Epidural

The Death of Natural Childbirth

The second article of this three-part series on technology and birth examines how the technological way of birth was implemented and institutionalized through the disabling of natural birth, initiating a cascade of consequences for mothers and babies from which we have not emerged.

Technology and Its Self-Fulfilling Prophecies
There used to be a distinction between “normal” and “abnormal” births, and obstetricians had initially taken control of unusual cases that presented special problems. But as obstetric perceptions and practices became increasingly commonplace, many births “were rendered abnormal,” as Pushed author Jennifer Block describes it, “requiring chemical and instrumental assistance. Without active physiological childbirth, the birth process needed active management.” This was particularly the case since the use of anesthetics in hospital childbirth (first chloroform and then scopolamine) blocked or slowed the natural bodily responses and reactions that otherwise aid labor and delivery. In particular, as Barbara Bridgman Perkins reveals in The Medical Delivery Business, the American obstetric profession’s “own studies [in the 1920s] found that its professional, institutional, and therapeutic developments had not improved birth outcomes.” This did not mean that these novelties had made no difference; they had made things worse.

Both maternal and infant mortality was higher in American cities with fewer midwives and more obstetric facilities. According to Perkins, “one specialist proposed that the profession suppress studies showing better outcomes in areas where midwives were active,” while a prominent and generally cautious obstetrician, John Whitridge Williams “rejected the better midwife outcomes as ‘contrary to reason,’ maintaining that acceptance of such reports might lead to the abolition of the physician’s role in birth, which, he affirmed, would be a ‘manifest absurdity.’” And it was not only in the United States that death in childbirth, at the beginning of the 20th century, increased with intervention. Irvine Loudon, author of Death in Childbirth, relates that “maternal mortality rates were very high in countries, states, regions, or areas where most deliveries were performed by physicians, especially in the hospital.” This is particularly striking when you consider than this was a period in which the overall mortality rate was sharply decreasing in these same places. Further highlighting the connection between obstetric intervention and decreasing safety was that, at this time, richer women were actually more likely to die in childbirth than their poorer counterparts. “The only plausible explanation for this social class difference,” argues Loudon, “is that the upper classes were more often delivered by physicians and, therefore, more likely to suffer unnecessary interference, whereas the lower classes were delivered by midwives.”

How could obstetrics and its tenets continue to gain ground in these circumstances? First, we should remember that technological solutions being increasingly called upon to solve technology’s escalating problems is a consistent dynamic of our age. Philosopher Hans Jonas observed the “reigning dialectics of a progress which, in providing solutions for the problems it has created, must create new ones and thus becomes its own compulsion.” Both aiding and connecting with this dynamic was a growing consumerism, in which the adoption of products and practices among high-earners both supported emerging industries and consistently created wider demand. Wealthy women were early and enthusiastic adopters of obstetric intervention, helping to fund its rise to prominence (in a way that also occurred with assisted reproduction 100 years later). Once anesthetics, episiotomies, and forceps became the norm among wealthier mothers, they became the default “modern” standard.

Consider twilight sleep medication, which was briefly all the rage in the United States before being utterly discredited and replaced by alternatives (especially Demerol). Popular publications like McClure’s and Woman’s Home Companion gushed about its utility, the International Socialist Review carped that the “corrupt capitalist regime” refused to put scopolamine “at the service of needy women,” while a National Twilight Sleep Association was formed to advocate for expanded use. The article in McClure’s was entitled “Painless Childbirth,” and this gets to the fraught issue especially aiding the appeal of obstetric intervention. The new techniques held out the promise that pain in childbirth could be alleviated or eliminated.

This is ultimately an area in which obstetricians were not simply meeting a need, but exacerbating and complicating one. Childbirth is an extremely variable and personal experience, in which the psychological state of both mother and child can have physiological effects on the labor. A woman’s “prior anxiety about pain”—as Jacqueline Wolf notes in her book on the subject, Deliver Me from Pain—“expectation of severe pain during labor, and belief that labor pain is a negative phenomenon are factors associated with the most painful labors.” In a number of ways, fear can both impede the birth and increase a woman’s pain, constricting muscles and restricting circulation, and creating a vicious cycle as expectations of difficulty and excessive pain become self-fulfilling. Therefore, a trend which accentuated the fear of childbirth could actually increase the need and dependence on intervention, strengthening the cause of institutionalization.

Obstetricians tended to highlight the dangers of childbirth, portraying all labor as a pathological situation requiring constant medical supervision. When the British National Health Service investigated childbirth trends in 1959, women’s organizations expressed the opinion, as Dutch doctor L.H. Lumey reports, “that the increased demand for hospital confinement was largely due to the interwar propaganda on maternal mortality.” Moreover, once the institutionalization of childbirth has systematized the artificial amelioration of the fear it generates, that anxiety is further perpetuated, because routine intervention ensures that impersonal, unfamiliar, and medical spaces must host the birth. “In a home birth, those attending are visitors in the family’s domain, and midwives and doctors must rely on the family for an understanding of local customs and practices,” report the multiple authors of “Where to Give Birth? Politics and the Place of Birth.” By contrast, “in a hospital birth a mother is placed in a dependent condition reinforced by the use of unfamiliar language and machinery,” and birth becomes not a personal and family experience, but “a routine event, accomplished with speed and efficiency.” Since anything which increases stress and anxiety for mothers in labor will also often increase the pain and difficulty they experience during birth, the process of institutionalization has been aided by the fear its conception of birth imposes on mothers and families.

Consolidation: The Post-War Monopoly of Technological Birth
Birth trends that were gaining traction in the first decades of the 20th century became rapidly and impregnably entrenched in the post-war years. In 1910, around 50 percent of American births still took place in the home, attended by midwives. But this proportion shrunk to around 20 percent in the next 35 years, and, by the mid-1950s, only six percent of births in the United States took place outside of a hospital. The process started later, but was similar and likewise precipitous elsewhere, with home-births in England and Wales going from 85 percent of the total in 1927 to 33 percent in 1955; over the following 20 years, home-birth virtually disappeared (as it did elsewhere in the UK). In Finland, home-births were down to 25 percent in the mid-50s, while, in Hungary, where home-birth rates had steadily decreased after World War I, institutional birth became compulsory under communist dictatorship in 1950. Although the means and contexts differed, from a mainly private system in the US to a democratic state monopoly in the UK to a totalitarian state monopoly in Hungary, the result has been the same across the West—near elimination of home-birth. Today, with the exception of the Netherlands, home-birth rates across Europe and North America hover around one percent. Despite the diversity of the countries which almost extinguished home-birth after the war, however, they did share a utopian, mechanistically oriented, scientifically defined, and abstractly conceived belief in technological change. And it was in this spirit that birthing trends became permanent realities.

It helped the cause of institutionalization that the further decline of home-births coincided with the rapid decrease of maternal mortality. But it was certainly not hospitalization that was responsible. Puerperal fever (or childbed fever) caused by uterine infections had been by far the biggest cause of maternal death in the preceding years, and it was the introduction and application of antibacterial medication, sulphonamides, which so drastically tamed this scourge. The death-reducing effects of sulphonamides were uniform across many countries with different degrees of hospitalization. For example, by 1950, the maternal mortality rates had been reduced to almost identically low levels in England and Wales, the United States, and the Netherlands. In fact, as Hungarian journalist Réka Kinga Papp has explained, the conventionally assumed connection between institutionalization and hygiene has long been faulty. Midwives were aware, long before the medical profession caught up, that it was important for those assisting with births to keep their hands clean. The relevance of this dawned on the Hungarian doctor Ignác Semmelweis, when he noticed, upon beginning work at a Viennese hospital in the 1840s, that mothers being tended there by doctors and medical students were almost five times more likely to die than those being cared for by midwives. Having isolated the cause of the disparity to the two groups’ hygiene practices, Semmelweis introduced chlorine hand-washing for the doctors. Despite positive effects, Semmelweis’s innovation was unpopular among doctors, and it would not be widely practiced for many years. Even then, institutional medicine was not an automatically safer or more hygienic option for childbirth than the home care of midwives.

Ignác Semmelweis, 1860 engraving by Jenő Doby

iStock.com / kipgodi

Instead, the imposition of an abstract “rationalization” on childbirth is the defining feature of interventionist hospital-birth’s triumph over natural home-birth, despite all the high-minded justifications regarding safety. Already in the first decades of the 20th century, maternity units and hospitals were built for assembly-line processes with labor separated into arbitrary stages, each presided over by a distinct specialized staff. And these organizational structures and designs in turn further encouraged the strategy and practice of intervention. This thinking was also significantly influenced and augmented by the extraordinarily influential “scientific management” concepts of Frederick Winslow Taylor, who died in 1915, but whose shadow lingers still. Taylorism involved the maximizing of “efficiency” through time and motion studies, which purported to objectively deduce the optimum strategy needed to produce the most output in the least amount of time. Behind this method of diagnosis lay the assumption that determining this “efficient” method would produce the best result for all concerned. It takes a detached and impersonal view of childbirth to imagine that Taylorism could be meaningfully applied to it, but this was exactly the perspective that many leading obstetricians promoted. Furthermore, after World War II, the basic tenets of so-called scientific management were being applied on a national scale, with the predilection on both sides of the Iron Curtain for economic planning and top-down system management. In this way, the majority of mothers in Europe and America came to give birth within an institutional process designed to produce clockwork deliveries.

“By the mid-1960s the American Hospital Association’s journal championed a ‘maternity center designed for “assembly-line” efficiency,’” Perkins explains, “advising that the purpose of such a center was to achieve a ‘continuous operational flow’ of patients.” Once not only units and hospitals, but whole disciplines and health systems, are designed according to this priority, routine intervention becomes a necessity that everyone within the process is committed to serving. This is the “active management of labor” which the Irish obstetrician Kieran O’Driscoll influentially systematized in the late 60s and early 70s. In a 1973 paper explaining his methodology, O’Driscoll commented that “obstetricians previously accepted labour as subject to wide natural variation,” before contentedly adding that, at the National Maternity Hospital in Ireland, “the passive concept of labour has been replaced by an intensive care situation…in which every labour is controlled.” O’Driscoll’s procedure insisted that every labor should last a maximum of twelve hours. “Cervical dilatation was plotted on a simple graph,” he went on to outline. “Intervention was mandatory unless cervical dilatation exceeded one centimeter each hour. Stimulation was by artificial rupture of the membranes followed by oxytocin infusion after an interval of one hour.” If the child still refused to comply with O’Driscoll’s timetable, then a caesarean procedure would be launched.

What happens when an abstract system such as this, designed according to priorities entirely external to childbirth’s own rhythms and patterns, is insistently pressed down upon mother and child? Timetables may indeed invariably be met, and success proclaimed, as an artificial and predictable process is enforced. But such arrogance always incurs a charge, as nature refuses to reshape itself to align neatly with the management plan. Induction and acceleration were engineered priorities which brought a host of dysfunctions to the process, requiring further corrective interventions. Lurking beneath O’Driscoll’s calm plotting of a micro-managed labor and delivery is the reality that such a process means that natural delivery is actually disabled for the sake of an artificial process that partly mimics and partly circumvents the natural one. In Stealing Fire: The Mythology of the Technocracy, Peter Reynolds calls this a “one-two punch,” whereby “industrial society destroys natural cycles with one hand while building fabrications of them with the other.” At the heart of this microcosmic example is the “oxytocin infusion.”

The Danger and Deficiency of the Synthetic
Oxytocin is indeed essential for the delivery of a baby, which is why a woman’s body naturally produces it at the right time, initiating uterine contractions, which steadily build in both frequency and strength. However, once a woman is given artificial infusions of oxytocin (usually in the form of Pitocin), her body will decrease or stop her own oxytocin secretion. This ensures the birth will be artificially managed and that it will begin before the bodies of both mother and child have signaled that it should. Often, labor is begun too early. The charts and figures may say that the baby is ready, but the body knows better. “What we understand now is that the baby participates in the initiation of labor,” French childbirth expert Michel Odent relates. “In particular, the baby gives a signal when its lungs are mature. For a baby to be born implies that the lungs are ready, because to be born is to breathe.” As Jennifer Block beautifully puts it, “the moment when spontaneous labor begins is a moment that remains mysterious, a private hormonal conversation between mother and fetus that scientists have yet to fully decode.” But what humans do not understand, they are nevertheless happy to override, and so, with the infusion of Pitocin, contractions begin.

While artificial oxytocin contracts the uterus, it does so in a way that lacks the safeguards a woman’s body ensures when left in charge of the process. Naturally stimulated contractions slowly build with the body’s pulsations, leaving time for both mother and baby to draw breath between each high-point, but infused oxytocin can produce contractions that are too strong or too frequent, entering the bloodstream constantly and over-stimulating. This creates a more painful and disturbing experience for the mother, but also brings great distress to the emerging child, who is deprived of oxygen. Such a desperate situation, in which artificially generated over-stimulation places the child in danger, leads to further extreme measures to prevent brain damage to the baby, which can nevertheless result. Studies have shown “a progressive fall in [the baby’s] cerebral oxygen saturation when contractions occurred more frequently than every 2.3 minutes,” reports Professor Laura Bennett, an expert on brain injury in newborns. “Any intervention which increases the frequency and/or duration of uterine contractions clearly places the fetus at increased risk of asphyxia.”

A mother’s health and life is likewise endangered, in this situation, with infused oxytocin creating a greater chance of uterine rupture and postpartum hemorrhage. The artificial process, in other words, can ape the biological effects of natural oxytocin, but does so in a way that replaces nature’s care with the heavy-hand of technological impatience, with devastating effects. Furthermore, artificial oxytocin is, as Block emphasizes, “a package deal. With Pitocin comes amniotomy, internal fetal monitoring, immobilization, epidural and urine catheter…. Intervention leads to intervention—chaos that the body may not be capable of resolving on its own.” It initiates a “cascade of interventions.” But we may not have described the worst aspect of the systematic imposition of synthetic oxytocin into childbirth.

Oxytocin has been called the hormone of love because a mutually stimulated increase in oxytocin is experienced alongside feelings of attachment; it infuses bodily functions, including orgasm, with emotion and euphoria. In short, there is an emotional response that is being generated by a woman’s own oxytocin, even as it facilitates birth. This release of oxytocin during a natural birth peaks in the final climactic moments, meaning that many women experience a surge of pleasure, drowning out the pain without medicine. But while natural oxytocin “has the ability to cross the blood-brain barrier,” Belgian midwifery expert Els Hendrix explains, “synthetic oxytocin cannot cross this barrier,” providing none of the emotional stimulation. Synthetic oxytocin not only shuts down this natural and important experiential depth, but replaces it with series of exclusively biological events. It insists that a woman must be the inert machine that obstetric perception and practice has long maintained. And the cost of this replacement is particularly felt in the moments immediately after birth.

When their ability to produce oxytocin has not been curtailed by its synthetic doppelganger, mothers experience their highest levels of oxytocin in the hour following birth. But having robbed a woman of her own means of contracting her uterus and giving birth, rendering her dependent on synthetic processes which replace rhythm and natural feedback-loops with insistent synthetic violence, induced labor also impedes the ways nature enables mothers to bond with their newborn children. After natural birth, mother and child are joined in an extraordinary oxytocin circuit. The mother and baby’s levels rise as they touch each other in those precious moments, encouraging the mother to produce breast milk, which also provides more oxytocin to the child, “so that during the first hour after birth,” Australian obstetrician Sarah Buckley summarizes, “both mother and baby are saturated with high levels of oxytocin, the love hormone.” Synthetically induced births prevent this not only by suppressing the production and effects of natural oxytocin, but also because the attendant interventions frequently leave neither mother nor child capable of such an immediate post-birth interaction.

Instead of allowing and assisting a woman to do what her body has, in most circumstances, been naturally endowed to do, medicalized childbirth has increasingly made her reliant on drugs that crudely mimic her hormones and dull her helpful reactions, while machines and instruments compound and complete her state of engineered helplessness. What we have done to the birth of children in our societies is such a mournfully exact microcosm of our larger technocentrism because it so plainly consists of the destruction of nature, and its replacement—in the name of progress and perfection—with a deeply inferior synthetic alternative. The latest manifestation of this process, in which birth is pathologized and women are alienated from it, is the normalization of epidural births and the inexorable rise of unnecessary caesarean sections. This is interventionism par excellence. But amid this sad scene, the antithesis of this approach has begun to reassert itself. Thus, the third and final article in this series looks at natural home birth, particularly as championed by Ágnes Geréb, and its principal opponents.