Birth

For most of human history, birth was exclusively the work of women who labored to push their babies from the private inner world of their wombs into the larger world of society and culture. Yet in the early twenty-first century, increasing numbers of babies are pulled from the vaginal canal with forceps or vacuum extractors, or are cut from their mothers' wombs via cesarean section. The medical definition of birth is the emergence of a baby from a womb—a definition that ignores women's involvement and agency.

BIRTH AND HUMAN EVOLUTION

Higher primates walk on all fours and have pelvises wide enough to allow the direct descent of the fetal head, making for easy labors and uncomplicated births. When humans began to walk upright, the pelvis narrowed, so that the human baby has to rotate as it descends through the birth canal. Non-human primate babies can climb onto their mothers' backs and cling immediately after birth. But the larger brains of human infants make it necessary for them to be born earlier in the developmental cycle, ensuring that human babies are 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 very few societies.

Evolutionary scientists postulate that midwifery evolved along with human birth. The presence of other women at a birth 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. For these reasons, more mothers and babies survived in societies that developed midwifery traditions early on, giving them a distinct evolutionary advantage.

BIRTH, CULTURE, AND WOMEN'S STATUS

Although childbirth is a universal fact of human physiology, the social nature of birth and its importance for survival ensure that this biological and intensely personal process carries heavy cultural overlay, resulting in wide variation in childbirth practices: Where, how, with whom, and even when a woman gives birth are increasingly culturally determined. In 1908 French ethnographer Arnold van Gennep (1873–1957) noted that cultures ritualize important life transitions—of which birth is a prime example. Birth practices reflect and reveal the core values and beliefs of the culture, telling the observer a great deal about the way that culture views the world and the place of women in it. Many religions, including Judiaism and Zoroastrianism, regard birth as polluting and require ablution and isolation for purification afterward.

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. Before modernization, women gave birth on dirty linens, attended only by female relatives or traditional midwives who were themselves regarded as polluting. 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 labor and birth.

THE EFFECTS OF PLACE OF BIRTH

Anthropologist Brigitte Jordan's comparative study of birthing systems in the Netherlands, Sweden, the United States, and Mexico's Yucatan, originally published in 1978, was the first to comprehensively document the wide cultural variations in birth. Her biocultural approach utilized the definition of birth, the place of birth, birth attendants, artifacts utilized to facilitate or control birth, and differences in knowledge systems about birth as foci for cross-cultural comparison.

Among these factors, place of birth has emerged as most salient for how birth happens. In home settings across cultures, from huts to houses, childbirth occurs according to the natural rhythms of labor and women's social routines. In early labor, women move about at will, stopping their activities during the 45 seconds or so per contraction, and then continuing their activities (which may include doing chores, chatting, walking, eating, singing, and dancing). Such activities subside as the women begin to concentrate more on the work of birthing, often aided in this labor by massage and emotional support from their labor companions, who are usually midwives. Many cultures have set patterns about who should be present at the birth (sometimes the father, sometimes only women, sometimes the whole family and/or friends), how labor support should be provided, what rituals should be performed to invoke the help of ancestors or spirits, and what herbs and hand maneuvers may be helpful to assist a birth or stop a postpartum hemorrhage. When birth is imminent, women at home usually take upright positions, squatting, sitting, standing, or balancing on hands and knees, often pulling on a rope or pole or on the necks or arms of their companions, and work hard to give birth. Postpartum practices vary widely: Some cultures encourage early breastfeeding, some define colustrum as harmful and feed the baby other fluids until breastmilk comes in (a practice now known to be medically dangerous—many babies die from imbibing contaminated water). Steam and herbal baths and periods of postpartum confinement are often culturally prescribed, varying in length from a few to forty days.

Where freestanding birth centers exist staffed by professional midwives, the experience of birth is resonant with the experience of birthing at home—a free flow. There are no absolute rules for how long birth should take. As long as the mother's vital signs are good and the baby's heartbeat is relatively stable, trained attendants allow the birth process to proceed at its own pace, keeping their focus on the needs of the mother, encouraging her to eat and drink at will, and to move about freely, adopting positions of her choice.

Birth in the hospital is an entirely different experience. The biomedical model dominant in hospitals demands that birth follow a certain pattern, including cervical dilation of 1 centimeter per hour—an arbitrary rule unsupported by science but consistent with industrial patterns of production. Ensuring the mechanical consistency of labor requires frequent manual checking of cervical dilation, which, if determined to be proceeding too slowly, will be augmented by breaking the amniotic sac and intravenous administration of the synthetic hormone pitocin (syntocinon) to speed labor. Women are often not allowed to eat or drink, and thus are routinely hydrated through intravenous lines, which also facilitate the administration of pitocin and other drugs. Electronic fetal monitoring to record the strength of the mother's contractions and the baby's heartbeat is pervasive in hospitals in developed countries, in spite of the fact that its routine use does not improve birth outcomes but does significantly raise cesarean rates because hospital personnel often misinterpret the monitor tracings, seeing an impending crisis where there is none. (Intermittent auscultation by a nurse, doctor, or midwife has been proven to be far more effective in identifying emerging problems.) Episiotomies to widen the vaginal outlet at the moment of birth are also common, although scientifically demonstrated to be unnecessary in 90 percent of births. Such routine obstetric procedures have been interpreted by cultural anthropologist Robbie Davis-Floyd as rituals that symbolically enact and display the core values of the technocracy, which supervalues progress through the development and application of increasingly advanced technologies to every aspect of human life, including reproduction.

IMPACT OF THE BIOMEDICAL MODEL ON BIRTH IN DEVELOPING COUNTRIES

The growing worldwide supervaluation of high technologies has induced many developing countries to suppress viable indigenous birthing systems and import the biomedical model from developed nations even when it is ill suited to the local situation. Hospitals built in the Third World may lack basic supplies such as bandages, clean sheets, and fresh needles yet be stocked with high-tech equipment. Hospital staff often has little understanding of or respect for local birth traditions and values, with the result that local women often avoid such hospitals. From northern India to Papua New Guinea to Mexico, indigenous women voice concerns about biomedical hospitals and clinics in both rural and urban areas: "They expose you;" "they shave you;" "they cut you;" "they leave you alone and ignore you, but won't let your family come in;" "they give you nothing to eat or drink;" and "they yell at you and sometimes slap you if you do not do what they say." 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 culturally insensitive technocratic approach.

The transglobal imposition of this model on childbirth, sold to goverments as modern health care and to women as managing risk and increasing safety in birth, has resulted in an explosion of technological interventions in birth unprecedented in human history, including numbers of cesarean sections. Despite the World Health Organization's (WHO) demonstration that cesarean rates should never be above 15 percent, cesarean rates for Taiwan, China, and Puerto Rico are well above 40 percent; for Mexico, Chile, and Brazil are at around 40 percent; for the United States are 30.2 percent, and for Canada and the United Kingdom are 22 percent. Physician convenience and economic gain, combined with deeply ingrained medical beliefs that birth is a pathological process that works best when technologically controlled, are other factors in the recent rise in the number of cesareans performed. The WHO standard is met in the Netherlands, with a cesarean rate of 12 percent, and is reinforced by the excellence of birth outcomes in that country. This success is entirely cultural: The definition of birth as a normal physiological process in the Netherlands, in combination with Dutch cultural values on family, midwifery care, and careful attention to scientific evidence, have led to minimal interventions in hospital birth and the high home birth rate (30%) in that country. In contrast, in most of the developed world, home birth rates hover around 1 percent, despite the demonstrated efficacy and safety of a planned, midwife-attended home birth.

CONTESTING BIOMEDICAL HEGEMONY

The massive disparity between the scientific evidence in favor of less intervention in birth and the increasing interventions in actual practice reflect widespread acceptance of the technocratic model of medicine—a model developed by white male physicians—as the model on which to base developing health care systems. The hegemony of this approach is ensured by the political and economic benefits to physicians and technocrats from the imposition of the model, the forces of globalization and their concurrent trends toward increasing technologization, and women's concomitant faith in the model as the safest practice.

Nevertheless this hegemony is heavily contested. In addition to the thousands of local birthing systems, two other paradigms for contemporary childbirth exist throughout the world: The humanistic and holistic models. The highly patriarchal technocratic model of biomedicine metaphorizes women's birthing bodies as dysfunctional machines and encourages aggressive intervention in the mechanistic process of birth. The reform effort located in the humanistic model stresses that the birthing body is an organism influenced by stress and emotion and calls for relationship-centered care; respect for women's needs and desires; and a physiological, evidence-based approach to birth. The more radical holistic model defines the body as an energy system, stresses spiritual and intuitive approaches to birth, and places high value on the feminine. In dozens of countries, humanistic and holistic practitioners and consumer members of growing birth activist movements are utilizing scientific evidence and anthropological research to challenge the technocratic model of birth. They seek to combine the best of indigenous and professional knowledge systems to create healthier, safer, and more cost-effective systems of birth care.

Yet, from a crosscultural point of view, the focus on care of the individual limits all three paradigms. For example mortality resulting from birth is widely recognized as a massive global problem; more than 529,000 women die annually from complications of pregnancy and birth (including unsafe abortion). Biomedicine identifies conditions such as hemorrhage and toxemia as major causes of maternal death, and advises investment in doctors, hospitals, and rural clinics to provide prenatal care to prevent toxemia, and active intervention immediately after birth (i.e., administration of pitocin, cord traction for rapid removal of the placenta) to prevent hemorrhage. This biomedical approach makes it appear that problems inhere in individuals and should be treated on an individual basis, patient by patient, hospital by hospital. In contrast social science research in countries with the highest maternal mortality rates highlights the general poor health of women, who in many patriarchal societies suffer from overwork, exhaustion, anemia, malnutrition, and a variety of diseases resulting from polluted water, showing that the most important interventions required for improving women's health and for increasing safety in birth are clean water, adequate nutrition, and improved educational and economic opportunities for women.

BACK TO THE FUTURE: SCIENCE AND MIDWIFERY CARE

In the United States, 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 centers have generated a midwifery renaissance. Indeed in the four countries in which infant perinatal mortality statistics are the lowest in the world—Japan, the Netherlands, Sweden, and Denmark—more than 70 percent of births are attended by midwives who serve as the woman's primary caregiver throughout pregnancy, birth, and the postpartum period.

see also Anthropology; Fatherhood; Motherhood.

BIBLIOGRAPHY

Davis-Floyd, Robbie E. 1992. Birth as an American Rite of Passage. Berkeley: University of California Press.

Davis-Floyd, Robbie E., and Carolyn Sargent, eds. 1997. Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives. Berkeley: University of California Press.

DeVries, Raymond; Edwin van Teijlingen; Sirpa Wrede; and Cecilia Benoit, eds. 2001. Birth by Design: Pregnancy, Maternity Care and Midwifery in North America and Europe. New York: Routledge.

Jordan, Brigitte (1993). Birth in Four Cultures: A Cross-Cultural Investigation of Childbirth in Yucatan, Holland, Sweden and the United States. 4th edition. Prospect Heights, IL: Waveland Press.

Kalpana, Ram, and Margaret Jolly, eds. 1998. Maternities and Modernities: Colonial and Post-Colonial Experiences in Asia and the Pacific. Cambridge, UK: Cambridge University Press.

Lukere, Vicki, and Margaret Jolly, eds. 2002. Birthing in the Pacific: Beyond Tradition and Modernity? Honolulu: University of Hawaii Press.

Murphy-Lawless, Jo. 1998. Reading Birth and Death: A History of Obstetric Thinking. Bloomington: Indiana University Press.

Van Hollen, Cecilia. 2003. Birth on the Threshold: Childbirth and Modernity in South India. Berkeley: University of California Press.

                                            Robbie Davis-Floyd