birth Although childbirth is a universal fact of human physiology, where, how, with whom, and even when a woman gives birth are often culturally determined.
Anthropological awareness of the social nature of human birth owes much to the pioneering work of Wenda Trevathan, an evolutionary anthropologist who studied the differences between human and higher primate birth. Because higher primates walk on all fours, their pelvis is wide enough to allow the direct descent of the fetal head, making for easy labours and uncomplicated births. When humans began to walk on two feet, the upright stance they had to adopt made the pelvis narrower, so that the baby has to rotate as it descends in order to pass through. Non-human primate babies can climb onto their mothers' backs and cling immediately after birth, but the larger brains of human infants made it necessary for them to be born earlier in their developmental cycle, ensuring that human babies would be relatively helpless at birth and require immediate nurturing. These factors encouraged the evolution of birth as a highly social process; women give birth alone and unaided in only a very few societies.
For these reasons, Trevathan postulated that midwifery evolved along with human birth. The presence of other women would have enhanced the success of the birth process as these women acquired skills such as turning the baby
in utero to ensure the optimal position for birth, assisting rotation of the head and shoulders at birth, massaging the mother's uterus and administering herbs to stop postpartum bleeding, and facilitating breastfeeding. Trevathan suggests that more mothers and babies would have survived in societies that developed midwifery traditions early on, giving such societies a distinct evolutionary advantage.
Both ancient and contemporary figurines and paintings from indigenous cultures all over the world show women giving birth upright: kneeling, sitting on a low stool or chair, or standing with women behind or on either side of them to hold and support them with a midwife kneeling in front with her hands out, waiting to catch the baby. This upright position, with its physiological advantages of facilitating fetal rotation and descent and the mother's ability to push effectively, was pervasive in birth until the advent of Western obstetrics. Its replacement by the flat-on-the-back position common in Western-style hospitals demonstrates the extensive cultural restructuring that has been applied to birth in industrialized countries.
The social nature of birth and its importance for survival ensure that this biological and intensely personal process will carry a heavy cultural overlay. In 1908, Arnold van Gennep noted that cultures ritualize important life transitions — of which birth is a prime example. Anthropologist and childbirth educator Sheila Kitzinger has noted that birth practices point ‘as sharply as an arrowhead’ to the core values and beliefs of the culture, telling the observer a great deal about the way that culture views the world and women's place in it. Where women's status is high, a rich set of nurturant traditions tends to develop around birth; where it is low, the opposite may occur. For example, in the highly patriarchal Islamic society of Bangladesh, in which the status of women is low, childbirth (like menstruation) has traditionally been regarded as highly polluting. It was believed that women should give birth on dirty linens, attended only by female relatives. An indigenous midwifery tradition never developed, and rates of infant mortality and puerperal infections are high. In contrast, in the matrilineal societies of Polynesia, where the status of women is high, pregnant women are pampered and nurtured. Skilled midwives administer frequent full-body massages during pregnancy and have a rich repertoire of techniques for assisting women during labour and birth.
Brigitte Jordan's comparative study of birthing systems in Holland, Sweden, the US, and Mexico's Yucatan was the first to demonstrate this wide variation in the definition, the locus, the attendants, and the artifacts of childbirth; it sparked general interest in the anthropology of birth. Jordan's work on American birth was expanded by anthropologists Emily Martin and Robbie Davis-Floyd. They have suggested that American hospital birth, like much of American society, is organized around models of factory production and the technological control of natural processes. In many American hospitals, over 80% of women have their labours artificially speeded up or induced, are routinely hooked up to the electronic fetal monitor, often for long periods, have IVs inserted into their arms to provide the fluids that they are not allowed to drink, and lie flat with their feet in stirrups to give birth. While such technological interventions can sometimes be lifesaving, their routine overuse often generates problems. (The degree of overuse of birth technologies in the US is highlighted by the much lower rates of most such interventions in Great Britain, where a vocal, active, and influential consumer movement arguing for evidence-based care has had a significant impact on obstetrical policies.) Such routine procedures have been interpreted by Davis-Floyd as rituals that symbolically enact and display the core values of the American technocracy, which centre around the supervaluation of technology in many aspects of American life.
The prestige of Western ‘high technologies’ has induced many developing countries to stamp out viable indigenous midwifery systems and import the Western model even when it is ill-suited to the local situation. Western style hospitals built in the Third World may lack the most basic supplies but are often stocked with several expensive machines that few know how to use or repair. The medically trained personnel who staff these hospitals often have little understanding of or respect for local birth traditions, with the result that local women often avoid such hospitals whenever possible. From Northern India to the Yucatan, indigenous women echo each other's concerns: ‘They expose you,’ ‘they shave you,’ ‘they cut you,’ ‘they leave you alone and ignore you, but won't let your family come in’. Ironically, none of the rules and procedures these women find so alarming are essential to good obstetric care; rather, they reflect the importation of the mechanistic Western model and its culturally insensitive imposition on indigenous groups.
In an effort to counteract this trend and build a bridge between technology and tradition, the World Health Organization and UNICEF have been promoting programs to ‘upgrade’ the skills of traditional midwives. Anthropological studies have shown, however, that because the medically trained personnel in these programmes tend to place a higher value on the Western techomedical approach, they generally fail to take advantage of the knowledge and skills developed by community midwives within the context of their own cultural traditions.
In 1978, Brigitte Jordan called for the ‘mutual accommodation’ of indigenous and Western birthing systems. In northern Brazil, an obstetrician, Dr Galba Araujo, demonstrated one form this ‘mutual accommodation’ might take: he oversaw the building of rural community clinics staffed by local midwives (who received culturally sensitive training that honoured their skills while imparting useful biomedical information), and linked them to one city hospital through a government funded ambulance system. (Lack of transportation to a hospital in emergencies is a significant cause of maternal death in the developing world.)
In the US, obstetricians solidified their control over birth during the first half of the twentieth century and nearly eliminated midwifery by the 1950s. Since then the demands of many women for natural childbirth, coupled with scientific research into the dangers of interventionist hospital birth and the benefits of planned, midwife attended births at home or in freestanding birth centres, have generated a midwifery renaissance. Indeed, in the four countries in which infant perinatal mortality statistics are the lowest in the world — Japan, Holland, Sweden, and Denmark — over 70% of births are attended by midwives who serve as the woman's primary caregiver.
Deep in the evolutionary past, our ancestors came to understand the benefits of women helping other women to give birth. Today, the most successful birthing systems combine midwifery care with solid scientific research on the physiology of birth. Contemporary midwives work in all settings, from hospital to home, and support women to avoid unnecessary interventions, to give birth in upright positions, to breastfeed, and to enjoy uninterrupted contact with their babies after birth. It has been repeatedly demonstrated that midwifery care results in fewer interventions, less iatrogenic damage to mothers and babies, improved outcomes (both psychological and physical), and lower costs. It is to be hoped that in short order the world will pass through the current phase of high-technology interventions in normal birth and come full spiral, uniting evolutionary understandings with contemporary science through midwives' skilled, nurturant, and woman-centered care.
Robbie Davis-Floyd
Bibliography
Davis-Floyd, R. E. (1992). Birth as an American rite of passage. University of California Press, Berkeley and London
Davis-Floyd, R. E. and and Sargent, C. (1997). Childbirth and authoritative knowledge: cross-cultural perspectives. University of California Press, Berkeley, California.
Jordan, Brigitte (1993; orig. pub. 1978). Birth in four cultures: a cross-cultural investigation of childbirth in Yucatan, Holland, Sweden and the United States, (4th edn) Waveland Press, Prospect Heights, Ohio.
See also
labour;
pregnancy.
