by Jane Pincus
Note from the author: The following article was written in the late 1990s. While some of the books listed are no longer in print, the article contains a brief history of childbearing and discusses a way of looking at books which I believe is still useful today.
The First Seven Books
Stepping Beyond the System: The Last Three Books
Over the past thirty years, popular childbirth literature in the United States has attested to women’s strongly felt need to understand pregnancy, labor, and birth, and to know what choices they have, if any, in regard to practitioner, birthplace, and how they might give birth. In the early 1960s, the only books widely available were Dick-Read’s Childbirth Without Fear, Karmel’s Thank You, Dr. Lamaze, Chabon’s Awake and Aware and Vellay’s Childbirth Without Pain. These progressive physicians discussed alternatives to the routine surgical birth of our mid-century decades. Today scores of books written by women (and men), mothers, childbirth educators, midwives, social scientists, and physicians provide information and advice about pregnancy, birth, and parenthood.
Before the late nineteenth century, women learned about childbearing from other women. In colonial United States, friends and relatives brought food and stayed for days, even weeks, to help (Wertz & Wertz). Often mothers served as their daughters’ faithful companions during the entire time of “confinement” (Leavitt). In the south, young African-Americans, after assisting their midwife grandmothers for years, later felt “called” to become midwives themselves (Smith/Holmes/ Logan/Clarke). Once physicians began attending births in homes, they too became a source of information. Once most women were moved into hospitals for labor and birth (by about 1950), it seemed as if the subject of birth literally disappeared from public discussion despite the efforts of some dedicated women to keep the subject alive (See Reclaiming Birth, Edwards and Waldorf). Indeed, the use of scopolamine meant that an entire generation of women shared a collective amnesia in regard to birth. In the late 1950s, birth reappeared as an issue. By that time, a significant number of women, having experienced the isolation and indignities of hospital practices, the dangers of general anesthesia and the obliteration of their memories, began to protest the situation. They wanted companions and support, and to be awake to see their babies born.
Although midwives in the United States did not attend many births during those years, many of the first nurse-midwives taught childbirth classes to a small number of women, some of whom helped to create groups like the original Childbirth Education Associations. By 1960, two national organizations were formed – the International Childbirth Education Association (ICEA) and the American Society for Prophylactic Obstetrics (ASPO) – built from the writings and teachings of dozens of women’s groups, writers and innovative professionals. “Family Centered Maternity Care” was their credo.
In the exciting open climate of the late 1960s, during the “second wave” of the women’s movement, middle-class women turned to each other again in greater numbers. They began to “claim” their bodies and their sexuality, analyzing their personal experiences in a cross-fertilization of facts, feelings and ideas. They discovered that they were not alone, that others had undergone similar events, and that male-dominated institutions had been responsible for minimizing and suppressing their needs and desires. They discovered the heady power that comes from talking together, telling deeply-felt birth stories, sharing information and forming groups to organize and work for change.
Many women (and some men) wrote books advocating childbirth reform. These books replaced the old-fashioned community of knowledge, and created new communities and organizations. Some of the authors of the late 1960s and the 1970s included Niles Newton, Barbara Ehrenreich & Deirdre English, Doris Haire, Lester Hazell, Sheila Kitzinger, Suzanne Arms, Ina May Gaskin, Yvonne Brackbill, Tom & Gail Brewer, Nancy Shaw, Birgitte Jordan, Raven Lang, Dick & Dorothy Wertz, Catherine Milinaire, and the Boston Women’s Health Book Collective). They spoke (or hoped to speak) for many women. Their books expressed dissatisfaction with prevailing medical practices, and shone as beacons of hope that practitioners and hospitals would become more responsive to their needs.
These authors described and critiqued modern obstetrics, locating the source of its philosophy, training and practice in several areas – in the aggressive development of nineteeth-century obstetrics, in male physicians’ desire to make money, and to have power over women by controlling the natural process of childbearing (see Horrors of the Half-Known Life, G.J. Barker-Benfield, for a history of early obstetrics – soon to be reprinted). They unearthed and gathered stories of pregnancy, labor and birth, collected and analyzed medical and historical data, and explored birth practices in the U.S. and other countries. Their work, implicitly or overtly, contained fragments of a vision of a woman-centered system of maternity care. That vision in its purest form located birth in the home and created a new generation of community midwives who learned through apprenticeship, home study, midwifery schools and nurse-midwifery programs. These newest midwives restored to this culture the phenomenon of positive births, developed midwifery schools and created local and national midwifery organizations.
In the 1970s, change seemed possible. People involved in childbirth reform hoped, even expected to alter the services that didn’t meet their needs and to develop new ones. They worked hard to introduce midwives into hospital practices and to create freestanding birth centers. They continued the struggle of earlier pioneers to establish hospital policies that would encourage fathers, siblings, family and friends into birthing rooms and permit rooming-in, breast-feeding on demand and early discharge. But they met resistance in most places.
Advances were hard-won and difficult to maintain because most obstetricians (predominantly male in those days), at the hub of power, would not or could not deviate from the conventional view that women’s bodies don’t work well by themselves. The obstetrical philosophy holds that pregnancy and birth are “high-risk conditions,” potential illnesses to be “managed” and controlled by physicians in hospitals with drugs and technology, inherently painful experiences which no woman should have to endure. While many women were learning about woman-centered birth and seeking to shape their experiences in personal and empowering ways, obstetrical ideology remained fundamentally unchanged. Most of the changes that did take place in the 1980s obstetrical world involved an intensified use of testing and technology — the almost routine application of ultrasound, AFP screening and amniocentesis, the continued use of pitocin, fetal monitoring and epidurals, and the notable increase in cesareans. Then, as now, physicians utilized these procedures regardless of their necessity, effectiveness or safety (Brackbill, Inch, Marieskind, Cohen/Estner, Goer). Then, as now, strong pressures from medical industries selling everything from fetal monitors to drugs to surrealistic plastic birthing chairs reinforced this tendency to intervene. The very existence and availability of technology inevitably restricts the arena of choice. Small important gains have indeed been made – birthing rooms, increased nurse-midwifery services, shorter hospital stays – but always, the physician within the hospital institution retains power and control.
This intensified medicalization of pregnancy and birth results from an adulation of technology combined with obstetrics’ historical imperative to “manage” and control the birth process. “What if something goes wrong…?” permeates the atmosphere, with many women increasingly fearful and worried. Almost everyone now accepts the purely medicalized description of pregnancy, labor and birth, expanded here and there with strictures about “lifestyle” — no drinks, no drugs, eat well, exercise adequately, get a lot of rest — almost as if the activism and analyses of the past three decades had never taken place. In the U.S., achieving some reforms has not fundamentally altered the maternity care system. But it has led many people to believe — or to fool themselves into believing? — that significant structural changes have occurred, that further reform can take place and that many real choices are available.
Most childbirth literature of the 1970s and early 1980s differs from that of the mid-eighties to late nineties, as it strongly expresses women’s desire for change, for choice and for more control of the birth experience. The childbirth preparation books we read today, strongly affected by the continued medicalization of childbirth, confusingly combine these desires with a renewed dependence upon physicians and technology.
Modern books about birth seek to reconcile two concepts. Women-centered birth places women at the heart of the childbearing experience. This viewpoint affirms pregnancy and birth to be normal, healthy life events. It values women’s strengths and perceptions of their needs, paying careful attention to the language they use and to their life experiences. It trusts that women know, or can learn, what they need to know to be healthy, to give birth well, and have healthy children. It takes into account the whole picture of women’s lives. It involves the practitioner’s use of a whole range of midwifery stills (which exist in a different realm than obstetrical skills). It conceives of health as a means to an end – a life fully lived – rather than as an end in itself. In contrast, medically manipulated and controlled birth focuses upon the risks and pathology of childbirth, as well as the primacy of obstetrics (a surgical specialty) and of medical technology. It almost always ignores the social, economic and spiritual circumstances of women’s lives and health, and concentrates upon medical surveillance and rescue in time of crisis. Often it pits mother against child, treating her as a container for her baby. So many women going through the obstetrical system feel undermined, their human rights denied, their bodily and spiritual integrity violated, and their very health threatened.
These two concepts often conflict. Sometimes they seem (and perhaps are) irreconcilable. Despite our work these past decades as educators and activists, the medical view predominates throughout the country; the obstetrical system, a medical monopoly, is too firmly entrenched to be shaken. It affects all of us. As authors describing the ways in which these conflicts often play themselves out, we use the mindset, words and arguments of the system we criticize. We are locked within a system that tolerates only a little deviation, and dictates the priorities to be addressed. We become defensive. No sooner do we mention women’s complex feelings, desires and concerns in our writing and teaching, then we must enter into discussions about discomfort, risk and technology. Unwittingly, we embrace the conventional obstetrical framework – its language, its categories of care — in order to caution and strategize against it. It shapes our thoughts and feelings and struggles and bends us toward compromise and capitulation. We offer either-or dichotomies, and foster misleading expectations. We guide women through a medical obstacle course they should never have to confront in the first place (and that they have little or no power to change). We advise them to learn about their capabilities while zeroing in upon the coercive aspects of a physician-dominated system. We urge them to wield their amazing ability to give birth in the very atmosphere that stifles and mutes childbearing in all its depth and dimensions, and at the very time they are the most vulnerable. We ask them to split themselves into parts, to dilute their strengths, and, at times, to abdicate their powers of feeling and reason.
Childbirth advice books thus influence our choices. They inform and guide; they also indoctrinate in a subtle way. Often they are confusing and contradictory. We are told that we are strong and capable and then cautioned about all the things that might go wrong. We are advised to fight for that “natural” birth and at the same time confronted with long lists of tests and interventions to circumvent, somehow, if possible. Almost every mention of a woman’s desires and concerns is immediately followed by a discussion of risk and danger. We are counseled to work for change if we are not satisfied, and to do so coolly, politely, in a lady-like manner. We are well-behaved, taking care not to offend the powers that be, as if a medical eye and mind hovering on the horizon were monitoring every sentence. We end up doing women a disservice by claiming that they may avoid the strictures of our obstetrical system when most of their their babies must be born within its bounds.
In this critique, by analyzing the language, organization and content in selected passages from ten childbirth books, we will uncover the underlying messages women receive. The following seven books focus specifically upon the issues of choice and preparation for childbirth within the framework of the obstetrical system. Birth Reborn, the eighth book, serves as a bridge between two ways of looking at childbearing. The Birth Book (long out of print) and Spiritual Midwifery suggest a way of understanding women and midwifery that enables us to fashion a maternity care service that truly meets women’s needs and enhances their lives and health.
Advice books proliferate and expire in the market quite speedily; only a few will last more than a few years. Some of the books mentioned and discussed are still in print. Others have been out of print for decades, and several excellent books are being reprinted. I hope that readers of this critique will use these pages as a tool for reading and analyzing current advice books, and those yet to be written.
THE FIRST SEVEN BOOKS
Choices in Childbirth
Choices in Childbirth (CC), by Dr. Sylvia Feldman (1979), demonstrates by its good will and its lack of critical sophistication the thinking of the general audience in the U.S. Its author, a psychotherapist, has encountered many women suffering from postpartum depression caused by difficult, even abusive, birth experiences and believes strongly that women must have choices that will strengthen and satisfy them. She makes an earnest effort to educate women and to dispel fear and ignorance, urging women to plan during pregnancy rather than be passive “patients,” and to consider various “methods” of dealing with labor and birth.
At its best, the book raises important issues. But it immediately sets two kinds of care in conflict. It presents choice in terms of “the natural camp” vs. “the least involvement and responsibility possible” (xiv), “natural childbirth advocates” vs. “technologists” (21), and (extrapolating from a doctor’s statement) “humanize(d) childbirth” set against the “benefits of modern obstetric care” (49). It is one thing to recognize that there are different ways to give birth and that conflicts between them exist. It is another to set them in such opposite camps that one seems to exclude the other totally, especially in a society that endorses technology and modern obstetric care and will lean toward it in theory and practice. Presenting such a dichotomy is good in that it suggests an alternative, but not helpful unless a woman can be sure that she and her practitioner can honor all the implications of her choices and help her to follow through with them. The first third of the book, apart from a chapter on nutrition and exercise, drops the “natural” side of the equation, and is taken up with information about medically managed and monitored birth, the Cesarean birth experience and the pros and cons of childbirth drugs.
Finally appears a chapter entitled “The Natural Way.” “Natural” methods, defined as the opposite of “medicalized” include the Dick-Read, Lamaze and Bradley Methods. (Later on we read about “Leboyer births, babies, baths, doctors and midwives”). (182-186) This is significant because it reveals that the author has heard about only the more or less accepted “brand-name” alternatives (all devised by men), and that she knows little about midwifery and all the unnamed, deeply experienced, organic ways in which women labor and give birth. One method mentioned is actually called “Doctor-Centered Natural Childbirth.” The description begins: “…more than with other natural childbirths, this is the doctor’s show. Everyone must accept his obstetrical practices. (He) uses electronic fetal monitors routinely” (111). On the one hand this seems a contradiction in terms; on the other, it proves to be an accurate indicator of the fact that these so-called “natural” methods can be easily integrated into standard obstetrical practice.
A pregnant women would likely be confused by the sentence above, and ask herself what the word “natural” really means. Bombarded with descriptions of conflict and with information about “technological” births, she has little chance to learn about alternatives. Well before she gets to the chapter about choosing a practitioner she is told to communicate with her doctor (always “he”) (35), and to “find a doctor whose…attitudes fit easily with your own.” (93) Midwives are not seriously mentioned until Chapter 10 “Finding Your Birth Assistant” (119). Nurse-midwives are contrasted with “non-medical” midwives (11), a biased and inaccurate distinction. Nurse-midwives would not necessarily like to be called “medical” practitioners, and independent midwives would not appreciate this cursory, implicitly negative description.
In a discussion of birthplace options the high-tech medical hospital comes first, followed by family-centered hospitals, birthing rooms within hospitals, midwifery services within hospitals and finally “More controversial options” (189) — controversial to whom? — which include out-of hospital birthplaces. An out-of-hospital birth is described at one point as “a less desirable setting” (180) immediately following an uneven discussion of the comparative advantages and disadvantages of home and hospital births. This ranking of possibilities could have been written by an enthusiastic advocate of the present obstetrical system.
Feldman uses terms “high-risk” (97) and “normal” (21) as if health professionals and childbearing women both agreed upon their definition: “Of course, high-risk patients are screened out” (180). Alternatives, couched in cautious terms, are presented less knowledgeably and less vigorously than the descriptions and critiques of medical tests and technologies.
The author constantly refers to the “qualified childbirth expert” (2, 13, 15, 47, 49, 85, 95), most often the doctor, and only occasionally the midwife or childbirth activist. “Expert” in fact is never defined; it seems to mean those in power rather than the women themselves who go through pregnancy, labor, and birth. Once again, this point of view is common in our society, and implies that only the experts know what’s best for women. The author’s reliance upon “experts” reinforces the attitude of “learned helplessness” she decries. (15)
A Good Birth, A Safe Birth and Sense & Sensibility
A Good Birth, A Safe Birth (AGB) by Diana Korte and Roberta Scaer (1984, revised 1992) and Sense and Sensibility in Childbirth (S&S;) by Judith Herzfeld (1987), exemplify this subversion. Intelligently and compassionately written, both present childbearing as occurring in a social and emotional matrix, not as a purely medical event. Both books emphasize women’s ability to labor and give birth naturally, with empathetic, knowledgeable labor support, in a calm, unhurried setting with minimal intervention. Both state strongly that what is best for mothers is best and safest for their babies, and that a growing amount of research validates women’s wishes for as natural a birth as possible. AGB makes a point of relating women’s experiences and desires, explicitly set down in the form of responses to questionnaires the authors sent out. They bring out the particularly female aspects of childbearing, and make the connection made between sexuality and childbearing. AGB talks about the similarity between sexual arousal and pregnancy, the facilitating role of the hormone oxytocin, a woman’s extreme vulnerability and openness during pregnancy and birth, the importance of touch during labor, and the erotic quality of breastfeeding. S&S; speaks of similarities between childbirth and lovemaking — “unusual muscular strength, restricted sensory perception, rhythmic contractions of the uterus…and sudden return of awareness and emotional reaction of deep satisfaction at completion.” Birth reaches fruition more readily if a woman can lose herself in it. It can be painful and frustrating to be self-conscious, to resist, or to have a partner (or a birth attendant) insensitive to her needs.
AGB then analyzes the existing obstetrical system. After describing the inappropriateness of crisis-oriented care for normal birthing, the authors then abruptly bid women to knock on hospital doors. By not carrying their analysis to its logical conclusion — the desirability of restructuring care for childbearing women — they do readers the disservice of describing two realities that cannot by definition exist in the same place at the same time.
This confusion occurs most strikingly at the heart of both books — the search for the “perfect” doctor, almost always “he.” AGB lists the rigors of obstetrical training, the time pressures on interns and residents in obstetrics, the emphasis on surgery, the disposition to use “new toys” — techniques and technologies — and the fact that residents practice upon low-income women who have neither the education nor support to state what they really want and need. What’s more, the authors state “Asking an obstetrician to ‘sit on his hands’ and wait for nature to take its course goes against his beliefs, training and experience…they want to practice medicine in the style to which they have become accustomed. And that style definitely affects the care an obstetrician gives you” (74). In the U.S., doctors fear malpractice suits and thus practice defensive medicine, performing most available tests and procedures just “in case” something goes wrong. Insurance companies reinforce doctors’ urge to intervene by reimbursing these costly procedures. The authors point out that in some areas a surplus of obstetricians leads these same physicians to attempt to eliminate the competition represented by family practitioners and midwives.
After listing all these facts one would expect the authors to advise readers to seek out the midwives and family practitioners experienced in normal birth whose skills they have carefully described and praised. Instead they tell us: “There is a doctor for you.” S&S; calls him “a guardian angel.” (100?) AGB, less romantic, more contemporary, calls him “Dr. Right” (81). “Because nearly all of you will choose a physician, we call your birth attendant Dr. Right. For most of you, he (sic) is an obstetrician. For others, a family practitioner, or, for a few, an osteopath. If your search is for a midwife, you can still follow the same process” (83).
Note the main assumption and the ordering of practitioners. “Dr. Right” has been defined as right for you because you have chosen him? After listing a series of interview questions to ask prospective doctors, the authors, in discussing HMOs and group practices, go on to say: “In spite of knowing your obstetrician may not be there, you may still decide that (he) is Dr. Right.” Absence as perfection? They continue: “…tell him that you would like to meet all the doctors who might cover for him when your baby is born…there may be literally a dozen or more doctors who might be on call…” (91). A dozen! Even if Dr. Right exists, Dr. Wrong will be attending most births! Women may indeed have to believe in Dr. Right so much because they truly want a birth attendant who will be sensitive to their needs; and so they deceive themselves into settling for less than they deserve, despite the veneer of rational choice.
S&S; follows a similar pattern. Herzfeld discusses economic and institutional realities in a chapter entitled “In the Interests of All Concerned” — the malpractice threat, the pressure on doctors to adhere to standard practice and not alienate other doctors, anesthesiologists and nurses. She points out that hospitals must protect their financial interests, using equipment and services to capacity. “In our fee-for-service system, every IV placed, every pill dispensed, and every (fetal) monitor brings extra income into the hospital,” as does each administration of anesthesia. In teaching hospitals, “…it is the obligation of the maternity unit to provide (learning) opportunities to residents in ob/gyn and ob/gyn anesthesiology…Although patients may have the right to refuse the care of a resident…they are discouraged from doing so.” Nurses may perceive family members, friends and “labor coaches” present during labor as interfering with what they see as their duty. Hospital routines set up for efficiency and for the benefit of its staff are not flexible enough to accommodate the fluctuating rhythms of individual women’s labors.
The pregnant woman’s interests may indeed conflict with those of both obstetrician and hospital: If she wants to be in control of the circumstances surrounding the birth of her baby, it would be reasonable for her to decide to look elsewhere if possible. Yet instead of encouraging that awareness, S&S; tells her that she has to somehow “be aware of the inevitably diverse interests that are involved in obstetrics and make arrangements that realistically take these into account. A simple fact of life is that you can count on people to serve your best interests if they see these as also being in their own interests, or at least not in conflict.” (S&S; 84) She learns only one way to avoid these conflicts: She should shop around for the doctor who should “protect you from aggressive residents, anesthesiologists and nurses. He himself should avoid unnecessary prophylaxis, minimize environmental disturbances, and resist the ever-present temptation to tamper” (AGB 99) He should explain why intervention is necessary and list the side effects. And he should have “patience, humility, caring, tolerance, sensitivity and humor, qualities that are not particularly cultivated in medical training.” The second half of this sentence negates the first half). The assumption is also made that if these qualities are present in the initial interview they will persist during labor and delivery.
In the same vein the author continues: “Doctors who are partners, not bosses, have less pressure on them to be godlike. All of us can, and do, make mistakes — including physicians. Inviting a doctor to be your partner ultimately allows him to function at his best” (AGB 103). (There are doctors who consider each woman’s pregnancy as an individual and special event, who value good communication and respect their clients. Such an attitude requires recognition of the other’s strengths. It involves balancing women’s beliefs, self-knowledge and wishes with a doctor’s experience. But the authors have emphasized that obstetricians acquire a set of priorities, beliefs and mechanisms for survival during training and practice which can all too quickly come into conflict with a woman’s desire to take (or share) responsibility. Rarely does each party have equal access to power. Though doctors may bend here or there, it becomes almost second nature for them to insist on control. The statement “You hire him as a source of specialized information and as a technician with pertinent skills” (AGB? 105) may be more in line with what obstetricians actually learn, but is this the appropriate practitioner for pregnancy, labor and birth, or simply for backup help if emergencies arise?).
After reading that midwifery skills and attitudes are preferable, women are told to seek out surgical specialists who have neither the inclination nor opportunity to learn these skills. A complete lack of explanation for this hiatus should give rise to questions: Are the authors unaware of what they are saying? Do they know enough about midwifery to make meaningful distinctions between midwifery and obstetrics? Do they really believe that most women, given alternatives, will choose obstetricians? Or do their discussions originate in some fundamental awareness that most women, in fact, have very little real choice? Are women free to make choices when power relationships are so unequal and the medical view of birth is so institutionalized? “Unfortunately… the smorgasbord in obstetrics is largely illusory because one or two choices can determine the rest of the menu.” (S&S;, 7). As a mere reader one might tolerate this dissonance but as a pregnant woman seeking guidance for one of the most important events of her life…what is she to think?
Only those women who live in an area populated with many kinds of practitioners, who are not bound by the regulations of their HMO or their insurance policies, and who have enough time and money to look around can dream of choice. Even then they can be locked into medicalized care while being encouraged to fight its philosophy and practice. Urged to develop offensive or defensive strategies (or a combination of both) they find themselves in the untenable position of having to depend on the people they are strategizing against. Too often the struggle takes place in the midst of labor. It is no wonder that a woman wanting a normal birth feels she has to “prove” herself, to produce a “perfect” experience out of the choice which she and only she has made. No wonder she feels tense, beleaguered, assaulted, then gives up her autonomy bit by bit. No wonder that she blames herself when she “fails.” Though she may have learned a lot, she has not been given the analytical tools for understanding that she and her doctors are acting out a drama set into motion and perpetuated by forces beyond themselves.
I suggest that these two books are organized and worded in ways that prejudice and direct the reader’s thinking. Although certain comments may seem to conflict with some of the information offered, they indicate that the authors’ own ideologies were shaped more by medical indoctrination than by any convincing, lived experience of alternatives. It is like advising a fledgling diver not to experience the sweep and feel of the dive but to begin by being terrified of breaking her neck. In reality there is no such thing as a “balanced” point of view — the medical outlook is weighted far more heavily than its “opposite.” The underlying imbalance betrays women by holding out the desireability and possibility of choice, and then subverting the most valuable insights and recommendations.
Your Baby, Your Way
Your Baby, Your Way (YBYW) Sheila Kitzinger (1987), extremely knowledgeable about birth, has talked with hundreds of women. Her five children were born at home. She has studied birth in many countries, lectured round the world and written many useful books. She understands women’s wishes and needs as well as anyone. Her personal warmth shines through the text: “When you really start to swim with the waves of contractions, it can be a deeply satisfying experience. I remember feeling myself — and I am a far from athletic person — ‘Oh, this is a sport I can really do!'” (244)
While words and philosophy are weighted one way, the organization of the book tells a different story, and organized in rigid obstetrical categories.. For instance, the unit entitled “The Way Birth Is” is divided into six parts. “The Journey Through Labor” consists of a schematic table detailing the phases of labor, the physical signs, how a woman might feel, how she can help herself and what her companion can do. In providing these guidelines, the author describes a “typical” abstract labor. Such guidelines can be comforting and helpful, but description can become prescription if women feel their labors are not “normal” when they aren’t following the sequence and timing of events outlined in the book.
The next chapter, “Dealing With Pain,” begins by listing the physiological and emotional causes of pain, mentioning the drugs used by physicians to dull the pain and then describing how to handle pain with one’s own resources – another instance showing us that the ordering of topics can influence a reader’s orientation towards the issue. “Obstetrically Directed Birth” contains a section on “high-quality obstetrically directed labor with each person having her own personal midwife and continuity of care” as practiced in Dr. Kieran O’Driscoll’s Dublin hospital. This “Managed Labor” approach – obstetrically directed labor at its best” (the latest thing in U.S. hospitals) – is contrasted with “autocratic and invasive obstetric management which routinely interferes with the natural process of labor and introduces unnecessary risks.” (252) It may be difficult for and ordinary reader to distinguish between the two methods, for each requires an inordinate amount of medical control. Discussions of induction, “labor by the clock,” fetal monitoring, amniotomy, IV drips, episiotomy and cesareans follow. Next comes a chapter called “Ceremonial Birth Procedures,” which includes sections on “preps,” enemas, immobilization, transfer to delivery rooms, drapes and masks, and “pushing to order.”
A reader might wonder at the unqualified use of the word “ceremony,” which can imply joy as well as torment, but here definitely describes unpleasant hospital procedures to avoid if possible. Why are the interventions common to obstetrically managed births not linked with the in-hospital “ceremonies” described? It is clear that they all belong to that class of modern medical rituals designed to control the course of labor. (Kitzinger has made this connection strongly in other books and in the talks she has given). In leaning so heavily upon issues of pain and interventions, the author makes their occurrence more probable, even as she advises women about how to handle the events and procedures they are worried about or do not want to accept as part of their birth experience.
The fifth chapter, only seven pages long, is called “Autonomous Birth.” Its placement at the end of the Birth unit and its brevity implicitly inform readers of the numerous hurdles they will have to jump before they can even dream of autonomy. The possibilities are slim for them to realize their wish to give birth in a way that makes them feel, like one woman whose story is told, as though they “hold the universe in their hands.” (293)
The reader is plunged simultaneously into a recognition of women’s capabilities and a barrage of concerns and cautions about obstetrical tests and interventions. This profusion of information may reassure and strengthen, but it can also lead to more questions, more worry. Readers are shuttled from fact to advice to critical analysis and back again in dizzying fashion without much guidance as to how to weigh one kind of statement against another.
One reason for this confusion is that the book is written in several “languages” — the language of women talking about themselves, an inward, subjective phenomenon, and the language of “scientific” speculation which moves outward into an objective yet also perilous world. “What if’s” take place not in the past or present, which are somehow comprehensible, but hovering, threatening, in an unpredictable abstract future. Pregnancy, a personal affair becomes vulnerable to medical scrutiny and assault.
When the author falls into the “medical risk” mode she perpetuates it even while criticizing it. It is wonderful to hear that a woman who is pregnant is “…performing a normal physiological function for which her body is beautifully made.” But then: “…things can go wrong.” And then, a paragraph later: “…thinking in terms of risk is…dangerous. It is a self-fulfilling prophecy: if doctors continually remind a woman of risk factors and all the disasters that may be just round the corner, after a while she is bound to lose confidence in her body and see it as an enemy, rather than something through which she expresses herself by giving birth” (7). Once the author begins describing the advantages and drawbacks of tests and procedures, covering the interventions she believes women should know about, she becomes bound by technology’s promise to tell us more than we can ever find out by ourselves. If amniocentesis reveals approximately 400 genetic conditions, the very fact that it exists and offers an “acceptable” kind of information makes it hard to resist. To decide against it means rejecting information we are encouraged to absorb, which sets a woman against herself (and sometimes her family and practitioner). Once chosen, the procedure can cause worry both before and after receiving results. Some women can take in just the kind and amount of information they need. Others may not be sure when they will have read more than they ever wanted. When in the learning process does knowledge nourish, when does it undermine women’s confidence? (Rothman) When do women begin to internalize the medical model of birth while in another part of their psyches the inner voices and dreams of a woman-centered birth endure?
A Wise Birth
Even a book as promising and insightful as A Wise Birth (AWB) by Penny Armstrong and Sheryl Feldman (1990) undermines its own powerful message by bowing to the modern demand for “scientific proof.” This is not a childbirth preparation book but an amalgam of personal observations and an analysis of the current obstetrical system. The authors bear consistent, compassionate witness to the Amish women’s calm, grounded strength as they labor and give birth at home, and make it clear that pregnancy and birth, like sexuality, dying and death, are potent states of being and transition which escape most attempts to measure, tame and control them. They depict birth in words and concepts more poetic than we are accustomed to reading: “Birth is infinitely dynamic. We can not adequately understand it by naming anatomical parts and describing physiological processes, nor are we done when we describe its choreography. Birth functions in the context of mind and spirit. They act directly on birth and give it the complexity we associate with life. When we acknowledge this, we invite the power of birth” (50).
Even after this tribute, they suggest that it might be useful to justify and quantify precisely the kind of knowledge and experiences they have vividly described as by nature not quantifiable. They discuss the “language of combat” (83) that has evolved in answer to the systematic obstetrical suppression of midwives, not pointing out that this “combat” comes about precisely because the families upset and hurt by such suppression come into conflict with the prevailing obstetrical ethos and are forced to do battle. They claim that “the language of combat” diminishes the likelihood that midwives’ view of birth will be given serious consideration” (83) by the general public and, we might add, by the medical establishment. They then raise the issue of the verification of the effectiveness of midwifery: “The midwives showed that they could deliver babies very successfully under the worst of circumstances, but they did not, in fact, put forward the necessary scientific explanations for the success of the births they attended” (84). What follows is both a critique of “scientific” method (but “science” is never defined) and a sense that it is necessary to employ it: “…midwifery was a way of perceiving and assisting birth that was waiting for proof (who was waiting? one might ask). Midwives, cast by history into a laboratory that precluded much intervention, took hold of a method of birthing that worked well in that setting and kept it alive. And while they could describe some of the components that seemed to be present in easy births, they could not track precisely from cause to effect” (89).
Midwives are described as “… doers, not researchers and writers…they aren’t taught research, aren’t taught the basic tenets of the scientific method…” (186) because, the authors suggest, most don’t have the wish to do so, nor the time and money. It seems naive to believe that if midwives “scientifically” establish the effectiveness of hands-on techniques, then fewer women will have to undergo those tests and technologies that undermine women’s confidence in their bodies (187). In fact, the vast numbers of studies appearing in The Journal of Nurse-Midwifery, Birth, and many other journals that so clearly demonstrate the excellence, effectiveness and desirability of midwifery care on the whole exert negligible influence upon obstetrical practice.
Thus, the authors insist upon using one mode of proof to prove something that doesn’t really need to be proven, or, to put it a different way, that has already been proven by women to women in time-tested ways. In wondering why medical science “didn’t figure out what simple measures worked before they started up with the complicated ones” (188), they seem to misunderstand the nature and the politics of (medical) obstetrics, a baffling lack after they have spent so much time critiquing the ways in which obstetrics stifles women’s powers and controls the flow of childbirth. They say: “…we did much more than diminish women when we conducted births in antiseptic fashion. We abolished a creative force from all our lives. We took away our opportunity to witness. Not being able to feel it engulfing us, male and female…family following family, we made ourselves smaller, more finite, and less hopeful. Encountering life, we turned our backs and studied death.” (119)
Despite these strong convictions, they term the unmeasurable circumstances affecting birth as “invisible” (175) — invisible to whom? — a sure way of sabotaging their basic thesis that these are the very factors that constitute the significant, tangible and transcendent substance of harmonious birth.
Although they observe that medicine distorts the process it claims to observe “scientifically,” (87) the authors do not seriously consider the likelihood that “scientific” explanation is an inappropriate way to validate what they have learned about women and midwifery. Do they not believe sufficiently in the evidence and the critiques that they have gathered on every other page? Disappointingly, after gracefully stating that we must take on the prevailing culture by challenging prevailing medical practices, (246) the authors conclude the book by settling on freestanding birth centers as the “ideal” locale for women to give birth, combining “the best of two traditions.” (250) Though birth centers certainly can be wonderful places to have babies, they too are institutions with rules and protocols.
Do these two thoughtful, bold women feel that if, in the final analysis, they reaffirm all that they have learned attending births in the least interventive setting — the home –they won’t be credible? It seems a tame, restricted and insufficiently explained conclusion to an otherwise complex, dynamic and informative book, a book which contains some of the most beautiful prose ever written about birth.
What to Expect When You’re Expecting
Fear and anxiety permeate discussions about pregnancy and birth largely because we have had over one hundred years of crisis-oriented medical practice emphasizing risk, danger, medical intervention and control. What To Expect When You’re Expecting (WTE), by Arlene Eisenberg, Heidi Eisenberg and Sandee Eisenberg Hathaway revised 1996), a best-seller in the 1990s, is based entirely upon worry (“How This Book Was Born,” pp. 15-16). Under the guise of enlightenment it convinces women that worry is the norm. Its layout is eye-catching and attractive. It alternates between a folksy, matter-of-fact reassuring tone and a kind of truculence. It is a masterpiece of propaganda masquerading as benevolent objectivity: “Consumer advocates…are often tremendously helpful but almost as often they’re medically inaccurate, unnecessarily alarming, and/or disproportionately focused on the inadequacies of the health care profession, driving a wedge of suspicion and doubt between parents and their obstetrical caregivers” (l3) and “The three authors, each an experienced consumer of maternity care, have wisely concentrated on giving expectant parents the information that will allow them to intelligently play their central role without threatening the doctors and nurse-midwives with whom they must work closely and congenially”(14). Why should we trust these “consumers” any more than the ones they have criticized? In fact, throughout the book, the authors capitalize upon the changes and improvements brought about by the very “consumer advocates” that they have maligned above, owing much of their store of information to childbirth activists of the past forty years.
This book, a product of the late 1980s (and a best-seller into the late 1990s, having generated an industry of “What to expect…” advice books) is entirely oriented toward hospital birth. The concept of “choice” has become even more restricted. The “human” vs. “medical” birth categories remain, but gone is any notion that the obstetrical system needs to be changed. Pregnant women fall into one of three personality types (“What Kind of Patient Are You”?): One who believes that “doctor knows best?…then you probably will feel most comfortable with an obstetrician who has…a godlike aura, and an unswerving dedication to his or her own obstetrical philosophy.” Or one who wants to “run the show…and look for a physician or a nurse-midwife who’s willing to give up the starring role and serve as your consultant on the production (sic) of your baby.” Or one who wants “a practitioner who’ll put you in the position of partner…who will keep, as the number one priority, your health and the health of your baby, not some inflexible medical gospel or your whims or wishes” (23,24). Each category is restrictive, judgmental, and the last contains a hint of punitiveness directed towards the woman who dares to put herself in the second category.
From the start, with its emphasis on problems, the book medicalizes pregnancy. “Now That You Are Pregnant” — indeed, every chapter — begins with “What You May Be Concerned About.” Divided rather dryly into months of pregnancy, it highlights a vast number of anxious questions in italics at the head of each column of information. While some of the advice is good and some of the answers are adequate enough, most of them express the conventional medical point of view. For instance, a section headed “Your Weight Gain and the Baby’s Size” ends with this comment: “…when there is some suspicion of fetopelvic disproportion, the practitioner will allow a trial labor. If you progress, the labor will continue. If you don’t, labor may get a boost with the administration of oxytocin. If labor still doesn’t progress, a cesarean will usually be performed.”(205) This seeming clarity is in fact regressive, for except in some cases (rickets, polio, injuries from car accidents) “cephalopelvic disproportion” is rare. Amazingly, even now, many women are told that they are “too small” to give birth naturally, (pelvic assessment being a rite of medical control. A reader might get the idea that she is unfit to give birth naturally, when labor is actually a dynamic process, with women’s bones and muscles especially designed to open up and be moveable. “Failure to progress” itself is a catch-all term careless used. It often masks a multitude of reasons that labor may stall: The woman may be be laboring on her back without knowing that she can walk around and choose other positions. Perhaps she is too scared, tired or lonely to relax.
Although the authors mention debates about the use of various procedures (induction, forceps, episiotomies) most often they lean toward obstetrical intervention. For instance, the reasons for inserting IVs are given, and then the reader is told: “If you strongly object to a routine IV, say so. It may be possible to hold off until the need for one arises…if you end up needing one, don’t despair. (It) is only slightly uncomfortable as it’s inserted and thereafter should barely be noticed” (248). This kind of underground coercion occurs throughout the book. It permeates the discussion of cesarean births, as the authors state that “the major reason for the increase in cesareans is not bad medicine but good medicine,” (212) and urge women to be as equally prepared for a cesarean as for a vaginal birth, to “start looking forward to the birth of your baby instead of to an idealized childbirth experience,” to believe that “Any delivery (vaginal or abdominal, medicated or unmedicated, episiotomy or without) that yields a healthy baby is an unqualified success.” (215). All of these suggestions reveal the prevalence of the conventional medical point of view. Placed one after another, they are overwhelming.
The Well Pregnancy Book
The Well Pregnancy Book (WPB) by Mike and Nancy Samuels (updated 1996), one of the more positive modern guidebooks to pregnancy and birth, is also a book of the 1980s in that it doesn’t mention change. What makes this book interesting, and what makes it possible for this book to escape initially from the dichotomized or the medicalized views of preparation for birth is its authors’ holistic “new age” orientation. They begin with the concept of “the three-million-year-old mother,” the inborn body-wisdom within every woman.(5, 507) They describe some of the spiritual beliefs and cultural practices surrounding birth in other cultures. There is constant emphasis upon the mother’s comfort and relaxation and upon the value of her intuitive powers. Women are advised in many parts of the book to talk with other mothers. (7, 151, 200-201). Throughout, visuals include diagrams, drawings, paintings, sculptures and photos of mothers and babies, fertility statues and artifacts from around the world. That this book adventures in this way is one of its strongest points.
In general, the authors try to separate descriptions of pregnancy, labor and birth from discussions of medical concerns and procedures so that the reader does not constantly seesaw between health and risk. The inclusion of episiotomy in the chapter headed “The Mother’s Experience of Delivery” is an exception, as is the discussion of breech presentations within the section on Cesareans (which suggests that all breech babies will be born abdominally). Without explanation, “Prenatal Care” is conventionally relegated to a medical category brimming with descriptions of all the inevitable tests, rather than being considered as the care the woman takes of herself by eating well, exercising and becoming aware of the various events in her life that affect her and her pregnancy.
While the authors describe controversies and disagreements surrounding the use of fetal monitors and cesareans, their discussions lack clarity and focus. Trapped by the necessity of having to explain the reasons for certain obstetrical practices, even these authors get caught up in medical terminology and justification and forget to separate fact from theory. “More than ever,” they say, “in the face of increasing technology, the field of obstetrics must humanize the birth process so that the mother is confident and unafraid, and is able to participate in this primeval experience with joy and enthusiasm…such humanization is not only necessary for the mother’s comfort, but is essential to optimize the physiology of labor and delivery, reduce complications, and maximize the health of the newborn.” (508) We as readers are back where we started, with the same fallacious assumptions rampant: That the practice and philosophy of obstetrics is compatible with optimizing the flow of the birth process; that it can be separated from the use of technology; that it can be compatible with midwifery; that it can enhance the mother’s powers and confidence.
Stepping Beyond the System: The Last Three Books
The authors of these books rarely ask the crucial questions: Why should women have to “…seek far and be extraordinarily persistent?” (YBYW 108), “…do complicated detective work” (YBYW 110), “…think through alternatives in advance” (S&S; 7), negotiate, expect confrontation, be cautious, assertive, write up elaborate birth plans (which have no legal clout) and work for change (AGB 301-319)? Why does our society go to great lengths to deny almost everyone knowledgeable, compassionate care? The fact that women either have to pursue the extravagant activities these books outline so carefully, or be treated like containers on an assembly line shows without a doubt that modern obstetrics is seriously lacking.
It seems that, out of unwitting ignorance and a kind of generalized caution (“Don’t you want a healthy baby? Don’t you care about your baby? What if something goes wrong?”), the very people who have been instrumental in bringing to light women’s needs and desires for humane childbirth and identifying the indignities of the obstetrical system have lost sight of any powerful alternative to the present system. Childbirth educators owe women the fruits of their knowledge by carrying their analyses of the conventional obstetrical system to the logical end – the creation of a midwifery-based, women-oriented maternity care system.
It becomes so important, then, to recall what women can accomplish when they give birth on their own turf, on their own terms. It is not necessary to invent a vision of what true woman-centered childbearing could be. Some people are keeping this information alive, learning from “a worldful of women who have assisted one another at birth.” (AWB 146).
These authors step outside the system. They remove themselves from the modern “obstetrical gaze” (Arney) by learning about childbearing practices and politics of other cultures (Newton, Jordan, Kitzinger, Ashford), by gathering and describing midwifery techniques, experiences and philosophies (Baldwin, Gaskin, Davis, Steiger, AWB, Holmes) and by going to the very heart of birth to listen carefully to the stories women tell (Lang, Gaskin, Odent). In this realm, “Women’s culture, when it disentangles itself from the medical monoculture, is so rich, so full of variation and interesting detail…women (give) birth in ways totally unknown within hospitals.” (Jutta Mason, “The Meaning of Birth Stories,” The Birth Gazette, Vol.6, No. 3, pp. l4-19).
For instance, in A Wise Birth, we read about the matter-of-fact births in Amish homes which take place in an atmosphere of peace and quiet, with “power…grace and simplicity.” (34) Sometimes the authors use language that may sound extravagant and flowery, but it succeeds in capturing the wealth of information that women take in through all their senses. It is poetic, using metaphor and the words of everyday life lived intensely. It is blessedly free of medical terminology.
The midwife talks about a birth: “Later she got back on the bed and not too long afterward we smelled the burst of sweat that marks the beginning of the pushing phase of labor…the ligaments and tendons, warmed by the vigor of labor and pressured by waves from the contracting uterus, eased out…”(19) “Penny, one hand on a woman’s knee, has seen (power) steal into a lackluster labor and radiate a child out. I felt it erupting in me when I had my children. It sounds in our bodies.” (20). “The subtle moves of muscle and bone…” (49) “Seeing birth work well, seeing that women generously attended abide its pain and rejoice in its fruition, we remember that nature wants her young.”(24) The authors mention episiotomy: “It is shocking to see vibrant muscle cut…maybe we don’t think of these women’s muscles with the same regard (as male athletes’ muscles) because of where they’re located. We don’t see them crossing and gliding as they make our hips swing; we don’t watch them spreading into broad ribbony bands when we squat down. We don’t imagine them roiling with sex. Because we can’t see them, maybe we think of them as static…but I have seen the muscles in women…when the cut was made across three or four major muscle groups, I’ve seen them retreat and lie there…the music of the body, the resonance and the potential for rapture are interrupted.” (39)
And finally, “We do not woo women into giving birth. We do not trail our fingertips on the beds we’ve made up, anticipating their coming. We do not bake their favorite bread, pick flowers, hurry down the path to greet them, settle down with them, and ask them about their trip…We do not touch them, rejoice in them, admire them, laugh with them, or stand by them. We do not treat them as if they were all our daughters, whom we have adored and who are taking up major work…we have chosen to show little love.” (236)
A French midwife speaks in Birth Reborn (BR): “…Let the roles be reversed!..I’m listening to you. What are you feeling?..Talk to me, teach me…I can sit back, listen, be part of an intimate act. The woman is standing. She lets me know what’s going on: that she feels changes in her body; that she wants to push; that she has to open a bit more; that the membranes full of waters are bulging between her fingers…She expresses her feelings…that I’m not always as gentle as she would like me to be; that she wants it to be over; that she wants to scream; that she is going to do it. I hear her as she cries out, and I no longer try to quiet her. She becomes my teacher…I myself am also pregnant…with her words, her pains, her strange cries which even she does not recognize as her own…She is creative, inventive, full of life…She is exhausted and yet so vital. As she throws herself upon me, I am covered in her sweat. I am obliged to do as she wishes. But she is beautiful, she is the life that she is about to bring forth.” (113).
This language of feeling, compassion and sensuality expresses an awareness and a form of skilled knowledge practically unknown to the medical world, or if encountered there, devalued, vitiated or ignored. It focuses upon the humanity, womanliness and strength of the mother. It relegates pertinent medical knowledge or occasional intervention to the ancillary place where they belong.
Birth Reborn (BR) by Michel Odent (deliberately and proudly “unrevised,” 1994) serves as a bridge between two worlds. It tells the story of how practitioners in a hospital setting unlearned many of their medicalized attitudes by paying careful attention to the women who came to give birth at Pithiviers. “For both men and women, childbirth was an intense, intimate, all-encompassing experience. As the doctor, I was far from the central figure in the drama; at times I even felt like an intruder…” (6) Little by little, midwives and doctor alike significantly altered their philosophy and practice. Increasingly, they questioned their most accepted procedures, one after another, and discovered that breaking the amniotic sac, wearing rubber gloves, and using high tables and bright lights for deliveries hindered the concentration of women in labor. They began to see themselves as “facilitators…whose task was to intervene as little as possible…” (7) To disturb the physiology of labor is to hinder the body’s natural powers. (14-15) Many photos in the book show women intensely concentrated upon their labors, close to their partners or the midwives assisting them. Women’s and midwives’ stories give the text depth.
Discussion of obstetrical interventions occurs only toward the end of the book in a chapter called “Anti-Obstetrics.” Women who would automatically be labeled “high-risk” in the U.S. generally have few problems at Pithiviers. “We have had at least our fair share of difficult cases. Yet for nine out of ten women who give birth at Pithiviers, warmth, calm, quiet, freedom of movement, and the presence of sensitive birth attendants are sufficient to insure a smooth progression of labor. Indeed, the harder we expect a labor to be, the more we pay attention to the quality of the atmosphere.” (94) The attendants’ dedication to helping women give birth on their own determines when and how they intervene should a problem arise. Since every woman’s situation is different, there is no standardized pattern of intervention. (94) Amniotomies, episiotomies and cesareans are performed only when absolutely necessary.
Yet, a caveat: While the climate at Pithiviers offered choices unavailable in conventional hospitals, it exerts subtler forms of coercion. It is no accident that “Most women…give birth in supported squatting positions,” (BR 47) considered by Odent to be the most physiologically and psychologically efficient. (Midwives attending home births often find that women give birth most comfortably lying supported half-upright on a bed). While this sort of pressure is relatively benign, other expectations can become oppressive. An emphasis upon finding alternatives to medicalized birth may mean reintroducing very old ideas into modern culture, as when Odent speaks of restoring women to their “proper, central place” in childbirth (12) by letting – nay, expecting – them to “forget” themselves and undergo changes in their level of consciousness in the “salle sauvage” (the “natural room”); as when he mentions the beneficial role that relaxation, endorphins, human touch and warm water play in labor. While this approach can be empowering, note that once again that a man is once again presenting an ideology of birth. Beliefs and practices that seem radical and liberating at the outset may become as prescriptive and controlling as medical interventions. Once they become the “Way” and freeze into dogma, they will inevitably fail to correspond with some women’s needs and desires, as all women are different.
In her vehement critique of French in-hospital prenatal programs designed to spare women pain during labor (Ces Hommes Qui Nous Accouchent…, Libre Expression, Stock: Canada, 1982), Marie-Jose Jaubert points out that often women are forgotten in the attempt to promote the effectiveness of a given ideology. Even in the most benevolent of circumstances certain methods may work only up to a certain point. If a woman becomes too tired or feels too much pain and thinks that what she has prepared or what is expected of her isn’t working, she may feel she has failed. “Each method becomes a trap which closes upon the woman (108). It is important to question the intent and efficacy of any structured alternative.
Toward the end of the book Odent asks: “What is a man’s proper role in a movement that seeks to return the childbirth experience to women?.. Presently I am seriously considering leaving obstetrics…male obstetricians would do well to retire progressively and restore childbirth to women.” (118) He continues: “How women give birth and how children are born are profoundly tied to our views of nature, science, health, medicine, freedom, and human — especially man-woman — relationships. Our ambitious project, which struggles to humanize and feminize birth, uses very simple means to achieve this end. In fact, the local women who have given birth at our clinic refer to our style of doing things as common sense. These women find our attitude so obvious that they can’t imagine what so many visitors and film crews are doing here. Their astonishment is worth thinking about.” (118)
The Birth Book and Spiritual Midwifery
The Birth Book (BB) by Raven Lang — out of print — and Spiritual Midwifery (SM) by Ina May Gaskin (1990) — in its third edition — are internally consistent, positive and passionate. Both books describe births occurring in two closely-knit rural communities, the first one located in Santa Cruz County, California in the early 1970s. At that time, a number of young women wanting natural births could not find obstetricians or hospitals that would support their wishes. Raven Lang helped start a Birth Center. She and other women began attending mothers in their homes, assisted by a sympathetic doctor friend when necessary. The second community is The Farm, started in 1970 by Stephen Gaskin and still going strong. During its cross-country caravan from California to its home in Tennessee pregnant women inevitably gave birth along the way, and Ina May Gaskin, out of inclination and necessity, became a midwife. Other Farm women also learned midwifery skills, and over the years the midwives developed a mutually satisfactory relationship with a local doctor.
Both books combine birth stories with information about pregnancy, labor and birth, the entire second half of SM consisting of “Instructions to Midwives.” What stands out in all these tales is the sound of each participant’s voice, one after the other, detail after detail, a collective chorus of events and emotions that make up the event of birth. The women speak of exaltation, fear, determination, effort, learning about themselves; of momentary lapses, pulling themselves together, of hard work and giving in, of contentment, amazement, ecstasy. The men participate as much as they can, watching, empathizing, helping (and sometimes hindering) them. The reader follows the individual course of each labor and birth, often seeing it from several viewpoints — the mother’s, the father’s, the midwife’s. Neither book glosses over difficulties. Depending on the circumstances, birth is presented in all ways — as simple or complex; as needing only patience and abundant good feeling or (rarely) as needing, in addition, some sort of intervention; as happy, or as sad in the very few instances when babies are stillborn or die soon after birth. Throughout, these mothers and fathers speak with energy and enthusiasm, with a desire to know themselves well and do the best they can, and, often, with a sense that, during labor and birth, they were connected with powers beyond themselves.
A word about the two books: The Birth Book was truly a book of the early 1970s. It existed in one trade edition, went into several printings and passed too soon out of print. It possesses a rare vitality and ingenuity. Well-produced, it has the feel of grass-roots effort and inspiration and bespeaks an optimism hard to come by nowadays: “We have been asking and asking the people in positions of responsibility to respond to our needs and the needs of our children. Now we realize that we must do more than just ask, so we have chosen to act…(joining) hands in a struggle for human birth.” (Introduction) It contains photo after photo of families and of women giving birth in many different positions. And simple statements: “I think what got to me the most…was that there was no break…I remember feeling, if I could of just had fifteen minutes ‘off’ I could have returned with better breath control. (Judy) “I could never accurately describe the power of those contractions except to say that it’s the same type of power that brings the sun up in the morning.’ (Estelle) “I felt whole – like a seed – I even felt like the shape of a seed.” (Emily)
SM has a similar spirit and strength. Farm women and midwives sometimes speak in a language of their own, expressing the transcendence of birth. One midwife in resuscitating a newborn says: “As “I squeezed his heart, there was a time when he was grunting very shallow, and I saw this pink aura of light come out from his heart and all these waves of ecstasy were going from my heart to my head.” (103) A mother describes labor: “Mary Louise came over and put her attention totally to me. She and I swapped bodies…she…did a few contractions for me. I found myself in a beautiful place with a green field and a house…a place I’d never seen before.” (73) Another mother: “I started to push hard on the baby to get him out. I made a lot of noise. I remember telling them that the louder I talked, the better I felt. Ina May was sitting right in front of me between my legs, and her face looked really clean. She talked to me in a real calm, even voice and showed me what to do with all that energy…she said ‘If you be really graceful, the baby will come out gracefully.’ That was a helpful one.” (176)
In both communities, women’s wishes, strengths and skills were the focal point. No one questioned that women would give birth as they wanted. Having to choose at the outset between a “natural” or a “medical” birth was not an issue. Pregnancies, labors and births progressed as they would, most often organically and naturally. When it turned out that women needed medical help, they made dignified decisions out of a necessity that they recognized. Their wishes and their rights were not violated. They remained whole.
Such a climate of confidence can exist in these tiny pockets because midwives and women devoted to midwifery supported women and midwives who believed in their own powers. Each community was supported in its efforts by at least one medical person who served as liaison with the local hospital. But when the midwifery practice threatened the medical establishment in the Santa Cruz area, doctors harassed the midwives, accusing them of practicing medicine without a license, and causing them to be arrested and brought to trial. As long as competition exists between obstetricians and midwives, women will be victims of this rivalry.
Women acquire knowledge in different ways. Niles Newton asks: “Why don’t we prepare women for the experiences of childbearing through giving them the type of information that their own great-grandmothers usually had available to them?” (“The Point of View of the Consumer,” Newton on Birth and Women, Seattle, Washington: Birth & Life Bookstore, 1990). Speaking of our silent grandmothers of today, “without birth stories” and of the essential questions about life and womanhood that go unanswered, Armstrong and Feldman say: “Women today take for granted the absence of the word. They must think it is the way life is, this having mothers who cannot describe what it’s like for the human female to bud, break and bear fruit. (They don’t know) that in other times the traditions of birth simmered, making the very aroma of women’s lives, that women tended each other in their homes and huts, chanting or singing hymns, preparing broths and hot cloths, oiling, massaging, whispering, giving instruction; that they slept by one another’s beds in chairs, prepared food, consulted in kitchens, entangled arms and legs, washed the living, dressed and buried the dead; that the dramas of birth staked women’s lives and lore unfurled from them.” (AWB 92)
If women cannot live on such intimate terms with birth as they used to, a second way of learning is by talking and telling stories (minimized and dismissed by doctors as “old wives’ tales”). Discussing prenatal care Sheila Kitzinger suggests that “What many women feel they need most…is the chance to talk to knowledgeable and understanding women who have first-hand experiences of pregnancy and birth” (YBYW 113). “We use information passed on by word of mouth,” says Shafia Monroe, a Boston, Massachusetts midwife. “I teach midwifery, and how to be a parent, how to give birth, by talking. We give information by paper, but we do most of our stuff hands-on, touching and talking.” (“Lay-Midwifery: The Traditional Childbearing Group,” Interview with Evelyn White, Sojourner, March 1991, p. 2H). Women have all kinds of quirky, local, personal experiences, and say the kinds of lively, poetic, raunchy and delicate things to each other that can rarely be found in books.
A third way of learning is through reading, watching videos and surfing the Internet. Almost every book or magazine contains useful facts and insights which inform and empower. They have the power to bring us imaginatively in touch with other women. Yet, paradoxically, they can also reinforce isolation, as each of us reads or watches at home. With the increasing proliferation of voices that occur in no particular community context, it becomes hard to know how to evaluate available information — what to keep, what to discard.
The assumption that knowledge is power fuels most childbirth books. This idea is true only up to a point. Different kinds of knowledge impart different degrees of power, depending on the circumstances and the complex dynamics between the people involved. A woman who has given birth several times at home might feel helpless in the turmoil of a big city hospital. Another woman who has gleaned what she could from twenty books may be undone by an unexpected event during labor. Most obstetricians will accept only a certain number of questions from a pregnant woman before feeling impinged upon. Even when a physician remains relatively open, limited time will be a factor (this will be true for almost all practitioners, midwives and doctors alike, who work in busy practices). Kitzinger has pointed out that there is built-in inequality between a doctor and a woman (YBYW 7, 105, 155) who by definition has become a “patient” — especially if the doctor is a man. The two may have conversations — indeed YBYW, AGB and S&S; provide readers with “model” dialogues — but rarely if ever in reality does it become a dialogue of equals.
Michel Odent has noted that many women arriving at the birth center at Pithiviers already in labor needed to know very little outside of themselves: “These women…seem quite calm about going through labor…” (BR 22). At one conference (New Hampshire, after the publication of BR in 1984) he mentioned that of the two midwives who attended births at the clinic at that time, both mothers themselves and “not too young,” it was the one who didn’t talk a lot, who had “nothing to say, nothing to teach” who was chosen most often by women in labor.
Were women in the U.S. to enjoy this kind of care they would not have to prepare and protect themselves so thoroughly. On the one hand, it is not right for them to go into hospitals unprepared. Yet it is unreasonable and unkind to suggest that they cram into their minds all the facts they can manage to retain, and to suggest that an individual can take on the system at such a physically, emotionally and spiritually vulnerable time. Such an expectation places a huge burden upon them. In a realm where surprises abound, women will never be able to foresee all possibilities.
Then there is the issue of class. The women who read these books are almost all middle-class. If even at this level of resources, sophistication and opportunity women cannot exercise genuine choice and feel humiliated by the system, then what is happening today to the women of color, economically disadvantaged women, and all women in the public hospital system of this country? Very few authors go beyond the realm of pregnancy and birth to address social and economic issues. Sheila Kitzinger is an exception: “…poor mothers and babies face greater danger than those who are well off…social factors have a greater influence on pregnancy and its outcome than anything (doctors) can do…In all Western countries the highest rates of death and sickness occur in the babies of working-class mothers and of recent immigrants from Third World countries.” She quotes Ann Oakley’s statement that to reduce social and economic disadvantage is to improve perinatal mortality and morbidity (YBYW 100).
For the past sixty-five years these facts have been well-documented in government reports, public health and social science studies and documents. An apolitical middle-class pregnant woman seeking an appropriate practitioner might well wonder at their relationship to her search. She might be interested to learn that the crisis-oriented, medicalized care deemed necessary for women in ill health because of poverty is the same kind of care she is being introduced to and warned about — the same kind of care that childbirth educators, authors and most women have struggled against and increasingly accepted over the past decade.
Which leads to a number of questions and challenges for authors of childbirth preparation books and videos: To what extent does each one of us believe that the system must be changed? To what extent, if any, can and do our books change the existing obstetrical system? What kinds of books make the most impact, and on whom? Does it make sense to try and educate one side of the equation — women — when we do not affect the other side — physicians — by our efforts? Can we influence obstetrical conditioning at all? How? To whom are we being genuinely helpful? How can we even think of improving maternity care for some and not for everyone? How can we be responsible to the majority of women who don’t read books at all? How can we promote midwifery effectively? How can we develop a strong force for change when our constituency changes constantly as pregnant women have their babies and, leaving childbirth concerns behind, go on to live their lives? How can we influence and improve maternity care policy on local, state and national levels in ways that really make a difference? What fears and constraints make us hesitate to go too far? How can we help each other address these issues and find answers to these questions? I believe that it is essential for advocates of childbearing reform (and revolution) to ask these questions and others like them.
Most people in the U.S. see maternity care only as a medical concern. Yet women’s interests have been inadequately served by medicine. The work of childbirth activists, in response to the dreams of women-centered birth that endure in women’s psyches, bears witness to that fact. One way to develop a view of a world in which excellent care becomes possible is always, in our theses, projects and books, to begin by imagining and depicting the creation of a midwifery-based maternity care system. This effort can change our consciousness. It carries us beyond “outcomes,” “infant mortality,” and “prenatal care” to look at the larger picture. It requires us to envision a society dedicated to the nurturing and enhancement of every life born into it. It leads us to realize that all of us must have adequate food, shelter, health care, education, job security, and physical and emotional safety; that poverty, racism and war must be eliminated; that birth must be considered as a natural, spiritual event of life, an intimate family experience; that women must freely choose to have their babies wherever they feel most comfortable, with the attendant of their choice; that women must control their procreative lives; and that practitioners must value women’s physical and spiritual integrity and the mother/child dyad. This is the starting point, this is a worthy goal. This is the vision to keep in mind. In this world, woman-centered childbearing would thrive.