My four children were born more than 20 years ago. I had four birth experiences, and I think about those experiences rarely, if ever. In nearly 30 years of motherhood, those acute hours quickly faded into insignificance compared with the reality of my children’s daily lives, their milestones, their achievements, their personalities, their challenges and the growth of our relationship as they changed from infants to school-age children to teenagers to adults.
I gave birth vaginally. But it never occurred to me that this was some kind of achievement, since it had nothing to do with me and everything to do with luck. My children, too, do not much care about the specifics of how they were born. This is, I suspect, typical for women of my generation and the ones that preceded us.
But for today’s new mothers, the expectations for childbirth and breast-feeding are higher than ever. Women are supposed to have the most authentic possible experience: They should reject pain relief; eliminate C-sections; embrace midwives, doulas and childbirth educators; and even defy standard obstetric recommendations when they conflict with those goals.
Two powerful forces have arisen to push this dogma. First, the crunchy natural-birth subculture has slowly morphed into an industry, mainly catering to the most privileged women in society. Second, a cabal of natural-birth activists — online, on the air and even inside hospitals — has formed to shame pregnant women who eschew the right-thinking path. For these forces, childbirth has become less about having a baby and more about having an experience. And those who don’t have “the perfect birth” can’t possibly be good mothers.
For most of human existence, unmedicated, vaginal childbirth was simply the painful, dangerous, unavoidable way to have a baby. But for the past 50 years, in developed countries, it has no longer been a relief for the mother and the child to survive; it’s been a given. So people began paying attention to how, not just whether, childbirth unfolded.
The original goals of this movement were “conscious deliveries,” fathers in the delivery room, childbirth education and research into and abolition of practices such as perineal shaving and enemas that either had no benefit or were harmful. But by the 1980s, all of these shifts in medical practice had taken place, and a new goal took shape among activists: following the proper, naturalistic birth philosophy.
Until the 20th century, American midwifery required no formal education — just a period of apprenticeship. With the rise of modern obstetrics, midwives saw the need to professionalize to compete. Emulating European practitioners, they created the credential of certified nurse-midwife. These are nurses who have undergone additional training in midwifery. The first two schools of nurse-midwifery opened in the 1930s, but the practice truly began to take off in the postwar years. In 1963, there were 275 credentialed nurse-midwives in the United States; by 1995, there were more than 4,000; today there are more than 11,000. The proportion of births attended by midwives has also risen, from 3 percent in 1989 to more than 8 percentin 2013 (12 percent of vaginal births that year).
Doulas and childbirth educators — people who often call themselves “birth workers” — have proliferated, too, mirroring the increase in midwives. Membership in DONA International, one of the leading doula certification organizations, increased from 750 in 1994 to 6,154 in 2012. There is a considerable body of scientific evidence suggesting that the presence of a doula can improve labor, both physically and psychologically. A doula can rub a woman’s back, get cool cloths for her head and provide companionship and empathy. The benefits exist whether the doula is a family member, friend or hired support person.
As the demand for alt-births rose, an industry grew to serve it. Although it’s difficult to determine exactly how much money the natural-birth industry rakes in per year, it’s clearly a lucrative field. It has several professional organizations, grass-roots activists and lobbyists working in state legislatures. Midwives make, on average, $75,000 to $99,000 per year across most of the country; doulas are paid$1,200 per birth, on average, according to WhattoExpect.com. The Midwives Alliance of North America (MANA), in part a creation of influential natural-childbirth advocate Ina May Gaskin (whose 2003natural-birth handbook remains a reproductive-health bestseller), is a major professional organization for American midwives but requires no educational credentials of its roughly 450 members beyond a high school diploma.
Women interested in birthing naturally can avail themselves of a variety of educational courses. These classes began gaining popularity in the 1960s; by 1975, the New York Times reported that the majority of hospitals had come to sponsor childbirth classes, compared with just 10 percent in 1970. By 2005, about half of expectant mothers had taken a childbirth class that year or during a prior pregnancy, according to a survey by Childbirth Connection, a nonprofit that studies childbirth and pregnancy. In the Washington area, one can attend birth classes costing anywhere from $160at Lamaze’s local chapter to $375 for a course with an instructor accredited by the childbirth-education group BirthWorks.
Among the more curious practices recommended by natural-childbirthing businesses include “using candles to bring a soft glow to the birth environment,” per GivingBirthNaturally.com, which offers its own online courses; using audio tracks to “re-train” the “subconscious mind” to eliminate the pain of contractions,per Hypnobabies, a company selling “real medical hypnosis techniques” for natural-birthing moms; and “steaming” the uterus post-birth per Natural Birth Works, a co-op of midwives, doulas and educators committed to a “natural way of life.”
Lamaze, perhaps the most famous brand of childbirth classes, serves as a good test case for the industry’s shifting interests. “In the early 1990s, the organization reinvented itself as the champion of normal birth,” Charlotte A. De Vries and Raymond G. De Vries wrote in their 2007 article “Childbirth Education in the 21st Century.” In a clinical sense, normal birth means no inductions or epidurals that aren’t medically necessary, and Lamaze says its education aims to give women “evidence-based information” about those interventions. “Seeking relief from labor pain without drugs protects your baby and your body from injury, helps labor progress, and facilitates breastfeeding, bonding, and other postpartum adjustments,” Lamaze’s website states, adding with a note of pity that an epidural still might be needed if a mother “can’t move beyond [her] fear of labor pain.”
Ultimately, the natural-childbirth industry aims to shepherd women toward an “ideal birth experience” — packed with emotional meaning and marketed as absolutely necessary and life-altering — sometimes at the expense of ideal health care (which is available from doctors at local hospitals). And it shows: A study in Oregon found that the death rate for babies delivered in planned home births with midwives in 2012 was roughly seven times that of hospital-born babies. Data collected by the Centers for Disease Control and Prevention from 2006 to 2009 revealed that babies delivered by midwives had higher death rates than hospital-born babies, whether they were born at home or in birthing centers. While not all natural births take place outside hospitals, home births represent an extreme and troubling iteration of the ideology, where the set-up, process and experience are sometimes valued over the outcome.
The natural-childbirth industry markets births more or less like weddings, suggesting to its targets that they have one chance to purchase the perfect day for themselves and their loved ones, as Markella Rutherford and Selina Gallo-Cruz explain in their 2008 paper “Great Expectations: Emotion as Central to the Experiential Consumption of Birth.” “The idealization of the birth experience offers a legitimate opportunity to orchestrate another emotional consumer experience in which the bride-now-turned-mother produces, directs, and plays the starring role,” the authors write. Mothers Naturally, an educational program produced by MANA, invites mothers to “create [their] ideal birth environment and be supported physically and emotionally” as they “discover the safe personal care of a midwife.”
But like the perfect wedding, the perfect birth is often a fiction; women who buy into the idealized experience can face enormous disappointment, distress and feelings of failure if they have a Caesarean section, choose an epidural or are unable to breast-feed immediately after delivery, all of which result, at times, from factors outside mothers’ control. A C-section, for instance, is typically done to save the life of a baby who may not survive without it, or whose risk of dying during a vaginal birth is much higher than usual — such as babies in unfavorable positions or those whose mothers have some obstruction to the birth canal. Yet for mothers in search of the perfect experience, any medical intervention, even a lifesaving one, can become a source of bitter shame. “Too often they’re hollowed out, haunted, hurting,”a self-declared “radical doula” wrote recently in New York magazine, referring to mothers whose births didn’t pan out as expected. “When they talk about giving birth, they sigh or shrug or burst into tears. Whatever, they say, shaking it off. My baby is here. My baby is alive. That’s what matters.
“Bulls---!I never dare say. You matter. What happened to you matters.”
Reinforcing that guilt isn’t helpful or supportive: It piles emotional distress atop an already stressful time. One mother recently reflected at Ravishly, a feminist website, on transferring to a hospital during a difficult home labor, writing that her son’s “health doesn’t negate my feeling of failure. His health doesn’t heal what I lost.”
“I felt inadequate and disappointed after my caesarean,” one mother wrote on BabyCentre, a British parenting website. “I was made to feel even worse by people constantly harping on about the wonders of ‘natural’ birth.”
This is tragic. Birth is beautiful, no matter the room or the lighting or the drug regimen. A healthy baby and mother — the hardest-won goals of modern obstetrics — matter more than anything else. Mothers already deal with enough judgment from society for their looks, their parenting choices and more. Without adding any benefits, the experience packaged and sold by the natural-childbirth industry only compounds their problems. As a doctor and a mother, I say: Enough is enough.
CORRECTION: An earlier version of this story stated that Lamaze “promotes one particular vision of labor as normal and therefore good.” In fact, Lamaze says, the organization provides women with a wide range of evidence-based information about childbirth and labor and does not believe different approaches to birth are “good” or “bad.”
Twitter: @ATuteur
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