If we can’t decide, should we just let ourselves be delivered?

Denouncing the hyper-medicalization of births often brings together activists around the rights of babies and rarely around the rights of ⁽¹⁾ women. Dr. Leboyer states, by for example, that « it is not the woman who gives birth, it is the child who is born ».⁽²⁾. In fact, in his book For a birth without violence, he denounced the violent reception that was reserved for the newborn, without trying to understand the experience of the woman who gave birth to him. 

Later, physiological approaches will focus on the processes taking place in the body of the woman giving birth. This is the beginning of an awareness. 

In this respect, the writings of Dr. Michel Odent
⁽³⁾
have made understandable, for the layman, the subtle transformations operated in the body and in the psyche of women during parturition, under the effect of the « cocktail of hormones of love ».

These two physicians have undoubtedly made a significant contribution to the debate on parturition rights. Nevertheless, many of us, women and feminists, were left wanting more because, if the reproductive processes discussed do involve major hormonal, physiological and morphological transformations, there is little in their books to help us understand the power issues that run through pregnancy, childbirth and the postpartum period. 

The biological approach is therefore not sufficient to understand the social issues of these facets of women’s health. It is necessary to call upon the human sciences to apprehend the complexity of the forces and conflicts that surround the birth of future generations and the renewal of Humanity, which takes place in the most intimate place of women’s bodies, where so many myths and injunctions, prohibitions and mysteries are hidden. 

Anthropological and historical views could serve as a starting point, but soon enough we will have to apprehend this subject with the help of a socio-political approach. 

CHILDBIRTH ELSEWHERE

Among the Ju’hoansi bushmen of the Kalahari, women share a desire, an ideal: to give birth alone and without any kind of assistance. 

As with many other facets of the lives of primitive peoples, this aspiration will be considered relatively acceptable… but, of course, only among them… 

What about this handful of « radicalized nature-mothers » in our post-industrial countries who share tips and advice on how to have a « free birth »: without fetal monitoring or careful examination, without epidural, without operating room, without doctor and midwife nearby? No control, no surveillance, no foreign presence or accompaniment. In our country, this raises problems, passions, deep fears, and questions: are women who espouse this ideal selfish, thinking first of their own interest to the detriment of the health and safety of their baby? 

But let us return to the Ju’hoansi of Bostwana. Little girls are raised there in the hope that one day they will be able to give birth alone in the bush. During labor, the women isolate themselves a few hundred meters from their camp, prepare a bed of leaves and wait in silence for their bodies to open up to let their babies out. Those who give birth during the night do not even allow themselves the protection, warmth and light of a fire. 

The delivery could not be more discreet and, with the first cries of the newborn, continues in the company of other women of the village who will assist her in the last phase of labor and the return home. 

We are far from the ideal of the highly technological childbirth where the hero is a surgeon who saves, in extremis, the life of the mother or the child (or even both), in a sequence of feats and sophisticated interventions, responding to an endless catalog of dangerous problems that inevitably and fatally arise when giving life. 

THE MEDICALIZATION OF BIRTHS IN EUROPE 

Most of us have been brought up to believe that pregnancy and childbirth are processes whose nature and complexity require knowledge reserved for a medical elite, the only ones with the technical skills to make them safe. 

However, despite its deep roots in mentalities, the medicalization of childbirth is not a very old phenomenon. It was not until the 17th century that the pioneers of obstetrics in Europe appeared, who « got their hands dirty » during the first hospital deliveries at a time when the maternal mortality rate was close to 50% of births in institutions, notably because of the obstinate refusal of doctors to wash their hands between autopsies and gynecological examinations, which were carried out one after the other! 

Outside of hospitals and in exceptional cases, doctors were also called to the bedside of middle and upper class parturients, when childbirth was difficult and the midwives had exhausted all their resources. They will therefore develop techniques and instruments which, at first, will serve to alleviate the problems that inevitably arise in some deliveries. Nevertheless, apart from indigent women who come to the hospital to give birth (often because they have no other place to go) and cases that are complicated at home, it is still the midwives who take care of the vast majority of births. The medical and scientific knowledge of human parturition thus appears in a very precise context, on the one hand around pathological cases (which are exceptional) and among a population of women whose health is not optimal. 

We can therefore affirm that the « scientific » interest for what until then was considered as « women’s business » and therefore depreciated and ignored by scientists and academics — occurs mainly in pathology and not in physiology. Obstetrics was not born to accompany a natural process but to intervene when things go wrong. No more in the 17th century than today, the specialists of this branch of medicine had the means to train themselves to observe and wait. They find their raison d’être in the action and intervention on the diseases and dysfunctions of parturition… when they do not produce them. But we will have the opportunity to return to the intrinsically iatrogenic character of the practice of obstetrics as a patriarchal discipline. 

FROM WOMEN TO THE GYNECO-OBSTETRICIAN: WHEN EXPERTISE REPLACES SOLIDARITY 

At the same time, another process is taking place that is essential for understanding the current over-medicalization of childbirth: the placing of midwives under control. 

Already in the 15th century and in parallel with the recognition of the profession, the protection of this profession was established, first very timidly, then in a more systematic way: between 1400 and 1900 the training and the social recognition of midwives ceased to be an aspect of the private domain and confined to that quasi-secret sphere reserved for the female body and experience. During these 5 centuries, this field of women’s health will change from the intimacy of the home to the very serious level of state business. 

Thus, in the 18th century, the training of midwives was organized in a scattered manner to consolidate and become mandatory in the 19th century in Northern Europe.Henceforth, as the art of obstetrics developed and birth became more medicalized, childbirth became a medical responsibility and the training of midwives became a political issue: at the beginning of the 19th century, childbirth was still in the hands of matrons, which made the authorities shudder to see the future of the nation entrusted to these women, who were judged to be uneducated and amoral. Very quickly, the idea of creating free childbirth classes developed. More than a simple course, it is the regulation of the profession that is organized »⁽⁴⁾.

The fight against these women, most often from working-class backgrounds, illiterate and drawing their knowledge from empirical practice, becomes an emergency and, with the progressive recognition of professional midwives, all those who practice on the bangs of official control will become the scapegoats for any problem related to the health of women and children. The Inquisition is not far away and neither are the bonfires. For doctors seeking recognition in a field where their legitimacy was to be built, matrons were the enemy to be destroyed, on whom the responsibility rested in case of problems. A birth that went wrong at the hands of the matrons was punishable by the most severe penalties, whether it was the result of an unforeseeable complication or a questionable practice. 

It is thus from the same figure that two characters emerge: the uneducated and dangerous matron (the witch) and the « good wise woman » docile to the learned authority of men. 

But even before this distinction is made, the ancestral midwife is not universal, and even if one accepts that it is the oldest (true) female profession in the world, it does not exist everywhere or in all societies. Long before we could talk about specialization in the art of childbirth, the knowledge of parturition belonged to all women. In the most primitive societies, being female was enough to have access to the available knowledge and know-how related to childbirth. 

Since the process of hominization, 6 million years ago, childbirth was considered a female matter: it concerned the woman who gave birth and her pairs. Mothers, mothers-in-law, daughters, sisters, cousins, co-wives, neighbors… those who assisted the woman in labour were members of her more or less close circle. Thus, a female community was built around this reproductive process. Knowledge was created and shared. Gestures were reproduced, a language was shaped and beliefs were born, reinforced and circulated. 

The Ju’hoansi ideal of a solitary, unassisted birth is a very rare exception. Throughout the ages and among the majority of peoples: the woman is rather well taken care of during childbirth. It is a whole community of women who come together during births, sharing knowledge of the body and parturition, exchanging goods, pooling resources such as firewood, linen, childcare tools, food and care. 

In the Anglo-Saxon countries, in the Middle Ages, these women called each other « god-sibs » to underline the importance and the strength of the bonds that unite them. This is the origin of the word « gossip »: the information that circulates in parallel to legitimate channels, away from male control. 

Historical references from the South and North of Europe describe a group of three or even five women who would stay at the woman’s home for several days or even weeks to assist her during the birth and also to take care of the domestic and productive tasks that the woman was not able to perform during the postpartum period. These women were a precious help for the household that was about to welcome a new member, but it was also an excuse to party among women without having to justify themselves to the men.⁽⁵⁾ In contexts where women had little autonomy and consideration, this opportunity to socialize was often more than welcome. 

Childbirth as a social event between women was the norm among most societies throughout history and among different strata of society until the advent of the bourgeoisie and the emergence of households built around the nuclear family. 

But even among our contemporaries, conceptions of the art of childbirth that concern the whole society and not a few specialists are still relevant. The Achuar of the Amazon rainforest continue to take care of childbirth collectively and non-professionally. Until very recently, Achuar women chose their vegetable garden as the birthplace of their children. They were most often accompanied by another woman of the family and it is only in recent years, when international NGO projects and Ecuadorian health authorities have been established in their region, that women are encouraged to give birth in the community or family home in order to facilitate the management of possible complications which, occurring in the forest, usually became very serious. 

Among the Achuar, there is no traditional midwife: everyone ‑and especially women- is able to assist women in childbirth. Thus, approaches to improving perinatal and maternal health in these communities are organized around the transmission of reproductive health skills to the entire population, since it is the entire population that is concerned. This approach is necessarily different from work in other communities where the figure of the traditional midwife is strong and well identified. In these communities, midwives will be the target of maternal and neonatal health projects. 

Unfortunately, these empirical midwives that remain in our time are most often instrumentalized to introduce practices deemed safer by health authorities. Thus, policies that include an « intercultural health » component that is little or not in line with the reality on the ground contribute to the weakening and disappearance of traditional midwives. This phenomenon is equivalent to the elimination of the only childbirth professional accepted and deemed competent by women for miles around. Often to be replaced by one (or more) health professional(s) from the city, having neither the legitimacy nor the knowledge to be accepted by the population and by women of childbearing age in particular. 

ATTENTION PATTERNS OF DELIVERIES AND SOCIO-ECONOMIC LOGICS 

Back to our latitudes and to our time, it is salutary to take a critical look at the model of childbirth management in force in our societies. A model organized around the medical authority and obeying the logic of economic production, in which the bodies ‑in good or bad health- must obey and submit to the requirements of profitability, productivity and a good ratio between costs and benefits. 

Certainly, a small minority of women escape and will always escape the pressure exerted by the media and by the official discourse presenting childbirth as a dangerous event by definition and systematically requiring close medical supervision and control, where the guideline is zero risk. These women are looked upon with suspicion and considered irresponsible because they prefer the satisfaction of an obscure desire for omnipotence to the safety of their child. Childbirth without high-tech medical assistance in our country is an aberration. 

Thus, the reproductive journey of almost all women who give birth in the countries of the North and in the wealthy and urbanized strata of the South is marked by an obligatory passage through the hands of a gyneco-obstetrician surgeon: whether it is a caesarean section (in 20% of births in Belgium) or another type of more or less heavy medical intervention (external version in case of breech presentation, use of suction cups or forceps during expulsion, artificial extraction of the placenta, .), recourse to this specialist in the pathology of childbirth is becoming widespread, even in countries that have developed a model of pregnancy and childbirth management organized around university midwives (empirical midwives having disappeared completely long ago in Northern Europe). 

In Holland, the rate of births attended by a midwife or general practitioner (at home or in a polyclinic) has been steadily declining, from over 60% of births during the 1960s to less than 23% in 2010. This country has a particular model for managing deliveries, based on sorting out cases that can be done at home and those that need institutional management. This triage is done by front-line providers, i.e., general practitioners and midwives. 

Childbirth as a family event disappears. But why? What logics are at work? Once again, we must look for answers in the cultural currents that surround us and in the economic and political systems that organize our lives. The productivist management that seems to be taking shape in the cultural sphere as well as in the economic and political spheres reinforces the role of experts and their authority. In the wake of this, hegemonic medicine, as a capitalist and patriarchal institution, imposes norms and imprints behaviors of prevention, screening, measurement and arrest. In these processes, which are above all disciplinary processes, the reproductive autonomy of women is limited. 

But it is not only at the level of the individual experience of people that hegemonic medicine has flaws and inconsistencies. From a purely cost-benefit perspective, encouraging the management of the majority of pregnancies and deliveries by specialist physicians is not very reasonable. However, the decline in low- or no-care births is a worldwide phenomenon and is occurring even in countries with a strong tradition of midwifery care, such as the Netherlands. This is a warning sign for observers of this issue around the world. This is particularly true when we see that cesarean section rates have been steadily increasing since the 1960s on all continents, reaching proportions of 90% or even 95% of births in some private clinics on the American continent. 

If you don’t mind metaphors, we could use the following one: it would be completely absurd to call a fireman to put out the candles on a birthday cake. So, why do we need a surgeon specializing in the pathologies of pregnancy and childbirth to take care of all cases? What about the fact that in most countries of the world, the specialist who has the most years of study behind him, the one who costs the most to the educational and health care system, the one who has the most recourse to expensive and sophisticated devices, techniques, drugs and instruments will be led to take charge of almost all deliveries, even those (85–90%) that do not need any intervention and this despite the recommendations of international public health authorities such as the World Health Organization or the United Nations Population Fund? These organizations consider midwives and general practitioners to be the most appropriate professionals to manage pregnancy, childbirth, and postpartum care in a population. They should be the foundation of any prenatal, delivery-related, and postnatal care system. The responsibility for sorting out which normal cases they should manage independently and which require the skills of specialists (ob-gyns) and surgical interventions such as episiotomy, vacuum extraction, or cesarean section should rest on their shoulders. 

However, what happens in most systems where there is free competition among professionals is that most women who have the opportunity to choose their health care provider will go to the specialist’s (private) practice because it will be considered the « safest » and most competent. In reality, it is the one that charges the highest fees for performing equivalent procedures and being within the reach of other health professionals, called « front line ». 

The only exception to this rule of free competition between professionals, which seems to be universal and favours specialist doctors, is New Zealand. In this country, midwifery had practically disappeared between the 1930s and 1980s. The few midwives who practiced did so as nurses or rather « technical assistants » to the specialist physician, and deliveries took place almost exclusively in hospital institutions (less than 0.3% of deliveries took place at home in the 1980s). Indeed, the New Zealand Board of Health had issued a document stating that home births were unsafe. 

In this context of multiple difficulties in accessing home births, aconsumer group has formed in this country, endorsing the demands of New Zealand midwives to reinstate this profession in the maternal and child health landscape. This advocacy work began to bear fruit in the 1990s, when reforms reopened midwifery schools independent of nursing schools. 

The advocacy work of the profession eventually led to the establishment of a system of « managed competition » among health care professionals. In this system, women who are expecting a child can choose the professional who will become their « primary maternal caregiver » and this person can be a general practitioner, an obstetrician-gynecologist or a midwife. 

In 2003, more than 78% of New Zealand women chose a midwife for their pregnancy, birth and postpartum care, regardless of where they chose to have it.⁽⁶⁾Unlike in Belgium, where very few facilities open their doors to private midwives for a birth in their technical facilities, New Zealand law requires institutions to treat all health care providers equally, whether they are OB-GYNs, GPs or midwives. New Zealand-style « managed competition » means that the basis for equality among providers is guaranteed. Unfortunately, this model is an exception in the world. 

THREATS TO FREEDOM DURING CHILDBIRTH 

After reviewing the cultural, historical, and economic factors that are at the origin of the increasing medicalization of childbirth in the world, we feel it is necessary to question the interest in maintaining and defending a model of care centered around the specific needs of this rare event in the lives of women. 

To do this, we are tempted to share experiences⁽⁷⁾ which, for those who have had the opportunity to experience a respected birth, allows for a deeper knowledge of oneself and one’s abilities. It is not our intention to reinforce the myth of the instinctive woman who knows how to give birth because her body is made for it. Instead, we would like to highlight the experiences of those women who have had one or more satisfying births and who have experienced an atmosphere of respect for their rhythms, needs and desires. Among them, the idea of a path of « empowerment⁽⁸⁾ is always present. What can we think of a system that makes it almost impossible to discover one’s capacities and to experiment with listening to oneself and one’s physiological, emotional and cultural needs? 

In 2013, new regulations in the United Kingdom will make home births with a private midwife difficult to access⁽⁹⁾. Indeed, new European regulations aim at prohibiting the practice of medical professions without specific insurance coverage, which is very expensive. 

Although there was already a problem for liberal midwives in France and Germany to access this professional insurance for home birth, some liberal midwives continued to practice in out-of-hospital settings in this country. What they did (and still do) is inform their patients that if there is a problem at home, they are not covered. In the near future, this arrangement, which was already precarious, may become downright impossible in view of the new laws. 

As for Belgian midwives, some of them wonder if the insurance for out-of-hospital deliveries will not increase in the near future, under the pressure of certain interest groups… 

It is possible to give birth respectfully in a hospital setting, but « The right to give birth outside the hospital setting is paramount for all women, whether they choose to give birth in a hospital or at home .

Respectful treatment of women who choose to give birth in a hospital setting can only be measured if they have the choice to leave that setting and give birth in another setting, even if they do not exercise that choice. There is a different dynamic where health care personnel make recommendations with the knowledge that the woman can choose to follow or not follow that advice and where it is known that the woman can be legally compelled to do so. »⁽¹⁰⁾.

There is a need to move away from simplistic dichotomies that frame the childbirth debate in terms of individual choice and access to information, with the criterion of safety as the only important one. What we are talking about here is autonomy, and this is not something to be begged for, but something to be conquered. Autonomy which, since the dawn of time, has been necessary at all times, but which is even more precious when it comes to the vulnerable but powerful bodies of women who give life 

Paola Hidalgo

Delegate for socio-political communication at Bruxelles Laïque