In this first part of a series on technology and birth, we will look at why long-established ways of caring for pregnant women and assisting childbirth were undermined and began to be replaced.
It was on October 12, 2010 that Ágnes Geréb first appeared in a Budapest court-room, shackled like a dangerous criminal. An obstetrician convinced of the need to bring childbirth back into the hands and homes of mothers, Geréb had assisted in 3,500 natural home-births over the previous 17 years. In that time, an ever-growing community of mothers and fathers regarded her as an honorary member of their family, grateful for a gift she had given them which had previously seemed out of reach. And with only three neonatal deaths under her care throughout that period, even a statistically-driven analysis could not undermine Geréb’s credibility.
Yet, caught in the grey zone of quasi-legality within which home-birth exists in so much of the modern world, Ágnes Geréb found herself accused of negligent malpractice. As this is being written in the spring of 2018, Geréb is on the verge of returning to prison, after a complex and torturous eight years of appeals and counter-appeals, including more than three years of strict house arrest. Now, with all other legal recourse exhausted, only a pardon from Hungarian President János Áder can prevent this noble woman’s imprisonment.
Sadly, when this case reaches the attention of the international press, it often does so merely to contribute to a critique of the current Hungarian government. This hypocritically and short-sightedly obscures the wider context and process of which Ágnes Geréb’s cause and plight is such a poignant consequence. For while many Hungarian supporters of Geréb would certainly advocate legal and attitudinal changes in their own country, this situation is part of a long and successful campaign across the Western world to control, pathologize, and institutionalize childbirth, resulting in a standard approach through which a woman is alienated from the birth of her own child, taught to fear the process as a patient fears a fatal disease, and subjected to a routine battery of excessive intervention and manipulation. The chains around Ágnes Geréb eight years ago, and the prison cell that may still await her, are a consequence of what our civilization has done to the most fundamental of human events. What has happened to childbirth is a horrible case study of our descent into a dehumanized, technological society.
What the Body Knows
“Normal, spontaneous childbirth is an automatic sequence,” explains Jennifer Block in Pushed: The Painful Truth about Childbirth and Modern Maternity Care, “a series of internal and external movements, voluntary and involuntary, that a woman’s body makes in order to have a baby.” A pregnant woman is neither a victim of fate nor a helpless object of the medical profession, but is naturally endowed, under usual circumstances, to finish what has begun, and deliver, under the rhythms of her own body and person, the baby she has carried with similar innate capacities. The way in which this has happened from Eve until today is worth, as Block relates it, elucidating and emphasizing.
“The pituitary gland releases the hormone oxytocin, which causes the smooth lining of the uterus to contract rhythmically, and those contractions gradually accelerate and intensify. The lower portion of the uterus, the cervix softens and opens into the vagina; the pelvic joints and ligaments become pliant; the amniotic sac—the membrane that surrounds the fetus and fluid—ruptures. The baby descends into the pelvis and through the dilated cervix, and with the aid of muscular efforts, bodily movement, and the stretching of the pelvic anatomy, is expelled from womb to world. This physiological sequence continues after the birth as well. The uterus contracts further; the remaining blood flows from the placenta to the fetus through the umbilical cord; the placenta detaches and is expelled. Still more contractions follow, which retract and repair the extensive network of uterine blood vessels left enlarged and exposed by the shorn placenta. The breasts, meanwhile, produce colostrum—highly concentrated breast milk—in the mammary glands.”
And so a new person arrives on center stage. “Both magnificently dynamic and somewhat predictable, the duration of each stage of the birth process, and even to some extent the order in which they occur, vary from woman to woman and birth to birth.” But this constant yet changeable and variable drama of nativity is no longer normal. “Very few women in the United States experience this physiological sequence,” Block sadly concludes, and, instead, “most American women give birth wired to a rig of machines.” This is not, of course, a solely American story, and we can see this situation across Europe and North America, as well as everywhere else that modern Western assumptions have become entrenched. But throughout the process, the United States has been a leading and extreme example of the journey from natural birth to mechanized, pathologized, and institutional birth. How did this happen?
The Technological Mind Reaches the Womb
It would not come as a surprise for anyone alert to the technological mind and life, which the West has particularly absorbed over the last two centuries, that nothing as societally central as parenting and childbirth could escape its influence. The essence of technology, in Mark Blitz’s paraphrasing of Heidegger, is “the structuring, ordering, and ‘requisitioning’ of everything around us, and of ourselves” (italics added). Yet it can come as a rude awakening to consider this particular intrusive reshaping because, perhaps more than most aspects of modern life, we have come to consider the contemporary way of giving birth as an axiomatically obvious situation. Of course it happens in hospital. Of course induction and other interventions are necessary. Of course a speedier labor is necessarily less traumatic and more healthy to mother and child. But these nostrums and the system which they help to support are as evidently and arbitrarily based on the technological mindset and its demands as anything around us.
If nature can and should be controlled and rationalized by the application of objective and de-personalized methods—a position widely accepted and crudely applied from the second half of the nineteenth century onwards—then the human body can and should be likewise suppressed to achieve “efficient” and “rational” results. As childbirth researcher and author Nadine Edwards summarizes the situation, “modernity meant assuming that applying a certain definition of rationality to our world provides a more accurate understanding of reality and thus provides the means to manipulate and control it more effectively.” And in general, Barbara Bridgman Perkins states in The Medical Delivery Business, the emerging and developing area of “specialty medicine defined itself as scientific and assumed that its clinical activities enacted the march of scientific progress.” Obstetrics was a late developer even within this trend, and had the disadvantage of needing to displace a long-established guardian of childbirth, midwifery. But the zeitgeist was most certainly on its side.
“In pre-modern times women practiced healing in domestic settings, and both healing and medicine were based on informal, experiential knowledge,” Edwards reflects. But in our times, the informal and experiential have long come to be assumed defective and insufficient, compared to the standardized and the abstract. “The modern mind’s belief in rationalism and faith in science apparently ‘freed birth from the constraints of nature and opened it to improvement,’” Edwards continues in Birthing Autonomy, and “the body was the material site on which to defy the constraints of, and improve on, nature.” When the human body itself becomes the latest place where the disconnection between abstract rationalism’s false objectivity and subjective reality is felt, the cost is deeper than ever. And it is a cost that starts with both harassed and maltreated women and their infants born with unnecessary technological brutality. A theoretical demeaning of the human body, along with the exaltation of technocratic and isolated medical thinking, has been, in Edwards’ words, “crucial in the development of birth practices based on technology and tools rather than on skilled midwives’ hands and able women’s bodies.”
The Profession Takes Over
With foundational abstract concepts taking hold; with the burgeoning of a new kind of medical profession seeking institutional recognition and protection; and with the nascent field of obstetrics finding its place within it, the necessary elements for a revolution in childbirth were in place. But since, as we have mentioned, local midwives had long overseen childbirth, this revolution was not inevitable. For a depersonalizing institutionalization of childbirth to take place, the leaders of obstetric medicine would need to wrest control over it from midwives and mothers. That this was decisive is conversely illustrated by the exceptional experience in the Netherlands.
The long-time Dutch exception to the western norm (recently under threat and in retreat) is, as Block puts it, “to support physiological birth, allowing labor to begin and progress in its own time, and intervening only when necessary.” This enduring ethic is inseparable from the retention of the midwife as both the guardian and primary attendant for mothers in childbirth (and the home as the normative location). In a context of professionalization that also effected the Netherlands, this required conscious systematic preservation. As far back as 1818, Hilary Marland explained within Successful Home Birth and Midwifery: The Dutch Model, “the first [Dutch] national law regulating midwives was passed…[and] of great and lasting significance was the fact that midwives were regulated together with other medical practitioners, and their duties and competence vis-à-vis men-midwives and obstetric doctors outlined.” In other words, the drive towards greater regulation and professionalization was not used as a way to marginalize midwives, as it was elsewhere, but to confirm their traditionally central role. “By the nineteenth century,” Dutch doctor and academic L.H. Lumey relates, “the division of labor between midwives and doctors ensured that normal deliveries remained within the professional domain of the midwives.”
This protection of midwifery did not happen elsewhere, leaving midwives and mothers vulnerable to the consequences of leading obstetricians cementing their status, while reconceptualizing childbirth itself in pathological terms. In order to persuade people that childbirth was a matter that should come under the institutional and systematized purview of this new male profession, it was necessary to convince people that there was something wrong with physiological childbirth itself. Furthermore, both of these aims relied upon and were furthered by the introduction and normalization of new surgical techniques within childbirth. “Treating birth as pathologic was an important strategy in obstetrics’ efforts to professionalize as a specialty and to achieve the dignity of full departmental status in the medical school,” Bridgman Perkins insists. “Obstetricians developed the paradigm of birth as pathologic intrinsic to their activities of building institutions and intervening in birth.” Therefore, Bridgman Perkins continues, “teaching hospitals led the way in routinizing technological and surgical interventions in birth.” Such intervention started with induction, and the goal of men like Dr. Charles B. Reed of Chicago for “scientific control of the labor from the very beginning,” which resulted in the routine insertion of the Vorhees bag into a woman’s uterus to precipitate labor. “We believe that labor is a surgical procedure,” proclaimed John Polak of Long Island College Hospital in 1922. Routine induction was, of course, just the beginning.
Intensive surgical intervention found its most effective advocate in Dr. Joseph B. DeLee, who founded the Chicago Lying-In Hospital in 1917. “If a woman falls on a pitchfork, and drives the handle through her perineum, we call that pathologic-abnormal,” DeLee posited, making a case for the necessity of his techniques, “but if a large baby is driven through the pelvic floor, we say that is natural, and therefore normal.” Pregnant women, in DeLee’s thinking, did not need mere assistance in birth, but often required new surgical solutions, and, in particular, his prophylactic forceps procedure. This most crucially involved an episiotomy, in which the perineum muscle between a woman’s vagina and anus is cut, and, second, the use of outlet forceps to precipitously pry the child from the birth canal. A “cruel and crazy intervention” is how midwife and natural birth advocate Ina May Gaskin describes this procedure, which she underwent for the birth of her first child. “I felt raped after that doctor was done with me, and I proved three times (by giving birth to three bigger babies) that his forceps hadn’t even been necessary.”
As is so often the case, the displacement of experiential and traditional knowledge with an abstract and supposedly objective approach had been crucial to DeLee’s perception of a problem that he sought to so brutally solve. In other words, his way of looking at the issue both framed it as a problem and suggested a particular kind of solution. Female physiology, many obstetricians assumed, was fundamentally ill-suited to the task of safely birthing a child in many or even most cases. But “the problem for Western medicine has been that few medical men were aware that a living woman’s pelvis is very different from that of a dead woman,” Gaskin argues. “The four bones of the pelvis in a living woman are able to flex and move in relation to each other…[so] that the internal shape and diameters of the pelvis change significantly according to the position taken by the woman and by the degree of flexion of her legs at the hip.” A woman’s body is in fact well suited to facilitating the child’s emergence from the womb; it was actually obstetric novelties that had made it more difficult.
A woman can be in no less advantageous position to give birth than lying on her back. Yet, by DeLee’s time, this had become standard in America. When a woman lies on her back, Gaskin explains, “the distance between her pubic bone and her tailbone and sacrum is significantly reduced,” immediately making what her body is naturally attempting to achieve more difficult. A woman’s contractions slow and her pain increases when she is on her back, robbed of the assistance of gravity and her body’s own facilitating movement, which is why it had never formed part of midwifery practice anywhere in the world. The counter-productive practice of making a woman lie on her back during labor was introduced through an obstetric profession that claimed to be liberating women from the “ignorance” of midwives. Not only did hospitalization and the surgical approach to birth encourage the new birth position, so too did the increasing medication of women, which accompanied it. DeLee advocated injecting women with scopolamine, a German practice referred to as “twilight sleep,” putting them in a disoriented state, which, as well as rendering them helpless during childbirth, blurred their memories of it.
Standardization, speed, and abstract efficiency were being systematically mistaken for the perfecting of nature and the amelioration of danger. Even as the obstetric profession was gaining control of childbirth in the name of science and rationality, it was doing so with methods that imposed realities rather than learned from them. And, unsurprisingly, the consequences were negative. Since safety is the trump card that apologists for institutional childbirth have always produced to justify each and every step towards routine intervention and hospitalization, it is important to make clear—as the second article in this series will—that these trends gained decisive control despite not because of their safety record. As we have already glimpsed through the issue of birth position, the difficulties produced by obstetric interventions served to further dependence on obstetric intervention.