Until recently in the history of human beings, childbirth has been the exclusive work of women, who labor and bear down with their uterine muscles to deliver their babies from their wombs into the larger world of society and culture. Today, however, increasing numbers of the world’s women deliver babies via the medical establishment’s use of forceps, vacuum extractors, surgery through cesarean section. The medical definition of birth is the emergence of a baby from a womb, a definition that minimizes women’s involvement and agency. This definition and its implications encode the challenges faced by social scientists who study childbirth.
Anthropologists have consistently shown that, 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 will carry a heavy cultural overlay, resulting in wide and culturally determined variation in childbirth practices: Where, how, with whom, and even when a woman gives birth are increasingly culturally determined.
Brigitte Jordan’s comparative study of birthing systems in Holland, Sweden, the United States, and Mexico’s Yucatan, originally published in 1978, was the first to comprehensively document the wide cultural variations. Her biocultural approach focused on the cultural definition of birth, the place of birth, birth attendants, artifacts to facilitate or control birth, and differences in knowledge systems about birth.
Among these, place of birth has emerged as most salient for how birth happens. In home settings across cultures, from huts to mansions, childbirth flows 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 continuing their activities, which may include doing chores, chatting, walking, eating, singing, dancing, and so on. Such activities subside as they 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 mid-wives. Many cultures have rich traditions about who should be present (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 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, rewarded by the baby in their arms. Postpartum practices vary widely: Some cultures encourage early breast-feeding; some code colustrum as harmful and feed the baby other fluids until the breastmilk comes in. Steam and herbal baths and periods of postpartum confinement are often culturally prescribed, varying in length from a few to 40 days.
Where freestanding birth centers exist, whether staffed by traditional or 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 birth to proceed at its own pace.
Birth in the hospital is a different experience. The biomedical model that dominates hospital care demands that births follow familiar patterns, including cervical dilation of 1 cm per hour—an arbitrary rule unsupported by science but consistent with industrial patterns of production. Ensuring a consistent labor requires frequent manual checking of cervical dilation, which, if determined to be proceeding too slowly, may be augmented by breaking the amniotic sac and administrating the synthetic hormone pitocin (syntocinon) intravenously to speed labor. In Western-style hospitals, staff may monitor the strength of the mother’s contractions and the baby’s heart rate. At the moment of birth, the vaginal opening may be deemed too narrow to permit an easy birth and so an episiotomy may be performed to widen the vaginal outlet. Such surgeries may be medically unnecessary in as many as 90% of births, but some researchers interpret such routine obstetric procedures as symbolic of the core values of the technocracy, which center around an ethos of progress through the development and application of ever-higher technologies to every aspect of human life, including reproduction.
In a world where the high technologies of Western medicine are valued, many developing countries destroy viable indigenous birthing 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 be stocked with high-tech equipment but lack the most basic supplies. Hospital staff may have little understanding of or respect for local birthing traditions and values, resulting in local women avoiding such hospitals whenever possible. From Northern India to Papua New Guinea to Mexico, indigenous women echo each other’s 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.” “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 model.
This Western-style model of childbirth, sold to governments as “modern health care” and to women as “managing risk” and “increasing safety in birth,” has resulted in an unprecedented explosion of technological interventions in birth, including cesarean sections. Despite the World Health Organization’s (WHO) demonstration that nowhere should cesarean rates be above 15%, cesarean rates for Taiwan and China are at 50%; for Puerto Rico at 48%; for Mexico, Chile, and Brazil at around 40%; for the United States at 27.6%; and for Canada and the United Kingdom at 22%. Other factors in the rise of cesarean births include physician convenience and economic gain and deeply ingrained medical beliefs that birth is a pathological process that works best when technologically controlled. The Netherlands meets the WHO standard with a cesarean rate of 12%, reinforced by the excellence of birth outcomes in that country. This success is entirely cultural: In combination with Dutch cultural values on family, midwifery care, and careful attention to scientific evidence, the definition of birth in the Netherlands is as a normal, physiological process, resulting in minimal interventions in hospital birth and the high home birth rate of 30%. In contrast, in most of the developed world, home birth rates hover around 1%, despite its demonstrated efficacy and safety.
The disparity between the scientific evidence in favor of less intervention in birth and the increasing interventions of actual practice reflects
- widespread acceptance of the Western technocratic model of medicine as the one on which to base developing health care systems;
- the political and economic benefits to physicians and technocrats from the imposition of this model;
- the forces of globalization and their concurrent trends toward increasing technologization;
- women’s concomitant faith in this model as the safest practice for birth
Nevertheless, many contest this model’s domination. In addition to the thousands of local birthing systems, three primary models for contemporary childbirth exist throughout the world: technocratic, humanistic, and holistic. The technocratic ideology of biomedicine views the body as a machine 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 and stresses spiritual and intuitive approaches to birth. In dozens of countries, humanistic and holistic practitioners and consumer members of growing birth activist movements use 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 an anthropological point of view, all three paradigms are limited by their focus on the care of the individual. For example, mortality resulting from birth is widely recognized as a massive global problem. Biomedicine identifies conditions such as hemorrhage and toxemia as major causes of maternal death, and it advises investment in doctors, hospitals, and rural clinics to provide prenatal care to prevent toxemia and active intervention immediately after birth to prevent hemorrhage. In contrast, anthropological research in countries with the highest maternal mortality rates highlights the general poor health of women, who 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 economic opportunities for women.
References:
- Davis-Floyd, R. E., & Sargent, C. (1997). Childbirth and authoritative knowledge: Cross-cultural perspectives. Berkeley: University of California Press.
- DeVries, R., van Teijlingen, E., Wrede, S., & Benoit, C. (Eds.). (2001). Birth by design: Pregnancy, maternity care, and midwifery in North America and Europe. New York: Routledge.
- Jordan, B. (1993). Birth in four cultures: A cross-cultural investigation of childbirth in Yucatan, Holland, Sweden, and the United States (4th ed.). Prospect Heights, OH: Waveland Press.
