Birthing Practices

Historically speaking, an overview of changing practices of childbirth offers an overview of the changing dynamics of gender and the increasing authority of professional medicine, particularly in the United States and Western Europe. As midwives began to be "phased out" in the late eighteenth century, they were replaced by male doctors, and birthing practices changed as a result. Increasing medical knowledge and experience reinforced this shift, eventually pathologizing pregnancy and childbirth and tying childbirth to a hospital environment. In the late twentieth century, however, many women began calling for a return to the earlier, less medicalized, models of childbirth, and the debate about the costs and benefits of various birthing practices continues to develop today.

In colonial America, deliveries were attended by midwives as a matter of course. These women drew upon years of experience, often passing their knowledge from one generation to the next, and generally attending hundreds of childbirths during their careers. In some cases, a midwife might call a "barber-surgeon" to assist with a particularly difficult case (though often the surgeon's skills were no better than the midwife's, and the patient and child were lost), but for the most part women (mothers and midwives) controlled the birthing process. With the rise in medical schools, however, and the teaching of obstetrics as the first specialty in eighteenth-century American medical schools, medical doctors began to assume control over childbirth.

Beginning in the 1830s, having a medical doctor in attendance at a birth became a sign of social prestige—middle-and upper-class women could afford to call in a doctor and did so more out of a desire to display their economic and political clout than out of medical necessity. Class pressures ensured that women would choose childbirth assistance from someone of their own class (that is, a medical doctor for the middle and upper classes, a midwife for working classes). These pressures also meant that crusades to persuade middle-and upper-class women that they "deserved" physicians, that no precaution was too great, and so on, were enormously effective in shifting public opinion toward the presumed superiority of medical doctors. As this kind of social pressure continued to spread throughout the Victorian era, lay practitioners lost more and more status, and medical doctors gained more and more control. Furthermore, the systematic exclusion of women from the medical profession, particularly during the nineteenth century, ensured that women themselves began losing control of childbirth, giving it up to the increasing authority of the male medical community.

Throughout the 1800s, doctors employed medical privilege to protect their professional status from the economic and social threat of midwives who lacked formal training. The Boston Women's Health Collective asserts that nineteenth-century physicians "waged a virulent campaign against midwives, stereotyping them as ignorant, dirty, and irresponsible. Physicians deliberately lied about midwifery outcomes to convince legislators that states should outlaw it." These strategies, coupled with the significant risks of childbirth (infant and maternal mortality rates remained high throughout the nineteenth century), helped to create a climate of fear surrounding pregnancy and birth. Rather than seeing childbirth as a natural practice, people began to see it as a medical emergency, one that should be relinquished to a physician's control.

Once childbirth had been pathologized, the door was opened to begin moving women in labor out of their homes and into hospitals where, according to the medical community, the "disease of childbirth" could best be battled. Until the beginning of the twentieth century, it was actually a stigma to have to give birth in a maternity ward, which had generally been reserved for the poor, immigrants, and unmarried girls. As better strategies were developed to prevent disease (especially deadly outbreaks of puerperal fever that had flourished in hospitals throughout the nineteenth century), the hospital birth, with its concomitant costs, was recast as a status symbol. Eventually, however, having babies in hospitals became a matter of course. According to Jessica Mitford, while only 5 percent of babies were born in hospitals in 1900, 75 percent were born in hospitals in 1935, and by the late 1960s, 95 percent of babies were born in hospitals. Eakins' American Way of Birth notes, "the relocation of obstetric care to the hospital provided the degree of control over both reproduction and women that would-be obstetricians needed in their ascent to professionalized power." This power was consolidated through non-medical channels, with advice columns, media attention, popular books, and community pressure working to reinforce the primacy of the professional medical community in managing women's childbirth experiences.

In the twentieth century, giving birth in a hospital environment has meant a loss of control for the mother as she becomes subject to numerous, standardized medical protocols; throughout her pregnancy, in fact, she will have been measured against statistics and fit into frameworks (low-risk vs. high-risk pregnancy; normal vs. abnormal pregnancy, and so on). As a result, the modern childbirth experience seems to depersonalize the mother, fitting her instead into a set of patient "guidelines." Women in labor enter alongside the ill, the injured, and the dying. Throughout most of the twentieth century, women were anesthetized as well, essentially being absent from their own birthing experience; fathers were forced to be absent as well, waiting for the announcement of his child's arrival in a hospital waiting room. If a woman's labor is judged to be progressing "too slowly" (a decision the doctor, rather than the mother, usually makes), she will find herself under the influence of artificial practices designed to speed up the process. More often than not, her pubic area will be shaved (a procedure that is essentially pointless) and sometimes cut (in an episiotomy) by medical personnel anxious to control the labor process. Further advances in medical technology, including usage of various technological devices and the rise in caesarian sections (Mitford cites rates as high as 30 percent in some hospitals), have also contributed to a climate of medicalization and fear for many women giving birth. This is not to say, of course, that many of these medical changes, including improved anesthetics (such as epidurals) and improved strategies for difficult birthing situations (breech births, fetal distress, etc.) have not been significant advances for women and their babies. But others argue that many of these changes have been for the doctors' convenience: delivering a baby while lying on one's back with one's feet in stirrups is surely designed for the obstetrician's convenience, and the rise in caesarian sections has often been linked to doctors' preferences rather than the mothers'.

In the 1960s and 1970s, as a result of their dissatisfaction with the medical establishment and with the rising cost of medical care, various groups began encouraging a return to older attitudes toward childbirth, a renewal of approaches that treat birthing as a natural process requiring minimal (if any) medical intervention. One of the first steps toward shifting the birthing experience away from the control of the medical establishment involved the introduction of childbirth classes for expectant parents. These courses often stress strategies for dealing with the medical community, for taking control of the birthing process, and for maintaining a "natural childbirth" experience through education; the most famous methods of natural childbirth are based on work by Grantly Dick-Read (Childbirth Without Fear), Fernand Lamaze, and Robert Bradley.

Also significant were various feminist critiques of the standard birth practices. The publication of the Boston Women's Health Collective's Our Bodies, Ourselves in 1984 offered a resource to women who wanted to investigate what had been essentially "under-ground" alternatives to the medicalized childbirth experience. Through this work (and others), women learned how to question their doctors more assertively about the doctors' practices, to file "birth plans" (which set out the mother's wishes for the birth), and to find networks of like-minded parents, midwives, and doctors who can assist in homebirths, underwater births, and other childbirth techniques. In some states, midwives not attached to hospitals are still outlaws, and groups continue to campaign to change that fact.

Finally, many hospitals are recognizing women's desire to move away from the dehumanizing and pathological approaches to childbirth associated with the professional medical community. In deference to these desires (or, more cynically, in deference to their financial bottom lines), some hospitals have built "Birthing Centers," semi-detached facilities dedicated specifically to treating childbirth as a natural process. Women enter the Birthing Center, rather than the hospital. There they are encouraged to remain mobile, to have family and friends in attendance, and to maintain some measure of control over their bodies. Often patient rooms are designed to look "homey," and women (without complications) give birth in their own room, rather than in an operating theater. Many of these facilities employ Nurse Midwives, women and men who have been trained as nurses in the traditional medical establishment but who are dedicated to demedicalizing the childbirth practice while still offering the security of a hospital environment.

As women and men continue to demand that childbirth be recognized as a natural, rather than unnatural, process, the dominant birthing practices will continue to shift. Additionally, rising pressures from the insurance industry to decrease costs are also likely to contribute to a decrease in the medical surveillance of childbirth—already new mothers' hospital stays have been drastically reduced in length as a cost-cutting measure. Clearly the move in recent years has meant a gradual return to earlier models of childbirth with a return of control to the mother and child at the center of the process.

—Deborah M. Mix