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Through networking and education, Midwifery Today's mission is to return midwifery care to its rightful position in the family, to make midwifery care the norm throughout the world, and to redefine midwifery as a vital partnership with women.
Reconsidering Our Preconceptions about Birth
by Valerie El Halta
© 2001 Midwifery Today, Inc. All rights reserved.
[Editor’s note: This article first appeared in Midwifery Today Issue 59, Autumn 2001.]
“No fear here” I whisper to the laboring woman, “no fear here.” She is coming close to the time she has long anticipated. Soon she will hold her newborn. Soon she will gaze into her baby’s eyes. Soon she will know joy.
The Roots of Fear
Recently my friend and I sat in her living room in Manhattan discussing various attitudes and preconceived notions women have about birth. A childbirth educator and counselor, she had noted that many of her clients are exceedingly fearful of birth, and most of her time is spent dealing with this stumbling block. Often her clients are unable to identify the origins of their fear, and at most, describe a general foreboding of the entire process. “Where does this fear come from?” we asked each other. “What are its roots?”
A woman today comes to her time of motherhood with a surplus of information. Not only does she possess genetic memory of birth from a thousand generations of women, but also she is assailed from every direction by information and disinformation about birth. Books, television shows, the Internet, childbirth classes and videotapes purport to inform and prepare her for giving birth, and without a doubt, information can certainly be an asset. But as I peruse the current available material, I find that three themes are repeatedly emphasized: the first is that labor is an excruciatingly painful experience that must be avoided or anesthetized as soon as possible. Second, the woman should place complete trust in her physician. And third, cesarean section is “just another mode of delivery” and must be prepared for as a possibility (and truthfully, it’s a probability for up to 25 percent of American women!).
The first person from whom a woman generally gets information about birth is her own mother. When I meet a prospective client for the first time, I usually ask her what impressions about birth she received from her mom. Some women tell me the subject of birth was never raised. Others say their moms described it as the most horrible experience imaginable. A few mothers said birth was a tolerable, rewarding experience. Most of the women whose mothers never discussed their birth experiences are left with a real dread of unknown suffering too awful to talk about. In all instances, if the message is negative, I try to get more information—from the woman’s mother if possible—to diminish fear and help the woman understand the situation. I find that many women’s mothers whose memories of childbirth are the most negative were completely anesthetized for birth! If we randomly select women from all walks of life and ask them about their strongest memory of when they gave birth, we will find the following in almost all instances: The women who received anesthesia at the peak of their labor, or before second stage, are left with the memory of the pain of the last contraction they felt. On the other hand, women who completed their labor without anesthesia will almost always remember the extreme exhilaration they felt when they saw their baby for the first time. You see, the brain releases miraculous hormones (endorphins) at the appropriate time, and they sublimate the pain of contractions, act as an amnestic, and help release oxytocins that enhance feelings of ecstasy in giving birth—every woman’s birthright!
A woman’s second source of information is the community in which she was reared, with all its cultural/religious/social customs and mores. It shapes her place in society, which in turn will shape her attitudes about herself and her innate ability to accomplish childbirth. In many instances, fear of childbirth is instilled purposefully as a means of maintaining chastity. Mothers have been heard to regularly repeat, “I almost died having you!” Because some of the best stories are birth stories, many are told when circles of women convene. With each telling, the stories are colored with more drama and each woman becomes the heroine of her own, sometimes highly exaggerated tale. Regrettably, young women are listening too, who will integrate the retold experiences into their consciousness, to be replayed when they give birth. Fortunate is the young woman who grows up in a society where birth is viewed as a healthy event, to be accomplished with ease and celebrated!
Following is a story of a woman raised in such an environment. Siene was about to give birth to her third child. During the weeks of prenatal visits, I had tried to learn as much as I could about the customs and traditions of her home, Samoa. She proudly showed me the beautiful bamboo mats she had been given as a wedding present, to be used especially for birth. We chose the special “lava‑lava,” a length of brightly colored fabric that must be wrapped around her after the birth, preferring the red flowered one for good luck. We shopped together for special foods the men in the family would prepare for the birthday feast, and I made sure that her female relatives were consulted about every aspect of her care and birth.
I was called to her labor at the usual wee hour of the morning. Despite our careful preparation, I still didn’t quite know what to expect during the actual birth, but I had promised her we would do it her way. When I approached her home, I could hear her yelling “hai! hai! hai!” I grabbed my bag and entered the house quickly. Several male relatives were in the kitchen cooking something that smelled wonderful. Other relatives, including several children, were in the living room playing and singing, and all were celebrating the coming event. When I walked into the room where the birth was to take place, I saw a radiantly smiling Siene. She was sitting on her special mats surrounded by the important women in her family. As another contraction began, she reclined into her mother’s arms, gave me a big grin, said “HALLO FAL!” then continued her powerful yelling. Asking permission from her grandmother, I checked her, found her cervical dilation complete, and said, “Okay Siene, you can push your baby out when you want to.” “HOKAY, FAL,” she responded, and with one enormous push 11-pound baby “Fal” was born, lustily making her presence known in the world.
Few women today can escape the continual onslaught of disinformation engendered by television and other popular media, the third factor that creates and maintains fear in birth. Few depictions of birth have not been traumatic, life-threatening and highly dramatized events. These erroneous portrayals are almost as detrimental to society as the constant violence the media puts forth. In fact, isn’t the misrepresentation of birth just another form of violence on which viewers have learned to thrive? Even more recent media stories of couples approaching parenthood and having babies often end in “emergency cesareans,” where the physician emerges as the focal point and the hero.
Although they certainly play an important role in society, physicians themselves are the fourth factor in promoting fear of birth. Along with the prenatal vitamins and prenatal testing, what messages of failure is the pregnant woman receiving from her obstetrician? The majority of young women have come to believe their bodies are incapable of giving birth without a physician by their side. It is important that we know our doctor’s beliefs and attitudes about childbearing. Why has he or she chosen obstetrics, for instance? We must remember that obstetric residency deals chiefly with gynecological surgery! What did he or she learn about normal birth in medical school? How have subsequent experiences in birth affected his or her current attitudes? I am sure most obstetricians are “good guys” who have the best interests of their patients at heart. Lest I be misunderstood, I don’t believe that the doctor is the problem but his or her education, experiences and beliefs may be.
It would seem that the emphasis of a modern medical school education, although nominally placed upon safety, is actually placed upon efficiency. Nature and her biological clock run too slowly for the pace set by scientific technology. Our physicians are the unfortunate product of an educational rat race, and the paranoia it instills in them dictates intervention for every condition that fails to fall under established “norms.” Sadly, most of the time a single intervention creates a “domino effect” that necessitates more and more intervention. Often when a procedure is called for, the safety of the patient is cited, but the physician’s real fear is more likely a malpractice suit should anything other than a “perfect” result be achieved, either by his or her action or inaction. Under pressure placed upon him by his education, his peers, and his medical associations should he fail to act within the standards set by them, there remains no safety in trusting nature and her idiosyncrasies. Few come out of an obstetric residency with the attitude that birth is a normal event, or that the process of birth can be trusted. Negative attitudes are then passed on to the expectant mother despite the best intentions, either by word—“Well I’m not sure; we had better have another ultrasound”; by touch—“I think this is the baby’s head”; and demeanor, as surely as teratogens coursing through an umbilical cord.
Another most persuasive voice affects almost every aspect of modern American pregnancy and birth. With ever-increasing power, this voice dictates our perceptions about our health, our attitudes, and about our physical selves while it increases our dependence on its products. It is the collaborative voice of the drug companies. This voice has the ear of medical schools as it whispers its message through large financial donations. Once the physician has established her own practice, whether it is affiliated with a hospital or not, she is barraged by drug company representatives. Oftentimes, huge incentives (bribes) are offered to the physician who will prescribe certain products. One day in a doctor’s office, I sat thumbing through a medical journal. Its centerpiece was an advertisement for a particular prenatal vitamin. The ad pictured a uterus enveloping what looked like a fetus of about five months’ gestation. It was quite a nice picture, but out of the pages leapt a glaring sentence that described the fetus as a parasite, sapping maternal reserves! What an awful description of a baby. Is this the way drug companies view the miracle of a developing human being, I wondered?
As we look for the root causes of inordinate fear of childbirth felt by both women and physicians, we need to identify those who benefit from promoting it. Drug companies, a multibillion-dollar industry, certainly gain an advantage if women continue to be fearful of the birth process. A healthy woman’s desire to give birth naturally, without unnecessary medications, is a huge threat to their interests, not to mention the threat homebirth and midwifery are to these mavens of misery!
As for cesarean section, the consensus of opinion in the United States is that our cesarean rate is too high, and many attempts are being made to lower it. But I wonder how a decreased rate will be accomplished when our basic belief about birth is that it doesn’t work—so much so that women are scheduling operative birth for no apparent reason other than to avoid the normal birth process. When women can restore their faith in the wonderful ability of their bodies to accomplish the work of birth and know that their spirits will rejoice in that accomplishment, then fear will be displaced by power, deception by truth, and pain will be banished by joy!
Empowered Women Are Fearless Women
The environment in which birth takes place has an enormous impact upon birth outcome, and the mother must be allowed to choose that place. How well labor progresses and pain is tolerated, the extent to which the woman thinks she needs medical intervention, fetal outcome and well-being, and the mother’s satisfaction with the birth experience—all are directly related to the mother’s sense of “safe place” in which she births.
“Safe place” has little to do with physical surroundings alone, yet for many women the home in which she resides, has prepared for her baby, has “nested” in and where she feels loved and secure, most clearly defines that place. “Safe place” also has to do with the people whose presence she feels most secure and comfortable with. And a little bit more finely tuned, the interaction of the several personalities involved in the woman’s labor and birth may either positively or adversely affect her sense of “safe place.” As we come to understand the importance of how these personalities affect the birth environment, we caregivers become more sensitive to the needs of the mother as she comes to the time of labor and birth.
Traditionally, birth was a very private affair in which only the most intimate of a woman’s relations attended her in labor. Grandmothers, aunts and wise women of the village whom the woman most trusted were the ones expected to be there. In today’s society, women are taught to place their trust in the medical model of childbirth and in medical professionals rather than in people with whom they are most familiar. They are taught to accept the place of birth that medical professionals choose (because it is their “safe place”?). That is a difficult and sometimes impossible transition for many women. It so seriously affects a woman’s sense of the familiar that patterns of labor are changed, birth pain is intensified, outcomes are less predictable and birth comes to be regarded as a difficult and painful ordeal, fraught with danger. To complicate matters, if the woman is in an unfamiliar and therefore “not safe place,” she will protect her baby by preventing it from being born—ceasing to contract, keeping her cervix closed and in general “failing to progress,” one of the major reasons for unplanned operative delivery.
Those of us who are certain that a woman’s home is the most suitable environment for her birth must be particularly aware of the influence we may have on the woman’s sense of safety. The most well-meaning midwife may nonetheless be a “stranger” to the mother and a threat to her need for privacy if the midwife is not fully trusted by the mother well before labor ensues.
How have midwives developed such a positive attitude about the birth process? Is it that after watching birth and women giving birth through eons of time, we know simply that “babies come out”? As is true everywhere in nature, sometimes there are less than perfect outcomes, but we are able to go on to the next labor with our belief in the process intact.
Midwives are able to maintain normalcy in birth and help bring about an optimum outcome for mother and baby because we provide both constancy and continuity of care. As the relationship between midwife and mother develops during the course of prenatal care, an increasing mutual trust creates a sense of safety and security. Communication becomes forthright and honest, and words flow easily between them. When it comes to the time of birth, rarely must we deal with psychological issues that may impede labor, because specters of the past have been met, dealt with and put in their proper place. Over the months preceding birth, through her manner, touch and words, the midwife has said such things to the mother as “I will never lie to you,” “I know you can do this work of birth,” “I trust you to grow a beautiful, healthy baby.” What comfort this is to the woman meeting birth for the first time, with so many questions!
Thousands of times I have sat with a young woman who is having her first baby. When her eyes gaze into mine and I can feel her contractions crashing through her body like tumultuous waves against the rock, and I know she is doubting her strength to go forward despite her great desire to complete her task, I say to her, “OK, Linda, now you will have to walk on water.” She grasps my hand a little harder and replies, “How far do you want me to walk?” Then, we walk together.
Every Woman’s Birth Right
I am called to Donna’s home in the wee hours of the morning. She is in early labor with her third baby. I stay, expecting that when it becomes active, her labor will go quickly. She spends the next few hours “nesting.” She walks and talks with her husband and finishes arranging her birth room. Several hours pass and the contractions gradually increase in strength and frequency. She asks to be checked after having three good contractions in 10 minutes, and we greet active labor at about five centimeters. Soon the contractions become very strong and I ask her if she would like to get into a warm bath. She loves the tub and is able to relax fully with contractions as we continually pour warm water over her tummy. Greg, her husband and lover (not coach), is right by her side offering praise and encouragement. She is breathing through each contraction with deep, slow breaths she has learned to do by listening to the rhythms of her body. As the contractions increase she begins to make wonderful full-throated sounds that are every woman’s birth song. We listen, and wait for the baby to come.
We regularly listen to baby’s heart tones, and all is well. At the peak of one long contraction the waters break and are clear as they flow into and mingle with the warm tub waters. I examine the birthing mother in the tub and find she is completely dilated. We help her out of the bath and she walks to the toilet where she empties her bladder and sits through another contraction, awaiting her pushing urge. During the next hour, she will walk and squat and dance her baby down the birth canal. When her legs begin to tire, she decides to climb into her big double bed, where she relaxes into the arms of her husband. Soon she says that the baby is “really coming.” We see the perineum beginning to bulge a little as she moves the baby down the birth canal with gentle pushes. The atmosphere in the room is peacefully expectant as her husband and midwife friends encourage her efforts.
As the baby begins to appear, Donna reaches down to touch its little head, and her hands remain there to help herself birth. We have prepared warm wet cloths to place over the introitus to help her completely relax her perineum. The baby slowly emerges. Donna, Greg and I gently lift the baby onto her tummy, where we discover that she is a little girl! There are no lacerations of the birth canal or perineum, and there is no blood on the birth bed. We do not suction or in any way disturb the baby, who naturally expels water and mucous from her mouth and nose, looks up at her mommy, and breathes. What a privilege it is to watch as this beautiful rose unfolds in the garden of life that is her mother’s arms!
The umbilical cord is pulsing strongly, supporting baby Kate’s breathing efforts. There is no sudden respiratory pain, no shock of transition, no crying she makes. Donna gently touches her breast to Kate’s mouth, which the baby receives with gusto, and nursing is established. While we are waiting for third stage to begin, we examine the baby from top to toe and proclaim her pink and perfect. We can do everything but weigh her while she is in mother’s arms, and I really don’t think her weight will change much if we wait an hour!
After the appropriate time the baby fidgets a little at the breast, wrinkles up her nose and makes “fussy” noises. This is our clue that the placenta has separated. We tell Donna that the placenta has released and ask her if she is ready to let it be born—reminding her that it has no bones! She laughs, says that she is ready and lets it come into the bowl. There is no blood on the birth bed. We examine the placenta, see that it is complete, wrap it up in a fresh pad and place it beside the mother. Everything is as it should be, so we leave Donna, Greg and Kate to experience their first togetherness.
About 30 minutes pass and Donna calls me into the birth room. “Are you going to cut the cord?” she asks. I ask if she’s ready for it and she says yes, so we clamp the cord and Donna takes the scissors and separates her baby from her first life support system. Baby Kate is nursing contentedly, and doesn’t notice the separation because, attached securely to her mother’s breast, there has been none for her. After we are certain that all is well with this new family, and Donna has eaten my chicken soup, we gather our things and leave.
We will come again the next day, and on the third day after birth we will find that Kate’s cord has completely dried up (it will fall off in a couple more days), Donna’s uterus is involuting beautifully and she only needs two pads a day. Kate is nursing vigorously and has lost no weight, there is no sign of jaundice and Donna’s milk is already coming in.
“No fear here,” I whisper to the laboring woman, “no fear here.” She is coming close to the time she has long anticipated. Soon she will hold her newborn. Soon she will gaze into her baby’s eyes. Soon she will know joy.
Valerie El Halta has practiced midwifery for 24 years. After having been director of the Garden Birth Center in Dearborn, Michigan, for nine years, she is now concentrating primarily on a homebirth practice.
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