ON THE IMPORTANCE OF GENTLE BIRTH: Midwifery and the medicalization of childbirth
By Vyky Reid previously published in Birth Issues Fall 2011
For as long as there have been humans, there has been childbirth. For thousands of years, women have birthed their babies squatting in fields, kneeling against their mates, or lying comfortably in their bedding. Traditionally, women have managed their own births, or they have been attended by midwives—women trained to assist a mother throughout pregnancy and birth. It is only recently that pregnancy and birth have been managed by physicians. Obstetricians, surgeons who specialize in abnormal pregnancy and birth, are now attending the majority of low-risk, normal pregnancies. Theoretically, having a doctor attend the birth of one’s child should increase the likelihood of a good outcome for both mother and child.
However, statistics show the opposite: births that occur in hospitals are actually more likely to have complications1. On the other hand, babies born peacefully at home, and the mothers who birth them are healthier in both the short and long term, exhibiting less instances of “lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birth weight, and assisted newborn ventilation”(1). The medical model of childbirth disempowers a birthing mother, resorts to unnecessary ‘routine’ interventions and provides a less satisfactory outcome for both mother and child when compared to a midwife-attended home birth.
Patriarchy is defined as a system of society in which men hold the power and women are largely excluded from it. Medicine has always been a predominantly male profession and, as a result, modern medicine has been largely shaped by the ideas, experiences and preferences of men. Pregnancy and childbirth are no exceptions. Conversely, the word ‘midwife’ is derived from the words “with woman.” Though midwife-attended births are actually the global norm, Simonds, Rothman and Norman indicate that since the early 1900s in North America, an entire society of women have been attended in childbirth by men(2).
They claim that, “quite simply, midwives are woman-centred. In a cultural environment that generally devalues women’s bodies, desires and experiences, midwives honour them”(3). When choosing a midwife-attended birth, a mother can expect to be treated with dignity, respect and empathy. Midwives practice with a holistic view of the birth process. They realize that it may be a short or long process, and that circumstances may vary greatly. Women are encouraged to listen to their bodies, to move around, and to eat and drink to keep their energy levels up. During the birth of the baby, different positions for pushing are used to ensure optimal positioning of the baby in relation to the birth canal and in consideration of the mother’s comfort.
Comparatively, in the hospital, the physician or institution’s policies often supersede the needs and desires of the mother. Her autonomy is stripped, much like her clothes when she is ordered into her hospital-issued backless gown. She becomes vulnerable and powerless to speak for herself, unable to make her wishes and preferences known. Throughout labour, strangers will enter her room uninvited to poke buttons on a machine, to read the print-outs spit out by fetal monitors, or to insert their fingers into her vagina to assess her progress. During the delivery of the baby (use of the word ‘delivery’ implies that the physician is the individual at work), the mother must often lay flat on her back with her legs open wide and her feet in stirrups.
The lithotomy position became the norm as it allows unencumbered view and access to the vagina by the medical staff. This position continues to be used despite evidence that shows that it decreases the size of the birth canal and is physiologically the least effective position for the second stage of labour. Cox claims that, “many positions other than lithotomy are more effective, safer, and more comfortable for the birthing woman”(4). Pushing in the lithotomy position often results in perineal tears and increases the likelihood of cephalopelvic disproportion: a condition in which the pelvis becomes too narrow to accommodate the fetus’ head(5). Regardless of more effective positions that could be utilized, the lithotomy remains the most common—it has become routine.
Simonds, Rothman and Norman state that, “routinization and objectification are inherent to institutionalization”(3). Simply put, the medical model of childbirth is disempowering for the mother. They also assert that, “the power that is the birthing woman’s has been drained from her and given to the institution in which she is placed” and that “giving birth at home returns that power to the woman”(6). This is not to say that medicine and childbirth are mutually exclusive, as there will always be situations in which it would be prudent to seek care from an obstetrician. Consider also that midwives are competent in emergency situations and have the ability to recognize when it is necessary to transfer the mother to the hospital in the event that complications do arise.
The medical model of childbirth assumes that women are unable to birth their babies without assistance. Wagner indicates that nearly all women who give birth in a hospital setting will be subjected to some form of intervention, routine or otherwise(7). Statistics show that over 90% of labouring mothers will have continuous fetal motoring, and 80% will be hooked up to intravenous fluids, being withheld food and water. Nearly 80% of mothers will accept medicinal pain relief, notably epidural blocks or opioid narcotics. More than half of all women have their labours started or augmented by a synthetic form of oxytocin. Perhaps the most disturbing statistic is that one third of all babies born in North America are born surgically(7). This is happening despite the fact that statistics also indicate that, “interfering with the normal physiological process of labour and birth in the absence of medical necessity increases the risk of complications for mother and baby”(8).
Figures suggest that a very small percentage of women will experience a “normal birth”, that is, a birth in total absence of hands-on medical intervention. We can accredit most of those births to midwives. Kitzinger says, “One-to-one midwife care is a major factor in preventing unnecessary caesarean sections”(9). In a home setting, women are free to let their bodies work through labour naturally. Midwives carry only the equipment necessary for infant and maternal resuscitation or for medical emergencies. Drugs are not used to start or speed labour or to intensify contractions—instead mothers are free to experiment with movement and position to help facilitate the descent of the baby within the birth canal. Mothers are encouraged to eat and drink instead of relying on IVs for hydration. They are urged to vocalize and draw support from their partners to distract themselves from the pain of contractions. Midwifery preserves the notion that as women, we are designed to birth our babies without the need for drugs or technology.
Western culture holds the belief that medical professionals always act in the best interest of their patients and that their expertise is not to be questioned. Though North Americans have the right to informed consent, they often choose not to exercise it. They blindly trust that the institution knows what’s best, and will act accordingly. Unfortunately, the maternity care system in place is broken; the best interests of mother and child are often ignored for the sake of doctor convenience, efficiency and resource management. Birthing mothers are placed under what can be described as ‘arrest’: confined to a bed, monitored, and immobilized with pain medications. The after effects of this can actually impact maternal and fetal well-being, physically and mentally.
The number of mothers suffering from postpartum depression is on the rise. Many women have been interviewed about their thoughts on their condition, “whereupon these women implicated lack of control over their birthing experience or a difficult birth”(10). Furthermore, many women are not told of the risks associated with medicinal pain relief. Maternal hypotension (which is even more concerning when a woman is lying on her back) and fetal respiratory distress are common side effects to the popular allopathic pain management approaches: opioid painkillers and the epidural block(11). It is also noted that narcotics can interfere with the initiation of breastfeeding. “Compared with newborns of women who do not receive narcotics, the newborns of women who receive narcotics may experience more difficulty breastfeeding in the first hours, days, and weeks after birth”(8).
Women who give birth at home will often escape these issues. Midwives do not offer narcotic pain relief; instead they will suggest non-medicinal alternatives to help deal with the pain of contractions. Because of the continuity of care that midwives offer, they are present for the first few hours after birth to assist the new mother and baby with breastfeeding. A successful breastfeeding relationship is an important factor in avoiding postpartum mood disorders such as depression(12). Postpartum mood disorders can also include Post-Traumatic Stress Disorder—a serious disorder that, according to Kitzinger, can affect up to one in twenty women after a traumatic birth experience (9). Because midwives strive to assist mothers in achieving a gentle birth, home-birthing mothers are far less likely to suffer from P.T.S.D. as a result of a negative birth experience.
“Birth is not dangerous; birth need not be frightening; birth does not require people well versed in the abnormalities of childbirth to observe and record it’s every fluctuation. Birth needs to be trusted and believed in. Birth is safe”(13). The North American model of maternity care does nothing to instil a sense of safety in a labouring mother. Instead, her instincts and wishes are overridden by bureaucratic policies and unnecessary, overused technologies. By choosing midwifery care over an obstetrically managed birth, a new mother can remain in control of the birth of her baby, avoid gratuitous medical procedures and can look forward to a gentle and healthy start to life for her newborn and herself as a mother. As Simonds, Rothman and Norman said, “birth belongs to the woman, not to the attendants”(14).
Vyky Reid is a doula and aspiring midwife, wife to supportive husband Chris, and mother to Lyra June, born by unnecessary cesarean in October 2009. In 2011, she proudly gave birth at home after a previous cesarean.
Editorial Notes:
1. Wax, Lucas, Lamont, Pinette, Cartin, and Blackstone, “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis” American Journal of Obstetrics & Gynecology 203, no. 3 (2010): 243.
2. Simonds, Rothman, and Norman, Laboring on: Birth in transition in the United States (1st ed.). New York, NY: Taylor & Francis Group, 2007, p.15
3. Ibid., p.158
4. Cox, Bonnie, “Culture and Attitude of Birth Caregivers.” International Journal of Childbirth Education 9, no. 2 (1994): 13-15.
5. Definition of Cephalopelvic disproportion (CPD). Mosby’s Dictionary of Medicine, Nursing, and Health Professions. 2009.
6. Simonds, Rothman, and Norman, Laboring on: Birth in transition in the United States (1st ed.). New York, NY: Taylor & Francis Group, 2007, p.72
7. Marsden Wagner, Born in the U.S.A.: how a broken maternity system must be fixed to put women and children first (1st ed.), Berkeley, CA: University of California Press, 2006.
8. Romano and Lothian, “Promoting, protecting, and supporting normal birth: a look at the evidence.” Journal Of Obstetric, Gynecologic, and Neonatal Nursing 37, no. 1 (2008): 94-104.
9. Sheila Kitzinger, “Birth as Rape: There must be an end to ‘just in case’ obstetrics” British Journal of Midwifery 14 (2006): 544-545.
10. Torres and DeVries, “Birthing Ethics.” Journal of Perinatal Education 18, no 1 (2009): 15.
11. Kumar and Paes, Epidural opioid analgesia and neonatal respiratory depression.” Journal of Perinatology 23, no. 5 (2003): 425-427.
12. Zauderer and Galea, “Breastfeeding and depression: empowering the new mother.” British Journal of Midwifery 18, no. 2 (2010): 88-91.
13. McCracken, A Declaration of the Rights of a Childbearing Mother, 1999. www.midwiferytoday.com/articles/declaration.asp (accessed June 2011).
14. Simonds, Rothman, and Norman, Laboring on: Birth in transition in the United States (1st ed.). New York, NY: Taylor & Francis Group, 2007, p.161
