Feminist critiques on the state of modern birth focus on how the transference of birth out of the home and into the hospital has medicalised the event and removed a woman’s agency to direct her birth experience. While being true to an extent, it does not allow for the influence of our social constructs of gender identity and how we, as women, have been ingrained to birth.
Rational, selfless, caring, polite, and kind.
Or
Screaming, yelling, self-centered, and demanding of pain-relief.
Which is an accurate portrayal of women birthing today in the United States?
The media would lead us to believe that the latter is more common however, Martin (2003) has argued that we have internalized our roles as women to such a degree that even in the throes of childbirth, many women are more concerned about those around them than they are about themselves. We have internalized our gender roles so deeply that we birth in “gendered ways from within” (Martin 2003).
Childbirth classes teach women methods of self-control and relaxation. Martin (2003) argues that the Bradley Method, teaches us that when we get to a point where we cannot take it any longer, our partner, our husband, the father, is our protector and will show us how to birth, and give us the strength to birth.
Understanding the way we birth, in the context of a technology of gender,[i] helps us to understand why so many women do not “ask what they need while giving birth, and/or … put themselves at the center of the birth experience” (Martin 2003). Martin argues that
“[w]hen these gendered technologies broke down, usually during the most exhausting and painful parts of labor, these women said that they felt bad about their behavior, and they often apologized for it. Furthermore, in the end, some of these women did not value their own lived experiences and found their husbands' or doctors' views of the birth more "real" than their own.”
Robbie Davis-Floyd (1987), in her essays on “The Technological Mode of Birth,” identifies that 54% of women seem happy about their birth experiences in hospitals. They are more comfortable with the interventions and, she argues, American women may even feel slighted out of their birth-right if they were not given access to the technologically prescribed modes of childbirth (see below).
This ideology that birth “happens to us” is prescribed by our embedded, gendered experience of childbirth. We enter the hospital to be sick, to be taken care of. Childbirth has become an illness to be treated.
Cultural Patterns in Childbirth
The above is an introduction to how we, as women, birth in hospitals today. There are, however, some generalizations that can be made around birth itself. The following is an observation made by Simmons (1952) from a cross-cultural comparative study on childbirth:
“1. All peoples everywhere tend to regard birth as a significant biological event and ritualize it somewhat accordingly.
2. All peoples recognize certain critical psychological implications for childbirth. Primitive people tend to stress the psychosocial even more than the physical, while we do the reverse. We moderns are waking up, however, and perhaps we can learn a great deal from our primitive contemporaries.
3. The psychosocial factors of birth are under better-almost automatic- regulation in stable societies with slowly changing cultural patterns.
4. Babies are amazingly malleable and adaptive in almost any set of consistent, stable cultural patterns.”
A woman entering a hospital today undergoes a ritual. Robbie Davis-Floyd (1987), in her definitive essay on “The Technological Model of Birth,” describes this ritual initiation as it occurred in an American hospital in 1987.:
Shortly after entry into the hospital, the laboring woman will be symbolically stripped of her individuality, her autonomy, and her sexuality as she is "prepped"-a multistep procedure in which she is separated from her husband, her clothes are removed, she is dressed in a hospital gown and tagged with an ID bracelet, her pubic hair is shaved or clipped (returning her body to a conceptual state of childishness), and she is ritually cleansed with an enema. Now marked as institutional property, she may be reunited with her husband, if he chooses to be present, and put to bed. Her access to food will be limited or prohibited, and an intravenous needle may be inserted in her hand or arm. Symbolically speaking, the IV constitutes her umbilical cord to the hospital, signifying her now-total dependence on the institution for her life, telling her not that she gives life, but rather that the institution does. The laboring woman's cervix will be checked for degree of dilation, at least once every two hours and sometimes more often. If dilation is not progressing in conformity with standard labor charts, pitocin will be added to the intravenous solution to speed her labor (80% of the women in my study group were given pitocin, or "pitted"). This "labor augmentation" indicates to the woman that her machine is defective, as it is not producing on schedule, in conformity with production timetables (labor time charts). The administration of analgesia and/or anesthesia further demonstrates to her the mechanicity of her labor; epidural anesthesia, which can numb a woman from the chest down, produces an especially clear physiological separation of her mind from the body-machine that produces the baby. This message is intensified by the external electronic fetal monitor, attached to her body by a large belt strapped around her waist to monitor the strength of her contractions and the baby's heartbeat.
As the moment of birth approaches, there is an intensification of actions performed on the woman, as she is transferred to a delivery room, placed in the lithotomy position, covered with sterile sheets and doused with antiseptic, and an episiotomy is cut to widen her vaginal opening. These procedures cumulatively make the birthing woman's body the stage on which the drama of society's production of its new member is played out, with the obstetrician as both the director and the star”
We can be thankful that many of these practices have evolved since then and most women’s experience of birth is much more humane. One thing that hasn’t changed is the focus on the all the machines that monitor our birth and make sure we are OK, even though nurse-midwives are widely available. The bed in a hospital labour and delivery unit stands proudly at its centre. In most hospitals, nurses provide the bulk of labour care mothers receive, the doctor, the hero, steps’ in for the final solo. He is the star of the show as the baby crowns, he catches the baby, thrusts her onto her mothers chest, and leaves the room.
Women today have lost their agency in their childbirth experience. Sargent and Bascope (1996) provide a comparative analysis of birth in the three cultures, two in hospitals (one in Jamaca and one in Texas) and a homebirth practice among the Maya in Yaxuna, Mexico. It is this latter group that draws an interesting comparison to the “ritual” of birth in America as described by Davis-Floyd.
Sargent and Bascope introduce us to a lay midwife (Dona Lila) and give us a very different view of agency and knowledge over birth. Dona Lila is a traditional midwife who is trusted by her community because of her experience through attending births. Her knowledge is observational and every woman in the village, more or less, has control over the same information of how birth happens. Dona Lila is set aside because of her privileged knowledge on cord-cutting and the use of pitocin for labour stimulation.
In this community, knowledge about birth is shared by women through their mutual experiences. A mother who has given birth repeatedly is considered to be as knowledgeable as the midwife and has autonomy over her birth. The midwife is there to perform a few procedures that are considered her domain or require special knowledge. Conversely, a mother who is birthing for the first time receives many more interventions and active management of her labour, including considerable fundal pressure, manual stretching of her cervix, and the use of pitocin to augment her labour (Sargent and Bascope, 1996).
Though both first time and more experienced mothers give birth in a traditional position, seated on a hammock with the midwife in front to receive the baby, mothers birthing for the first time receive many more interventions and active management of her labor than mothers who have birthed repeatedly. We can see how a woman’s knowledge of birth influences how she is treated, even among “traditional” societies[ii].
The comparison between the birth experiences of Mayan mothers and the ritual of American birth, as described by Davis-Floyd is important insomuch as woman in this Mayan village gain agency over future births by being initiated through their first birth. American women tend to have repeat experiences without much differentiation by hospital staff between the number of children the patient has birthed. Each mother’s experiential knowledge of birth is minimized and diminished below that of the physician. Martin (2003) confirms this however, she identifies that working-class women were more likely to make changes in subsequent births how their birth was managed, compared to women of higher social standing.
Positions in Childbirth
So how have women given birth historically and in different cultures?
A question arises regarding whether women birth the same today as their sisters of the past, and around the world. We all our influenced by our culture, but did ancient societies protect the culture of birth? Were their technologies of gender different than ours?
In 1884, George J. Engelmann published Labor Among Primitive Peoples. This is a thorough account of all the knowledge that we, as a modern society, had learned, culminating in the current obstetric practices of Engelmann’s time. It contains all the previously catalogued birthways of indigenous cultures or “primitive peoples”.
Engelmann documents the parturition, birth, and management of the third stage as observed in cultures from all around the world.
“…I had entered upon the study of the posture occupied during labor by the women of other people, I found a great variety in their customs; but it soon became evident, and impressed itself forcibly upon my mind, that the recumbent position in labor is rarely assumed among those people who live naturally and are, as yet, governed by their instincts and have escaped the influence of civilization and of modern obstetrics. It certainly appeared as if the ordinary obstetric position of to-day must be an unnatural one…”
He classified the birth positions he observed into the following:
A. Perpendicular:
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1. Standing
2. Partially suspended.
3. Suspended.
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B. Inclined:
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1. Sitting erect on stool, cushion, or stone.
2. Squatting, as in defecation.
3. Kneeling.
(a.) With the body inclined forward, and resting on a chair or staff.
(b.) Knee-elbow position, knee-breast, or knees and hands.
(c.) With the body erect or inclined backwards.
(d.) Not definitely described.
4. Semi-recumbent.
(a.) Sitting semi-recumbent on the ground, a stone, or stool.
(b.) On the lap or between the thighs of an assistant who is seated on a chair or on the floor.
(c.) The obstetric chair.
(d.) Semi-recumbent positions, strictly speaking.
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C. Horizontal or recumbent:
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(a.) On the back.
(b.) On the side
(c.) On the chest and stomach.
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In 1966, the British Medical Journal documented at least forty different postures women have adopted to give birth across various cultures. The author gives us points of considerations for optimal positions in labour which include: comfort of the mother, a position that does not impair the dilation of the cervix or expulsion of the baby, reduction to minimize harm to baby and mother, and lastly, ease of access by birth attendants.
PERPENDICULAR OR UPRIGHT POSTURE
Standing - common in Eastern, in India and parts of Africa.
Partially suspended
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| Brulé Sioux. Standing |
The standing posture may increase the risk of hemorrhage, prolapse of the uterus, and rupture of the perineum.
Most often a strong person supports a mother from behind and holds their arms, while others hold the separated legs, and the midwife can sit comfortably in front.
A variation seen amongst the groups along the eastern coast of India and in the vicinity of Madras, are delivered in an erect, standing posture, supported by an assistant under each shoulder.
Partially suspended
This can be seen to occur in a variety of ways, including the woman hangs on the neck of a husband or friend, swing themselves by a rope from the branch of a tree, or are tied up until the act is over, as if undergoing “punishment”.
Suspended
Engelmann provides several examples, including hanging on to the limb of a tree (Africa), hanging to a cross-bar (Finland), in Brazil, the parturient woman occasionally has her arms tied to a tree while she is waited on by some “old hags” until the delivery is completed.
INCLINED POSITIONS
Engelmann (1884) notes that this position for birthing is the most common among “civilized and savage” people, in both ancient and modern times.
The erect, sitting posture.
The pelvic axis is more inclined than in the standing posture. Englemann notes that women in this position make use of cushions, stones, stools, or “mother earth herself”; but the temptation to assume a somewhat reclining position, leaning against the assistant or some other support, that quite often women assume a somewhat reclining position.
The squatting position
The squatting position
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Squatting
Posture
of the
Tonkawas.
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The Irish were identified as also using this natural position, although the knee-elbow position is more common among them. Englemann notes a story where a poor Irish woman was found in a vacant lot in New York city, squatting on the ground, birthing her placenta, having already been delivered her baby in the same position.
Variations:
“during the first stages of labor the woman is in a stooping posture, with the buttocks resting on the heels. An assistant places herself back of the patient, clasping her body with her arms, letting the fingers reach below the ribs over the base of the uterus, making steady pressure backwards and outwards during the pains. During the third stage, or expulsion of the child, the patient, however, lies down indifferently on either side or on the back, while the pressure by the hands of the assistant is kept up continuously, if on the side; if on the back, the assistant remains by the side of the patient and keeps up the pressure in the before-mentioned directions.” In Mexico, they “sometimes suspend a cord from the ceiling, with a stick attached, so that the women can seize it in a half-upright, squatting position” The Zuñi women of New Mexico are delivered in this same position, which we may call a squatting one, and which is described to me as “half standing and half sitting;'' an attendant supports the patient, and facilitates expulsion by pressing the abdomen from above downward.The kneeling posture and its modifications
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| Southern Negress. |
· Hands and Knees.
· The body inclined forward.
· This position overdone; that is, with the body thrown completely forward, the patient resting on the hands and knees, or knees and elbows.
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Position for
Delivery
of very Fat
Women
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· Kneeling postures, where precise descriptions are lacking.
Kneeling has been referred to in the Bible as well as by the Roman poets. Englemann notes that kneeling was taught in ancient Rome, among the Arabs, and in Germany during the Middle Ages, and that there were definitive rules for the circumstances under which kneeling should be resorted to, suggesting that it was reserved for complications of birth, not normal birth. However, Englemann remarks that it is one of the most universal positions among Native Americans.
There are advantages and disadvantages to this position in that it is physiologically correct, and “appears most practically to favor the expulsion of the child”, however, it may increase the risk of hemorrhage.
Semi-Recumbent
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| Favorite Posture of the French Canadian |
The semi-recumbent positions are by far the most frequent among ancient cultures, especially among what Englemann calls “the more civilized people” of olden times. However, it is also a documented position used among many indigenous cultures of the present day.
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| Kaffir Woman in Labor |
In the position seen among the Kaffir a woman has full power to bear down and assist her pains. However, in this position, no support can be given to the perineum, Englemann suggests that there must be some “support given to the perineum from its resting on the firm floor of the hut, and the sudden passage of the child's head is thereby prevented.''
The simplest of the semi-recumbent positions may be where a mother is sitting on the ground, on a stone or cushion, with her body inclined backward, leaning against an assistant, a tree, or some other object.
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Oronoko Indian.
Seated semi-recumbent
in hammock.
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Alternatively, a woman may be seated in the lap of an assistant reclining against their chest. Englemann argues that the position reaches its greatest perfection in the obstetric chair.
HORIZONTAL OR RECUMBENT
Typical obstetrical position. Engelmann admits:
“not until I had undertaken this work, and had begun to study the positions assumed by savage and civilized people during labor, that I began to understand that there was a method in the instinctive movements of women in the last stage of labor. I had seen them toss about, and sought to quiet them; I bade them have patience, and lie still upon their backs; but, since entering upon this study, I have learned to look upon their movements in a very different light. I have watched them with interest and profit, and believe that I have learned to understand them. It has often appeared to me, as I sat watching a tedious labor case, how unnatural was the ordinary obstetric position for one parturient woman; the child is forced, I may say, upwards through the pelvic canal in the face of gravity, which acts in the intervals between the pains, and permits the presenting part of the child to sink back again, down the inclined canal. If we look upon the structure of the pelvis, more especially the direction of the pelvic canal and its axis, if we take into consideration the assistance which may be rendered by gravity, and, above all, by the abdominal muscles, the present obstetric position seems indeed a peculiar one.”
Where are we going?
Engelmann’s observation reflects the nature of a woman unencumbered by our technologies of gender that prevents us from trusting our instincts and birthing in the positions, moving the way, and making the sounds that aid in the birth our children.
Above is only a brief synopsis of the more than 62 positions that have been described throughout history and throughout the various regions, cultures and groups of people that have inhabited earth. We, as midwives, need not learn all these positions, but be aware of the breadth that exists. Not inhibit a woman’s movements in labour and instead be there for her, ready to receive or aid in her or her partner receiving their baby for the first time.
As early as the 19th Century, Engelmann identifies the unnatural state of the obstetric mode of delivery. That it’s only purpose is to facilitate the comfort of those attending a birthing woman, to the detriment of the process. He repeatedly highlights the practicality of traditional birthing positions, despite their crude or primitive nature, over the modern obstetric lithotomy position. Engelmann, in 1884 recognized that women in civilized society were bound by their technologies of birth that were engrained in them to be refined and proper. He saw not only the futility of this, but how these restrictions on women actually impeded the birth process, making it more difficult. He offers antidotes of how lay midwives have measures to aid women in emergencies, that it wasn’t always safe and prolapse of the uterus, for example, was common, yet manageable. The practices of these women, birthing with freedom, prevented many hemorrhages, because within themselves knew if a position was not working, when to change. They worked within themselves, within their environment to birth.
Engelmann’s ethnography of birth is worth reading. He is eloquent in his humble regard for ‘primitive’ woman and their strength compared to the ‘weak civilized’ women who have become reliant on, as Robbie Davis-Floyd puts it, the technological mode of birth, 19th C style.
We, as midwives, should aid women to break free of our technology of gender, which may be repressing our abilities as woman to birth without the aid of obstetric interventions and inventions.
This is not to be a judgment on women and families who give birth in hospitals. Hospitals serve a purpose and have become normalized within Western society. What we can, and should, do is challenge our community’s reliance, dependence and execution of birth in these facilities in hopes of making them a space that can facilitate birth in a way that empowers women. A space that makes the woman the centre of attention and aids them in finding within themselves what they need to birth their child, rather than looking to others, wanting to please others, fearing that she did not do her job as well as everyone expected. This should be our goal within our own practices, even within a woman’s home.
[i]“Internalized technologies of gender discipline us from the inside out. They produce who we are, even during seemingly natural experiences like birth. Foucault's notion of technologies of the self allows us a sharper understanding of these gendered ways of being by showing us how they discipline and control from the inside, how they compel us to act in gendered ways from within” (Martin, 2003).
[ii]
We may question the use of the term “traditional society” here. Dona Lila had exposure to a pharmaceutical salesman who touted the effectiveness of pitocin, which the community readily accepted as it fit within their pre-existing understanding of birth, that the quicker it was over, the safer it was.
* Images are from Engelmann's 19th C ethnography and were reprinted here from the University of Virgina, with many thanks.
References Cited
Author Unknown. Position in Childbirth. 1966. The British Medical Journal, Vol. 1, No. 5479, pp. 62-63.
Davis-Floyd, Robbie E. 1987. The Technological Model of Birth.
The Journal of American Folklore, Vol. 100, No. 398, Folklore and Feminism (Oct. -Dec.), pp. 479-495
Dunes, Lauren, MHS. 1987. Public Health Then and Now. The Evolution of Maternal Birthing Position. AJPH May 1987, Vol. 77, No. 5.
Engelmann, George J. 1884. Labor Among Primitive Peoples. J.H. Chambers & Co. St. Louis
http://etext.virginia.edu/etcbin/toccer-new2?id=EngLabo.sgm&images=images/modeng&data=/texts/english/modeng/parsed&tag=public&part=all
Marten, Karina. 2003. Giving Birth Like a Girl. Gender and Society, Vol. 17, No. 1 (Feb.), pp. 54-72
Sargent, Carolyn and Grace Bascope. 1996. Ways of Knowing about Birth in Three Cultures.
Medical Anthropology Quarterly, New Series, Vol. 10, No. 2, The Social Production of Authoritative Knowledge in Pregnancy and Childbirth (Jun.), pp. 213-236.
Dunes, Lauren, MHS. 1987. Public Health Then and Now. The Evolution of Maternal Birthing Position. AJPH May 1987, Vol. 77, No. 5.
Engelmann, George J. 1884. Labor Among Primitive Peoples. J.H. Chambers & Co. St. Louis
http://etext.virginia.edu/etcbin/toccer-new2?id=EngLabo.sgm&images=images/modeng&data=/texts/english/modeng/parsed&tag=public&part=all
Marten, Karina. 2003. Giving Birth Like a Girl. Gender and Society, Vol. 17, No. 1 (Feb.), pp. 54-72
Sargent, Carolyn and Grace Bascope. 1996. Ways of Knowing about Birth in Three Cultures.
Medical Anthropology Quarterly, New Series, Vol. 10, No. 2, The Social Production of Authoritative Knowledge in Pregnancy and Childbirth (Jun.), pp. 213-236.
What it really means to Birth from Within.
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