurtured by her mother, grandmother, aunts, friends and other wise women of the village.  Femininity was honored; revered as a symbol of universal fertility and life.  During labor, a woman would be supported and encouraged by her female support system, but largely it was a hands-off process; an individual journey.    The midwife or shaman was not called unless there was a severe problem with mother or baby, and even then, if death or illness ensued, it was viewed as a normal, natural part of life and no one was blamed.

During America's pioneer days when fearless explorers journeyed westward creating homesteads among the wilderness, there was no choice but to birth at home, usually unattended.  It is true that many died during these times, but not because of any inherent danger in homebirth, but because of the poor health and hygiene of the people during this period.  Antibiotics were not yet available nor were vitamin supplements.  Charging into a new frontier introduced new strains of bacteria and viruses for which the settlers had not yet acquired immunity to.  The natural, normal process of procreation encountered the same problems as did the entire population in this strange new world.

The Industrial Revolution gave us the ability to become a more efficient, technical, and "sophisticated" society.  We created machines to perform mundane tasks and to bring about the instant gratification that we have now become accustomed to.  The use of technology became seen as superior to relying on human capacity, which was slower, unreliable, and prone to error.  Gradually and insidiously, the machines that we created to make our lives easier and to serve us were the very machines which we now serve; the machines that control us.

From Europe came the belief that educated women would not subject themselves to the animalistic, uncivilized ways of birth.  They would birth with modesty and dignity at the hands of skilled physicians trained in the latest modern techniques.  With the use of forceps and chloroform, women could birth in a controlled, almost mechanized, fashion.  Birth now became a medical specialty and therefore, a medical event.  Childbirth then moved from homes to hospitals where it could be further quantized and controlled.  Women saw this as advancement and took advantage of modern medicine and its relatively newfound role in parturition.

However, a widespread fear emerged among women birthing in hospitals:  childbed fever-- a strange infection which afflicted a great deal of women despite being in the care of modern society's finest.  Many women died at the very hands of those who proclaimed superior knowledge about birth; those men who had never birthed, whose dirty hands passed deadly disease from one woman to another.  Not until it was discovered that handwashing could prevent such illness did this needless killer come under control.  Yet, hospital birth had already become deeply entrenched in our culture and was no longer a luxury for the well-to-do, but an expectation for most childbearing women.

The 1940’s were a busy time for hospital births with the baby boomers filling up the wards.  The standard of care included admitting the woman to a multi-bed unit where she was to labor on her own until it became close to the time to deliver the infant from her.  When it was near time for the child to be born, the woman was brought into a delivery room, her arms often strapped to the table with leather restrains, her legs positioned into cold metal stirrups and she was administered a series of drugs ("Twilight Sleep") which would render her unconscious at which time the baby could be extracted from her body with a routine episiotomy (cutting of the perineum to increase the diameter of the vagina) and forceps (metal tongs placed on either side of a baby's head to pull it from the birth canal).  Husbands were allowed no where near their wives and were often mandated to wait at home or on another floor of the hospital.  Mother and baby were promptly separated.  Baby was sent to the nursery and mother to her room to remain in bed for up to 10 days to recover.  The baby was brought in to be bottle-fed by the mother at regular 4 hour intervals.  Many times the father was not allowed to touch the baby in the hospital for fear of infection.  Many women had a difficult time adjusting to parenthood after their traumatic birth experiences.  They did not view what they had been through as necessarily traumatic; it was the "normal" birth at the time.

In the late 1960's and 1970's, women chose to re-educate themselves, seeking a better way of birth.  They began to (rightfully) question the medical establishment which dictated how a birth should be orchestrated.  Books such as Ina May Gaskin's "Spiritual Midwifery" introduced women to the idea of homebirth and midwifery.  It showed that birth was not an illness which required any medical care.  The support and encouragement of competent midwives was all a woman required to have a safe and satisfying birth.

By the late 1970's, hospitals began to respond to women's demands for change.  Husbands were now allowed to remain with their wives for the birth of their children (although they were required to don surgical garb to do so).  As we moved through the 1980's, the LDRP was born.  The homelike room in which women could labor and give birth allowed women to remain in a somewhat more comfortable environment with the support people of her choice (usually no more than 1 or 2).  Hospital rooms were converted to hotel rooms with decorative wallpaper, dimmer lights, soft curtains, rocking chairs and more natural looking birthing beds.  Behind the cozy exterior still remained the ability to intervene should a complication arise.  Because women were still subject to "hospital policies," births were expected to take place in a timely, expectable manner.

Little has changed (for the better) as far as birth in our culture today.  It has remained fairly consistent from the early 1990's through today.  The majority of women plan to give birth within a hospital.  They trust their doctors to determine the best mode of care for themselves and their babies.  Women are conditioned by our culture to expect to receive the "best" that technology has to offer them in their journey of childbirth:  epidural anesthesia, continuous electronic fetal monitoring, ultrasound, amniocentesis, elective cesarean sections, vacuum extraction, intravenous drips, and many other technological  "advances" that are now routinely available for those planning a hospital birth.  Yet, despite our allopathic advances in maternity care, the United States continues to plummet in maternal and infant mortality rates among industrialized countries.  As of 2002, the U.S. ranked 28th in the world in infant mortality and 21st in the world for maternal mortality.  And, cesarean sections have reached an all-time high, with 26.1% of all births culminating in a surgical delivery.  That translates to 1 out of every 3 or 4 women are deemed by the medical profession as incapable of having a normal vaginal birth.  Have our bodies somehow changed that dramatically?  Or has the medical model which paternalistically governs childbirth in this country demonstrated that it places more faith in technology than in humanity?

Part of the reason for the increase in surgically-assisted birth is that we live in a very litigious society and doctors have been coerced into doing everything that they can to prevent malpractice suits.  By using all the technology that is available to them, they believe (as do their lawyers) that they are doing "everything possible" to ensure the best possible outcome for mother and baby.  However, few mothers are made aware of all the risks inherent in doing the major abdominal surgery casually referred to as a c-section.  There is a 4 times greater risk that a mother will die as a result of a surgical birth as opposed to a vaginal birth.  But, if the worst case scenario occurs and the mother or baby dies, the doctor can still maintain that he/she did all that they could, providing what they believed to be the best and most technologically advanced care for that mother and child.  It is not until the medical profession realizes that what is deemed the most "technologically advanced" is often not what is truly the "best possible care," that any positive changes in our American birth culture will result.  Even more appalling is that the American College of Obstetrics and Gynecology publicly acknowledged its support for elective cesarean sections even in the absence of medical necessity, citing that a woman is entitled to having the option of surgical delivery despite any identifiable indications which would warrant such a radical procedure.  There have even been some obstetricians which have published such implausible ideas as the fact that all women should be routinely be given cesarean sections!

Another reason for the high rates of infant and maternal mortality as well as the unnecessarily high cesarean section rate in America is the prevalence in the routine use of epidural anesthesia.  Many women are duped into believing that the pain of childbirth is horrible, without purpose, unbearable, and something they needn't tolerate.  They believe that since we have become a more "advanced" society, that we should rise above the "inconveniences" with which our predecessors were faced.  Women are being taught that childbirth needn't be painful and that an epidural is their saving grace.  I am not saying that an epidural has no place in birth, because for a few women it is very beneficial, and of course in those rare instances where surgical intervention is in fact necessary, spinal/epidural anesthesia allows a woman to be conscious for the birth of her child, which is indeed a wonderful benefit.  The rate of epidural anesthesia for childbirth is as high as 80-90% in many hospitals across the country.  Yes, labor is more difficult to tolerate when a woman's autonomy is stripped from her in the name of hospital policy.  Once she walks through the doors, she is at the mercy of the medical model.  Routine I.V.'s and external fetal monitors confine her to bed, often impeding the natural process of labor, in which case her contractions become ineffectual and a Pitocin drip is administered to speed things along.  Using the artificial hormone to enhance labor produces powerful and often intolerably painful contractions which in turn necessitates the administration of epidural anesthesia.  The introduction of the epidural brings with it the necessity of inserting a Foley catheter into the bladder since the woman can no longer feel anything below the waist.  And since an epidural may cause a sudden decrease in blood pressure, the woman's blood pressure must be continually monitored.  Another side effect of epidural anesthesia is an increase in body temperature which could also be a sign of infection, so the woman and baby must be treated prophylactically for infection with the administration of powerful antibiotic drugs.  Sometimes an epidural may slow down cervical dilation in labor, especially if given too soon, before labor has gotten well underway.  If a woman is taking too long to deliver or not making sufficient progress, she is now demonstrating "failure to progress" and if the baby cannot be removed from her body with forceps or a vacuum extractor, a cesarean section is often performed.

Hospital policies requiring women to remain in bed, hooked up to fetal monitors and I.V.'s, prevent women from being able to tune into their own bodies and position themselves in the most physiologically conducive ways to optimally birth a baby.  By the way, the routine use of fetal monitoring has shown absolutely NO benefit in the outcome of births, nor has it reduced the incidence of cerebral palsy.  All it has served to do is keep women on their backs, raise medical costs, and contribute to the increase in cesarean sections.  The use of anesthesia further limits a woman's ability to change position and is a major contributor in the whole "failure to progress" scenario.  Rather than listening to and trusting her own body, a woman often will look to the doctors and nurses caring for her for support and advice.  She believes that they know what is best for her and has been conditioned to doubt her own intuition in lieu of receiving, what she believes to be, the safest and best birth she can have.  By merely placing herself in the unfamiliar environment of the hospital surrounded by strangers, a woman has unknowingly compromised her chances of having a smooth and easy birth.  Women who are able to have unmedicated births where no unnecessary medical procedures are performed, despite being in the hospital environment, are not only rare, but they are very lucky.

I believe that we are fortunate to live in a time when modern medical advances are available for those who need them.  We are blessed with the ability to prevent, treat, and cure illnesses for which, even 50 years ago, there was no cure.  We can now save the lives of premature babies born as early as 21 weeks gestation.  We can allow infertile couples to bear children of their own.  But pregnancy and childbirth, in and of themselves, are not medical conditions requiring treatment.  We do not seek medical assistance each time we urinate, defecate, vomit, sneeze, cough, hiccup, burp, or engage in the act of procreation.  Just because childbirth is physical does not automatically make it medical. As women, our bodies were created to conceive, nurture life, and give birth.  Rather than being taught to trust in our bodies and in the process of birth, we are taught that birth requires assistance; that our bodies are somehow imperfect; and we must place our trust in obstetricians, nurses, and midwives rather than in ourselves.

There are two primary schools of thought for those who hold non-conformist, non-medical views regarding childbirth:  the midwifery model of care and the "unassisted childbirth" model.  The midwifery model of care views childbirth as a normal, natural process which can best serve the needs of women by offering them education and support during pregnancy and birth.  Midwives are trained to intervene should a situation warrant intervention.  Meaning "with woman," a midwife continues the longstanding tradition of a female "wise woman" birth attendant.  A traditional midwife learns her trade through an apprenticeship with an experienced midwife.  Through reading, practicing, assisting and experiencing many births with a seasoned professional, an apprentice gains valuable knowledge not available in a purely didactic setting.  This method embraces the tradition of passing on knowledge and skills from one woman to another.

Historically and anthropologically, women have not chosen to give birth alone.  While some women seek privacy and solitude during their labor, most women seek the support and companionship of other women, at least at some point during their pregnancies and births.  We no longer live in a tribal community where our neighbors are an extension of our families.  So, a midwife may help to fill this void left when we chose to isolate ourselves via our modernistic lifestyle.  Women seek the guidance of someone who has been there before; someone who can answer their questions and reassure them of the normalcy of birth.  A midwife who is truly “with woman” can provide the expertise coupled with the companionship and support a pregnant women needs.  A doctor or obstetrician often approaches pregnancy and birth as pathological conditions (for this is what they were trained to recognize and treat) and is often a paternalistic figure for the pregnant women, whereas a midwife is a peer. 

Other resources for pregnant women today include mothers’ groups, friends, church groups, female family members, books, magazines, and the Internet, which has opened doors for women who would otherwise be dependent upon the medical model alone.  Educating ourselves is the first step toward reclaiming our bodies and our births, but in doing so, we need to be selective in what resources we are choosing since many merely reiterate the cultural fallacy of birth as an illness based upon the medical model.  To truly enlighten ourselves, we must go beyond the cultural and medical jargon and get to the root of birth, searching for the ultimate truth.  When we do find it, we will resonate with that truth and will consciously and subconsciously discern that it is what is unquestionably valid.

In stark contrast to the world of routine hospitalization, c-sections and epidurals is the philosophy of unassisted childbirth.  This is a choice made by women who have empowered themselves with confidence in their bodies’ inherent ability to birth and have rejected the medical model and even the midwifery model which, too, is often tainted with medicalization.  This decision is often met with disdain by those who blindly follow the cultural norm.  Naysayers will often cite that the mother is being selfish and endangering the life of her child by not putting her pregnancy and birth into the capable hands of medical professionals.  But, research clearly shows that a baby is at far greater risk of being subjected to unnecessary interventions which often produce complications when they are allowed to be put under the care of “medical professionals”.  Most hospital protocols are based on convenience and resistance to change as opposed to evidence-based research.  Women who choose a “do it yourself birth” are fully educated and have found that resonant truth about birth inside of themselves, despite the fierce opposition they must face. 

An ideal birth happens in the same manner is which conception of the child occurs: in the privacy and comfort of the home; surrounded by love and trust.  Unless there is truly a medical condition which affects mother and/or baby, there is no good reason to plan to give birth in a hospital/medical setting.  If complications arise during the birth, medical care is no more than a phone call away in most cases.  But why make all births a potential risk when in fact most births (without medical intervention) occur without difficulty?  The main contributor to a problematic birth is the very environment which claims to make it “better.”  The American way of birth has taken an intricate process, a combination of the physical, mental, emotional, and spiritual, and quantified it into a mechanized process.  It has taken the deeply meaningful natural process of childbirth and contorted it into a series of measurements and tests, making a multifaceted and mysterious natural phenomenon into a two-dimensional, mechanical procedure.  Until women reclaim the sacred ground of childbirth, it will continue to belong to a highly imperfect realm of rote medicalization and unnecessary interference.  Birth belongs to us, not to science.  It is time to make it ours again.


 

Bibliography

 

Arms, S. (1994). Immaculate deception II: Myth, magic & birth.
           Berkley, CA: Celestial Arts.

Davis-Floyd, R. (1992). Birth as an American rite of passage.
           Berkley, CA: University of California Press.

Frye, A. (1997). Understanding diagnostic tests in the childbearing year (6th edition).
           Portland, OR: Labrys Press.

Gaskin, I.M. (2003). Ina May’s guide to childbirth.
           New York, NY: Bantam Dell.

Goer, H. (1995). Obstetric myth versus research realities: A guide to the medical literature.
           Westport, CT: Bergin & Garvey.

Goer, H. (1999). The thinking woman’s guide to a better birth.
           New York, NY: The Berkley Publishing Group.

Kitzinger, S. (2001). Rediscovering birth.
           New York, NY: Pocket Books.

Mitford, J. (1993). The American way of birth.
           New York, NY: Penguin Books USA Inc.

Morgan, L. (2003). The power of pleasurable childbirth.
           Lincoln, NE: Writers Club Press.

Shanley, L. (1994). Unassisted childbirth.
           Westport, CT: Bergin & Garvey.

Wagner, M. (1994). Pursuing the birth machine: The search for appropriate birth technology.
           Camperdown NSW, Australia: ACE Graphics.

 

 

 

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