It is a strange paradox that as labor and birth moved over the last century from the home to the hospital, their association with pain and fear have grown.
Such fear is not entirely unfounded. Mothers who give birth in the United States do so in the “most dangerous place to deliver in the developed world,” with maternal mortality rates currently at 0.02 percent and rising. Even mothers whose birth experiences result in healthy outcomes for mother and baby report traumatic childbirth experiences at the hands of healthcare providers.
While the medical techniques popularized in the last century have certainly saved many lives, their ascendence has also impeded women’s active participation in childbirth. Women are routinely dismissed by “experts” who assert control over the process of labor and demean women who question the status quo. Additionally, although interventions such as induction and cesarean section can be lifesaving, they can also create new medical complications and necessitate further interventions.
The choices surrounding childbirth are some of the most personal decisions a woman will ever make. Yet these “choices” are often made for her by medical providers who are complete strangers to her, determined by the lottery of an on-call schedule. The timing of spontaneous labor is nearly impossible to control, and the likelihood that a woman’s physician of choice will be available to deliver is often no better than chance.
If we want to improve birth outcomes and make the delivery room a truly life- and dignity-affirming space for every woman, we must make progress on two fronts. First, we must educate and empower women, so that they can be active participants in their own births. Second, we must fight the hegemony of the technocratic model of obstetric medicine, restoring a more humanistic vision of maternity care, like that traditionally provided by midwives.
Childbirth throughout History
For much of human history, childbirth was the exclusive realm of women. In many indigenous cultures, it still is. Midwives and other female family and community members attended labor and birth, passing down knowledge and techniques for pain reduction, optimal birthing positions, and herbal treatments to the next generation. As this natural process moved from bedrooms to hospitals, becoming increasingly medicalized, what was once a realm of female power and expertise was wrested from women’s hands and placed in those of physicians. Many contemporary “advances” have come at the cost of depersonalizing and dehumanizing treatment of laboring women. Even as the field of obstetrics has shifted to include a majority of female physicians, the technocracy of birth remains built on masculine models of power and control, encouraging women and their providers to view birth as a dangerous medical event rather than a natural bodily process.
With the invention of forceps in the early seventeenth century, (male) surgeons began attending births and rushing labor by their premature use, sometimes even before full dilation. By the 1920s, it became standard practice to deliver babies via forceps and a large episiotomy. This development popularized the back-lying “lithotomy” position of birth that has now become the norm. Despite making the process lengthier and more difficult for the laboring mother by working against the flow of gravity and narrowing the pelvic outlet, this position makes it easiest for medical professionals to employ the use of various birthing instruments.
Beginning around 1910, some women’s rights campaigners began to advocate for pain relief in labor via the use of medications such as chloroform. Through the 1950s, use of Twilight Sleep, a mixture of narcotic and amnesiac medication, became popular. Although women gave birth screaming and often were tied down or straight-jacketed, they remembered essentially nothing of the experience, save the occasional horrific flashback.
With the development of the Friedman curve as a standardized measure of progression of labor in 1955 came the techno-medical model of birth we know today. As Leah Jacobson reflects, “All of these practices were meant to make birth safer, quicker, and less painful, but some may have resulted in robbing women of the experience altogether and left them wondering about their own abilities to naturally birth their children.” This lack of confidence in our bodies’ natural abilities has grown deep roots and, particularly in the United States, led to an overemphasis on medicalized childbirth that, despite challenges, continues today.
This method of childbirth, with doctors and nurses as the primary agents and women mentally absent, was standard for over fifty years. Thankfully, the 1960s and 1970s saw increased emphasis on the importance of midwifery and working with a woman’s body to facilitate childbirth naturally. This led to significant changes in standard operating procedures in hospital labor and delivery wards. Still, despite statistics that point to the positive outcomes of midwife and home birth, the standard of care in the United States remains the obstetric model.
Midwifery versus the Techno-Medical Model
In our society, we privilege the scientific over the natural. Women who seek physiologic birth are sometimes openly mocked, stereotyped as “crunchy,” high-maintenance, and out of touch with reality. Even some feminists are harshly critical of the notion that minimizing interventions, including the use of epidural and pain medications, might in some way benefit women. “No one ever asks a man if he’s having a ‘natural root canal.’ No one ever asks a man if he is having a ‘natural vasectomy,’” Jessi Klein points out.
This might be a fair criticism if childbirth were indeed the extraction of something diseased, the pain a sign that something has gone wrong. But labor contractions are part of a physiological process in its ideal state, signaling that everything is going right. Research suggests that the very intensity of the contractions that we seek to dull contributes to vital bonding processes. For all that we claim to be a society devoted to science, we appear to be very suspicious of research surrounding the natural process of birth.
Take, for example, the two midwifery centers in the United Kingdom analyzed by author Milli Hill in her 2019 book Give Birth Like a Feminist. One-to-One Midwives and the Albany Midwifery Practice both have outstanding credentials. Hill reports that One-to-One’s home birth rate is 7 percent, and their stillbirth rate and neonatal death rates are a half and a quarter of the UK average, respectively. Albany beat the UK’s average stats by leaps and bounds as well, with a 20 percent lower induction rate, 10 percent lower C-section rate, and only 30 percent of mothers experiencing any vaginal tearing (and with no fourth-degree tears at all). Compare this with the statistics reported by the UK’s Royal College of Obstetrics and Gynecology, which find that 90 percent of women tear during birth.
A degree of this discrepancy of outcomes may certainly be due to differences in population. Midwives do not see patients who are classified as “high risk,” so perhaps their patient population is destined for better outcomes. Yet, even so, a large retrospective cohort study across eleven hospitals in the US that excluded patients with high-risk conditions found that midwife-attended birth had lower rates of intervention, a 30-40 percent lower risk of C-section, and decreased rate of operative vaginal births.
Despite overwhelmingly positive outcomes, both practices faced intense scrutiny, and Albany was suddenly shut down by the King’s College Trust due to “safety concerns.” No evidence was offered to justify the decision. As Hill observes, “Those who believe that maternity safety will only be achieved by technocracy and the absolute dominance of obstetrics will certainly not feel that there is anything wrong with pulling into line [anyone who] misguidedly thinks there is a value to ‘hands off,’ ‘physiological,’ or even ‘normal’ birth.”
This perspective of the physician as the primary mediator of childbirth dominates our view in the United States as well. A former coworker of mine scoffed at my suggestions about learning breathing techniques, informing me that she intended to get the epidural; her physician had instructed her, “Leave that to me. I will coach you through.” Her epidural worked only on one side, and despite his lofty promises, the physician was not present for the birth. My sister-in-law eyed me with suspicion as I cited statistics among my reasons for forgoing interventions at my hospital birth. “I’ll still probably get the epidural,” she responded. Despite being both a nurse and one of the strongest women I know, when it came to birthing her baby, she lacked confidence in her own abilities. And though the statistics on positive outcomes for women who forgo interventions are publicly available, many women assume that they “could never do” what so many generations of mothers have done before them.
Surrendering Our Power
One of the unintended results of medicalizing childbirth is that women’s knowledge of their own bodies and their own capabilities is much more limited than it has been historically. In previous eras, helping with the childbirth of a close family member or neighbor went much deeper than dropping off a hot casserole. Women commonly filled the role of doula or midwife for one another. Today, the first childbirth a woman experiences is usually her own. The most trusted expert she relies on is her OBGYN. While these physicians have intensive training in obstetric surgery, few are trained to facilitate natural, unmedicated childbirth. Many have never even seen one. They see the process of childbirth primarily through the lens of medical ailment.
In the United States, this has led to a birth culture in which women surrender more of their power and autonomy in the process of birth than they otherwise might. We mentally place childbirth in the same category as kidney removal. An overly medicalized approach to childbirth contributes to rates of induction, C-section, and maternal mortality that are significantly higher than those of other developed countries. One of the primary differences between the United States and many other developed countries—aside higher baseline cardiometabolic risk—is the type of health care practitioner who normally oversees prenatal care and childbirth. When we privilege obstetric care over midwife care, we privilege the surgical over the natural. As a country, we have medicalized a natural process when, in the majority of cases, a natural approach is in the better interest of mother and baby.
This is not to say that a blanket approach suffices for all women or indeed all pregnancies; natural birth is not always the best choice. The argument here is that expectant mothers don’t have the information they need to make truly informed choices. While the gap is lessening in the age of social media, blogs, and YouTube, it ought not to be only the women who seek out information about childbirth who benefit. All pregnant women have the right to greater education and transparency than it is currently the standard practice to provide. Women need to be informed and empowered to make as many decisions regarding prenatal care and childbirth as are medically safe for the pregnancy in question.
The choices in childbirth ought not to be presented as mere preferences, nor should they be made out of fear. If an expectant mother follows the recommended guidelines for prenatal care, she attends ten or more appointments. That should be ample time to discuss childbirth options and labor interventions so that women can make informed decisions about childbirth based on the expertise and recommendations of their providers. Instead, most women who come by this information do so on their own time, informing themselves through reading and opting in to childbirth classes.
These usually well-educated, usually white women are often mocked for having the audacity to form opinions about how they would like to give birth, to the point of being referred to as “birthzillas” by the very providers they turn to for assistance. And yet the disparity between outcomes for white mothers and those for their minority counterparts is shocking. According to the CDC, most pregnancy-related deaths are preventable, and maternal mortality rates are two to three times higher for Black and Native women—higher rates that persist even in studies that control for socioeconomic factors and pre-pregnancy cardiovascular health. If we want to reverse these statistics and change the tide for all women, but especially for those most at risk, perhaps we ought to be promoting education about choices in childbirth, rather than leaving women in the hands of a system that is structured for intervention and efficiency over personalized care.
Toward the Humanization of Birth
Natural or home birth is not appropriate in every case, and it is certainly not an end to be pursued “at any cost.” We have much to be grateful for in the way of birthing advancements. Especially for conditions like preeclampsia and other medical emergencies, the obstetric model is lifesaving. But must it be all or nothing?
When we look at the trajectory of medicalized birth, circumstances are brighter today than in the days when women were drugged, blindfolded, and strapped to a table. Still, the drive towards the humanization of birth is far from over. We need to promote conversations about options and create opportunities for physicians to learn from midwives and doulas and to attend home births as part of their education. As medicine continues to evolve and our capabilities progress, we must continue to advocate for women-centered options that humanize the birth experience rather than alienate women from their bodies.
When it comes to childbirth, a healthy baby should be a minimum expectation—but not our only one. A healthy baby is not all that matters! We can and ought to work to minimize birth trauma and promote education so fewer women are left lamenting, “If only I had known …”
This essay draws on material from my earlier book, Reclaiming Motherhood from a Culture Gone Mad (rights reverted), and has been revised and updated for Fairer Disputations readers.
