This piece of Etruscan pottery is one of the earliest representation of childbirth in Western Art.
As someone who has never experienced a pregnancy or a birth, my impression of it seems complicated, scary, and embarrassing. Thank you television and hearsay. The idea that one could birth a child in a field somewhere, or in a car, far from the knowing hand of Western medicine seemed impossible. Turns out, Western medicine is at the root of a lot of that fear, shame, and pain.
The following is a slightly edited paper I wrote in 2010. I tried to updated the sources as much as possible.
Childbirth in American Hospitals
I. Trading The Squat For The Stirrups
Since recorded history, childbirth has been performed in an upright position, attended by midwives. The earliest records of birth in the upright positions come from the Babylonia culture, 2000 B.C. There are images of Cleopatra birthing upright in Ancient Egypt all the way up into Colonial America. Despite this long standing practice of birthing in upright position, the lithotomy position made its way from Europe to America in the 1800s.
The lithotomy position is when the woman is on her back, buttock near the edge of the table, with her legs supported in stirrups. If that sounds familiar, it is because it is still the most common – and often insisted upon – birthing position in the United States, despite overwhelming evidence against it.
The position puts all the weight on the tail bone, which not only forces the baby upwards against gravity, but makes labor longer and more difficult, contractions weaker and less frequent, increases risk for perineal tears, and compresses major blood vessels, which lowers the oxygen supply for the baby (Davis-Floyd). The lithotomy position is also known to cause compartment syndrome in the mother, which is basically nerve death resulting from holding a position that compresses tissue for an extended period of time (Cohen).
Roberto Caldeyro-Barcia, past president of the International Federation of Obstetricians and Gynecologists, states unequivocally, “Except for being hanged by the feet, the supine position is the worst conceivable position for labor and delivery” (Davis-Floyd).
It is clear that, given the chance to try alternative positions, women agree. One study showed, “without exception, more positive responses from women using the upright position” and another study found “95% of the subjects in this study wanted to use this [alternate] position in subsequent births” (Davis-Floyd).
Despite all this information, the lithotomy position prevails because it is more convenient for the attendants (Dunes). I think that, given the tremendous effort labor entails, it should fall on the doctor to be a little inconvenienced for the health and comfort of the mother and baby.
II. The Convenient Induction
Unfortunately, sacrificing the comfort of the mother for the convenience of the doctor does not end there. Inducing labor is extremely wide spread in the United States. 20% of births are induced – that’s twice as high as the World Health Organizations recommended rate of induction per geographic region.
Inducing labor with drugs like Pitocin speed up labor, but also causes much stronger contractions with less rest periods in between. While some women prefer a speedier labor, others would have preferred a less painful birth at a slower pace (Davis-Floyd).
However, labor induction is not without risk. The drugs are extremely powerful and must be administered in the smallest possible amount and closely monitored. The stronger contractions can be rough on the baby, compressing the umbilical cord and cutting off oxygen to the baby. In extreme cases, induction drugs like Cytotec can cause uterine rupture, which can be deadly to mother and baby.
The World Health Organization specifically says labor should not be induced for convenience, which is unfortunately the case in most American hospitals where births are scheduled to fit the doctor’s schedule. All three of my mother’s children were induced; the youngest was induced so the doctor could make the Super Bowl kick-off.
Two other preparatory procedures that were commonly part of all hospital births are the enema and perineal shaving. Enemas, the process of cleaning out the mother’s bowels before labor, it was argued, would decrease the chances of infection in mother and baby during labor. This argument has been discredited for causing unnecessary medical costs and discomfort to the mother. Similarly the process of perennial shaving before labor was argued to decrease infection and allow the doctor to have more convenient access. In actuality, shaving can increase the risk of infection by inflaming the skin (Basevi). Luckily, both of these procedures are no longer routine in the US.
IV. The Episiotomy
A final procedure that is no longer routine, but still considerably common, is the episiotomy. As the perineum starts to stretch, the attendant snips the stretching skin toward the anus, which supposedly protects the baby’s head during pushing, hastens delivery. In the United States episiotomies are estimated to occur in one third of all vaginal births. The rate varies around the country, but 70%-80% of first time mothers will undergo episiotomies.
Contrary to the arguments mentioned above, there is no evidence to support the use of episiotomies. Women who have them tend to need more stitches, experience more pain after birth, and are twice as likely to experience fecal incontinence in the first three months. Women who have episiotomies are actually at a great risk for a more severe tear than might happen naturally.
V. C For Convinient
Another alarming trend in American hospitals is the rise in cesarean sections. While sometimes medically necessary, many cesareans are only necessary because of a previous medial intervention like induction. Physicians are being critiqued for promoting cesareans for convenience.
“Cesarean birth ends up being a profit center in hospitals, so there’s not a lot of incentive to reduce them,” said Dr. Elliot Main, chief of obstetrics for Sutter Health, a Northern California hospital chain. “Among California hospitals, cesareans range from 16% to 62% of births. Such variation means a lot of women are getting unnecessary cesareans”, Main said. “There’s no justification for that kind of variation”. The World Health Organization says there is no justifiable reason for any geographic area to have more than 10-15% of births delivered by cesarean section.
Physicians are being critiqued for letting women opt into cesarean births without fully disclosing the dangers of the procedure. As with any highly invasive surgery, there are many more risks, plus hospital stay and recovery are longer and harder.
My mother, whose second child was breached, had a scheduled cesarean. Of her experience she said:
This example of the denial of women’s experience is all too common, and can be particularly upsetting during childbirth. Childbirth puts women in an extremely vulnerable situation and it is the hope of all involved that measures are taken to alleviate as much of that discomfort as possible.
VI. Childbirth and PTSD
In a recent study of more than 900 U.S. mothers, 9% screened positive for meeting all of the formal criteria for PTSD set out in the Diagnostic and Statistical Manual of Mental Disorders, and 8% of respondents had some signs of the disorder.
Some suspect that increased medical obstetric procedures like cesareans and premature births may be contributing to PTSD. “The mothers who reported signs of PTSD in the survey appeared to have a higher rate of medical interventions and describe feeling powerless in a threatening environment” says Cheryl Beck, a professor at the University of Connecticut School of Nursing.
VII. Home Birth In The Netherlands
The Netherlands is a great example of the successful incorporation of midwifery and hospital-based childbirth. 30% of births occur in the home, overseen by professional midwives (Wiegers).
Midwives are assigned to a mother before the birth, allowing for time to build familiarity and trust, as well as prepare for the birth. They also assist the mother for the early weeks of motherhood, helping with the baby and preparing light meals for the mother while she sees visitors.
During the birth, the midwife lets the mother move around and give birth in preferred positions, which reduces pain and the need for drugs (Dutch women only receive anesthesia in hospitals and only in emergencies). They can also regulating pushing and use massage to prevent or reduce perennial tearing. Perhaps most importantly, midwives are trained to recognize potential dangers and know when it’s time to transfer the birth to a hospital (Westerweel).
This type of birth allows women to feel more in control, more comfortable, and without unnecessary intervention. Interestingly, the Netherlands has a lower infant mortality rate than the United states, clocking in 4.59 deaths per 1000 births compared to the United State’s 6.06 (the United Kingdom, which also promotes midwifery is at 4.62).
VIII. The Right To Choose
Unfortunately, in the United States, midwifery is illegal in ten states. Far from protecting the health of the mother and baby, much like anti-abortion laws, criminalization actually puts mothers who use midwifes out of choice or necessity at risk. There is no proof that home birth is any more dangerous than hospital birth, which means women should be given the information and support necessary to make their own choices about their bodies and experiences.
Lastly, check out the awesome blog Radical Doula to read about midwifery as it intersects with social-activism.