Questioning Childbirth Folklore

Questioning Childbirth Folklore“When, therefore, we repeat the truism that ‘most births are normal,’ let us remind ourselves that the substantial minority that are not could entail death or mutilation for the mother.” ~Edward Shorter[1]

In 1833, the respected midwife Veronika Paul was summoned to the bedside of a laboring woman after the local midwife required help. Paul examined the mother whose baby was trying to come out sideways, a rare and difficult transverse lie. The skilled midwife assured the worried family she had supervised many similar births. She finagled one of the infant’s hands through the vagina. Next, she pulled. And pulled. And pulled. She tore the infant’s arm off, leaving its body inside the mother. The mother, and presumably her baby, died (80).

Thankfully, this horrifying story wasn’t typical, but for most of human history, death or mutilation from childbirth was the experience of a “sizable minority.” A mother’s chance of avoiding this depended on the skill of her birthing attendant and on the medical procedures at her disposal.

Contrary to myth, traditional pre-medicalized childbirth was not the beneficiary of millennia of received wisdom. It was often the stomping ground of incantations, brutal interventions, un-repaired tears, uncontrollable hemorrhaging, and possible death.[2]

This post is not a diatribe against midwives. Heck, my first two children were delivered by certified nurse midwives and my mother-in-law is a certified nurse midwife (not to be confused with midwives without medical training). Ignorant or foolish doctors of the past also maimed their patients. In fact, as doctors took over childbirth in the first decades of the twentieth century, maternal mortality increased![3]

Therefore, this post is not about midwives versus doctors. It is about dispelling mythology, about critically examining the folklore of birth as natural and uneventful, about questioning the impetus to cast the medicalization of childbirth as a greedy, patriarchal villain who slapped us on our backs, gave us pain relief, but cut us open as the compromise.

Traditionally, birth could be scary, disfiguring, and complicated. True, a majority of the time, women didn’t die in childbirth. Their babies didn’t die. But, other uncountable unlucky women did encounter ghoulish dilemmas and their after-effects.

I focus on this sizable minority because they represent real women whose lives were cut short, whose babies were killed, or who spent the rest of their years battling infections, prolapse, even fistula.

As you have probably surmised, this topic is one of my “buttons.” I try not to get worked up about too much involving postpartum bodies or the mommy wars: Not about boobs and what comes out of them, not about what kind of diaper you use, not about whether you carry your 15 year old in a sling. Nope. Not going there.

But historical myth making? That gets to me. Therefore, indulge me my soapbox for a moment.

Why is this topic important to me?

1) I would have been one of those sizable minorities. You can read my story here. Honestly, I’m still part of the sizable minority today. I have repercussions from childbirth that most women don’t face, but at least I live now. I am incredibly lucky to live in this “over-medicalized” time, and I reject protestations that we should always trust the female body and its instincts. Nope. Sometimes Mother Nature can be a b-t-h.

2) I am a former student and forever fan of history. I didn’t pursue history for my graduate studies, sometimes I wonder why (oh right, jobs), but I did major in History at Gettysburg College and have incredibly fond memories of searching through primary sources, working in special collections, listening to the microfilm scroll, deciphering 18th century newspapers, and breathing in the musty historical societies (And later, if you ever visited Boston’s Otis House, yours truly could have been the oh so exciting docent).

History is amazing. It is also contentious and misused. I can’t pretend to be a historian. Undergraduate studies do not a historian make. I don’t mention my long ago past to throw around credentials I don’t have. Instead, I merely describe the tunnel through which I view myth-making.

History is not dumped in our laps. It is molded; it is analyzed; it is created. Interpretation and disagreement are par for the course. But, it shouldn’t be a propaganda crutch for present day agendas.

3) I’m kinda annoyed about my 3 months of Bradley Classes. Over time my memory of those classes has morphed from enthusiasm, to ambivalence, to bafflement. Much of the information was fine, but much was misleading. The details don’t matter. Rather, I mention it because it represents a particular popular viewpoint, a vision of birth that criticizes present day hospitals as somehow denuding childbirth of its inherent safety and beauty. In this version of history, hospitals stand in for patriarchy and traditional childbirth represents a lost feminism.

I don’t care how other women give birth. I really don’t — other than wanting birthing practices to keep mothers and babies alive and to not cause pathological postpartum bodies. My main concern is with mythology. Mythology that seeps into our new mom brains and makes us feel bad about our birth story or makes us romanticize a past that never existed.

As far as I’m concerned, medicalizing childbirth has been one of the greatest feminist successes of our time.

To be clear, even most modern home birth in the developed world is a form of medicalized birth because a distressed mother is moved to the hospital. The hospital is always waiting in the wings, assuming the home birth midwife knows what she is doing. If you plan for a home birth, you actually have more than a 1 in 10 chance of going to the hospital. Look at impoverished undeveloped countries to see what un-medicalized, traditional childbirth really looks like.

Your Birth Plan is a Privilege

Being able to make a birth plan is the result of modern medicine. Let me repeat that. Being able to give a rat’s ass about how you give birth is the result of approaching birth from a place of excitement rather than a place of dread. In other words, a birth plan is evidence that in this microsecond of human history we are at a place of profound progress for the birthing mother and her baby.

This doesn’t mean all present day hospital births are good. This doesn’t mean all c-sections are necessary. This doesn’t mean certain hospital rules and regulations shouldn’t change. I’m not wading into that debate right now. All it means is we must be skeptical of a folkloric past invoked to counter the modern medical establishment.

That past was dirty. It was a breeding ground for infection. It was the time of old wives’ tales that could kill the mother. It was the time of putting a hook into a baby’s head to pull it out (called embryotomy, done by doctors and midwives) (86). It was the time of uteruses dangling from un-sutured perineal tears, etc…

Despite the popular naturalist refrain, hospitals didn’t steal women’s autonomy. It is reductive to say hospitals were patriarchal institutions trying to medicalize the natural and rip childbirth out of women’s hands. Childbirth was never in their hands. They weren’t making choices. They were trying to not die. Choosing a hospital was perhaps the first choice many women had about childbirth. It is a sad irony that this choice at the wrong time in history could have been deadly.

Nonetheless, before this choice, women weren’t trusting the ingrained knowledge of their bodies in some sort of pre-industrial birthing bliss. Before the hospital became a safety net, traditional birth was not inherently empowering.

Even if most women didn’t die during traditional childbirth, most women knew of someone who did. Death was in the air. Every time a woman gave birth, which was more than most of us, she faced those possibilities. For example, before 1800, a women who had 6 children had an 8% lifetime risk that she would die in childbirth (98). That might not seem like much, but it is. Childbirth was the second leading cause of death for women in their childbearing years (Second to tuberculosis. That reminds me, did you get your TB test?)

As childbirth became medicalized, yet still unregulated in the early 20th century, it actually became more deadly. That’s tragic. However, beginning in roughly the mid 1920s, as the medical establishment began to clean up its act, the maternal mortality rate plummeted. Therefore, the reduction in the maternal death rate in the early and mid twentieth century cannot be extricated from medical advances.[4]

In the developed world, we are history’s lottery winners. I say this as someone who has reservations about my birth experiences, who still faces the repercussions of large children, who might need surgery in the future. Nonetheless, I am lucky, and I refuse to romanticize the past.

Instinct isn’t innate

Eventually, the midwives and doctors with the best training and knowledge of the female body helped make birth safer. Instinct did not. The instinct of many untrained midwives, who did the majority of rural births, was to pull as hard as they could on anything that presented itself (79). Let’s abandon the image of the “granny midwife” patiently letting the uterus do the work, calmly helping the mother birth down, or eschewing interventions.

No. Some were literally pulling off heads and limbs. Many were tugging on placentas so forcefully that the uterus came with it. They were intervening when they shouldn’t and throwing up their hands when they should have been intervening. They were trusting their “instincts.”

Ultimately, instinct is a misnomer. Instinct isn’t innate. It is culture. When we say instinct, we really mean received wisdom, and sometimes received wisdom is awesome, but sometimes it is dumb. Science helps separate out the two.

Your Shampoo isn’t “toxic”

Again, I won’t pretend early hospitals were glorious improvements for all aspects of childbirth. For example, close quarters could be swift breeding grounds for infection. Remarkably, only in the last 75 years or so have our infection expectations changed. It was everywhere. Even home births were petri dishes and about 4% resulted in a serious infection for the mother. (Before asepsis took off in all levels of society, mild infections were actually considered normal) (107).

Therefore, when thinking about historical birth, we should imagine the microbes creeping into the mother’s body, causing death or permanent discomfort and pain. If you spend sleepless nights worrying your shampoo is full of “toxins,” you are fretting over a #firstworldproblem (I’m also a product of the first world because I once spent hours making homemade “nontoxic” deodorant. It smelled lovely, but did little for my own stink).

Real toxins arose from decreased oxygen to the tissues in the cervix and vagina, or from the poking and prodding hands of the doctor or midwife, or from contact with another infected person.

Anaerobic and aerobic toxins were carried throughout the poor mother’s body. Keep in mind, the prevalence of infection was “a state of affairs that had always existed” (122). Infection was normal. If it didn’t kill the mother a couple weeks after birth, it could cause smelly vaginal discharge, pelvic inflammatory disease, and pain throughout the entire body.

From Resignation to Choice

Women were fatalist about the risks of childbirth. Edward Shorter argues, “Traditional mothers accepted obstetric risks with the same fatalistic resignation that villagers displayed toward all risks they felt themselves unable to control, such as hail, plague, and war” (160). Once doctors and midwives began advertising their new techniques (including forceps, episiotomies, pain relief, and c-sections), this resignation turned to choice. And once the c-section became a relatively safe and viable option in the 1920s, women increasingly turned towards the hospital based doctors and away from traditional midwives.

Today, many birth advocates see this move from traditional midwives to male hospital based doctors as patriarchy writ large, as evidence of decreasing autonomy for mothers, as a historical mistake. I agree and disagree. It’s my blog. I’m allowed to do that.

For many women, it was a mistake. Hospitals were pretty deadly at the turn of the twentieth century. However, hospitals with their male doctors weren’t caricatures of capital P patriarchy. Sure. Patriarchy isn’t absent from the story. The doctors were men. That’s because they were afforded the education and opportunities. From this standpoint, all of medicine and science and innovation is capital P patriarchy. Unfortunately, this outdated and decades old feminist interpretation overlooks the burgeoning autonomy of the women who chose the hospitals. Women weren’t always bamboozled into hospitals. They went willingly.

Hospitals were often way too interventionist. Some early pain medicine was itself deadly. And episiotomies were certainly overdone in routine childbirth, but jeez louise, at least they were sewn back together. Before modern medical care, a woman could tear through to her rectum and the midwife would leave it. Or maybe not. Luck of the midwife draw.

Hospitals didn’t represent perfection. Of course not. But they did represent the first step towards progress, progress that has been remarkably swift in the context of women’s historical birthing experience.

Eventually, doctor training improved, dangerous techniques were abandoned, and regulatory boards stepped in. Traditional childbirth — free from doctors, from hospitals, from pitocin, from c-sections, from epidurals, from monitors, from unfeeling and authoritarian medical staff —that childbirth was not folklore’s empowering feat. It was a crapshoot. Let us never forget that.

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  1. Edward Shorter, A History of Women’s Bodies, New York: Basic Books Inc., 1982, 88. All in-text citations are from this book. The information for this post has been gleaned from Shorter’s thoroughly researched work. It is an old book, almost as old as me, and some might argue outdated. Although portions referring to the present day birth experience clearly are outdated, the book is mostly about primary materials from the 18th and 19th centuries. I don’t agree with all Shorter’s conclusions or theses, but the source material is intriguing, devastating, and well researched.  ↩
  2. Midwives were childbirth attendants for much of history. I’d like to note that pre-medicalized or “traditional” midwifery is not the same as standardized and highly trained midwifery. Many urban midwives were well-trained and associated with hospitals or medical establishments. In this respect, they were usually more similar to the doctors of the time period than to the traditional rural midwives. Indeed, often they were better equipped for emergency situations than male doctors. However, even the best trained urban midwife was unable to perform a safe c-section or vaginal operation before the rise of hospital births.  ↩
  3. Laura Helmuth, “The Disturbing, Shameful History of Childbirth Deaths,” Slate, Sep. 10 2013.  ↩
  4. Helmuth  ↩

6 thoughts on “Questioning Childbirth Folklore

  1. The dangers of childbirth in the past are evident even in our traditional stories like Cinderella and Hansel and Gretal, with the prevalence of step-mothers. These characters weren’t getting step-mothers because their parents divorced.

    Another alarming fact: life-expectancy in rural China in the early 20th century was something like 25 for men and 24 for women. Women had a shorter life expectancy because they had a large incidence of dying in childbirth.

    THAT’S what “normal birth” looks like (actually, the example of China is also illustrative of what you get with “traditional Chinese medicine”)

    1. Oooh, I love your point about the fairy tales. I never thought about how the fear of the disappearing mother was related to actual cultural fears about maternal mortality. I’ll be sure to tell my daughter that as she dresses up like Cinderella for the umpteenth time this week…kidding. (Although, because she’s my kid and therefore a little weird, she does love to hear the gory details of her own birth story and about how scary it was for everyone…the fact that I can tell her this story because I’m not, you know, dead is a major score for the medical establishment).

  2. Saying that a hospital births are a privilege while calling non-medical models of birth folklore really does injustice, I think, to many women’s experiences in hospital birth. On the other hand, given the incredibly difficult experiences with birth you had, saying that radical opposite also does injustice to your & similar experiences. This topic is always grey and is complicated by, like you say, interpreted (and distorted) histories.

    It’s important to note that, within a Western context, “non-medical” models of birth are not, nor should they claim to be, a return to the “good ole’ past.” If anything they are a dance between modern understandings of health & medicine, and the naturally-occurring process of birth. Midwives are not supposed to agree to home births for women who are not medically assessed as “low risk.” They are also trained to watch for symptoms that indicate that a hospital transfer might need to be done, and are required to pass on care to an obstetrician if these symptoms present. Modern medicine plays a large role in assessing whether or not home birth will be safe and is used continually by the midwife to ensure a safe delivery (in hospital if need be). In the past, some women and babies would have died even if they were in hospital, because the medicine/technology was not as advanced as it is today. The privilege lies more in our current understandings of medicine & the availability of technology, when needed, than in hospital birth.

    Second, home births of the “past” were complicated by poverty and poor hygiene. Women who were impoverished were likely not receiving pre-natal care and may have been malnourished and weak; a bad combination for the exhausting process of childbirth. Homes of the poor were often overcrowded and sanitation may not have been ideal, leading to greater potential for infection of both mother & baby. In the late 1800s/early-mid 1900s it was the poor who couldn’t afford to go to the hospital, despite the fact that they may have benefited the most from this option (for the reasons above), leading to a higher and sad morbidity and mortality rate. This is not the picture of home birth today. In fact, most women who are choosing home birth today are of the middle-classes and are quite physically strong comparatively speaking (due to diet, exercised etc.) Home births are also not happening in poor, unhygienic conditions like they were in the past. Midwives are also highly trained today (not to be confused with nurse-midwives who undertake vastly different work). In Canada all midwives must legally have a 4-year Bachelor of Science in Midwifery degree. In the past a “midwife” could have been a woman who had had a few babies and decided to call herself a midwife.

    The medical model of birth is deeply flawed in so many ways, and that’s why I think it is a stretch to call it a privilege. The aspect of obstetrics that saves lives (like yours) is not what I refer to when I say this. But, the “natural” model of birth just makes sense in a lot of really important ways. For starters, moving around and not being confined to bed is, physiologically, a really important part of birth and pain management – yet, in most Western hospitals this is discouraged, or made impossible by constant [unnecessary] fetal-monitoring. (Caveat: fetal monitoring is important, but regular monitoring with a fetoscope accomplishes the same goal without restricted movement). In Western hospitals most women are told to, or are made to, give birth lying on their back. This is a position which is convenient for the medical staff, and not one which is conducive to how women’s bodies are made to give birth. It often also leads to greater instances of perineal tearing which could usually be avoided by squatting or all-four positions. Women cannot eat or drink during one of the most exhausting times in their life. Until recently women were receiving mandatory “shave preps” at the request of obstetricians who preferred no hair, and painful enemas so they wouldn’t defecate while pushing. Natural pain management is not being properly used in hospitals, and most maternity nurses don’t know how to use natural pain management, yet alone teach it. Instead, women are left in bed, with a tight fetal monitor on, scared and in immense pain. Fear causes more pain etc.

    I think the non-medical model of birth could be accomplished in hospital. Unfortunately it is not at this point in history, and on the contrary, the opposite is happening. When someone’s life is in danger, of course medicine is needed and is great! But, when it isn’t, we shouldn’t pathologize that which doesn’t need to be pathologized simply because it’s better than the tragedies of the past.

    1. Thank you for the very thoughtful comment. I actually agree with quite a bit of what you’ve said. I do think hospitals can do a better job, but I think I disagree that hospitals can’t incorporate a different, less interventionist model. Indeed, where I had my first two children in San Diego, they have a whole separate floor with birthing rooms that don’t use constant monitoring, pain medicine etc.. And moms there are delivered by midwives. The next floor is the traditional labor and delivery and a mom can choose to move to that or be transferred for medical reasons. I had some issues with the decisions during those births, but I did choose that hospital because of what I viewed as a new, awesome model for hospital births (although not perfect. I still didn’t like that pain relief was considered taboo on the birthing center floor. I don’t think such a clear demarcation is necessary). The problem with home births is if an intervention is required, getting to the hospital can be costly in terms of time, even minutes make a huge difference (as is true with all emergencies, but birth isn’t usually a surprise like most emergencies and therefore the risk feels less justified). That said, my main point in this post isn’t about hospitals versus home births, but about rethinking the mythology often used to valorize one type of birth experience. This mythology isn’t based on a true account of history, and that’s the part that gets to me. We can’t have honest conversations without lifting that veil. Oh, and one more off topic comment. I should note home birth midwives in the US are (usually) NOT well trained, which is crazy to me. They are not the same as certified nurse midwives who require years of training and who are usually affiliated with a hospital in the U.S. I know Canada and the UK have different requirements for their home birth midwives, which is why some people don’t realize the difference between midwife types in the U.S. Thanks again for weighing in. You bring up some good issues.

  3. Thank you for your thoughtful reply! The hospital you describe is so unlike any hospital I have ever heard of here in Canada! Women here usually do not have those options.

    It’s funny, because Canada and the US are often clumped into one group in these discussions. But, based on the difference in options in-hospital and of midwife certifications, they are clearly two distinct beasts!
    Thank you for writing this, I very much enjoy your blog 🙂

    1. Yes, the San Diego hospital is a bit of an anomaly in the US too, but I know more are popping up. However, even at this more “progressive” hospital, I felt like the mythology was still embedded in many of the midwive’s brains (and huge omissions, like never mentioning prolapse with large babies at all). Rather than separating the doctors and midwives, it would make more sense to take the best from both worlds (I don’t know how feasible this is, but it sounds idyllic in my mind:))

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