Giving Birth in a Climate of Fear

by Teresa Rust Smith

For some women, giving birth is a personally affirming and gratifying experience — a life-changing event, an accomplishment that instills a sense of agency and power. Unfortunately, too few women experience birth in this way Although a basic biological process, childbirth is invested with layers of social and cultural meaning. In the United States today, the cultural associations include a pervading sense of fear and shame about the female body and its functions.

While the arrival of the child itself is generally viewed positively, the birth process is not. Childbirth is often seen as a burden and an ordeal, fraught with pain and danger, even disgusting In a recent class on gender roles, I asked my students to make a list of words they associate with childbirth. Words such as "painful," "risky," "gross" and "scary" appeared on the board. Why, in a time when the industrialized world enjoys perinatal and maternal mortality rates much lower than at any time in history, is childbirth viewed as dangerous and risky?

Low-Risk Births, Heroic Measures

Childbirth, unpredictable by its very nature, defies attempts to standardize it. Undeterred, physicians have used ever increasing levels of technology to make the birth process conform to a uniform standard.

How risky is childbirth? In the United States, less than one woman in 10.000 dies in childbirth, according to the Maternal and Child Health Bureau. The infant mortality rate is about seven per thousand, and this includes losses of premature infants and other high-risk situations.' How much of a role does medical management play in keeping the rates so low? Many are shocked to learn that outcomes are best for women giving birth with midwives rather than physicians, and whose births take place outside of the hospital, in a freestanding birth center or at home. Countries with the best childbirth outcomes use midwives for all normal births, reserving physicians for high-risk cases.

The United States is not among these countries. Here, mortality rates have declined since the turn of the century, a fact attributable primarily to improvements in public health as a result of better nutrition and sanitation, birth control and its reductions in the fertility rate, and other nonmedical measures. Mortality from childbirth declined as well, due to many of the same factors and further reduced by mid-2Oth century advances such as antibiotics." Physicians attributed these improvements to the superiority of medical management over midwifery care and hospitalization rather than home birth. This thinking had begun to take hold in the previous century with assertions that childbirth was too dangerous to be left in the hands of "unqualified" midwives. In fact, physicians sought to gain control of birth not because it was so dangerous, but because it was so safe. In contrast to other conditions and diseases of the time, childbirth outcomes were generally good, leading to increased respect for the emerging medical profession.

Ironically, the promised safety often failed to follow; in 1925, a government researcher determined that in the nation's capital, more than three times as many women died in childbirth in the hospital than while giving birth at home. Even so, the efforts of the medical profession were successful, and childbirth became a medical event.

By the 1970s, the perinatal mortality rate in the United States was significantly better than in earlier times, but still worse than the rates of many other countries. Maintaining that their efforts would lower this rate, physicians turned to increasingly higher levels of technology in the delivery room. Equipment and procedures designed for use in high-risk labor and delivery — and frequently lifesaving when applied in such cases — became routine for low-risk birth as well. Today, women entering the hospital for a normal, uncomplicated birth are confronted with a daunting array of complicated medical machines and procedures, including the electronic fetal monitor, routine use of an intravenous drip, drugs to hasten the progress of labor, routine cpisiotomy and unsolicited pain medication. Almost 25 percent of birthing women give birth surgically, up from 5.5 percent in 1970.'

While heroic measures may indeed produce miraculous results in high-risk situations, nothing can remove all uncertainty from childbirth or guarantee a healthy baby to every mother. In fact, the use of such technology in low risk births often causes complications that might not have otherwise occurred The delicate mechanisms at work in the birth process are such that once an intervention disrupts the process, further interventions are needed For example, immobilizing the laboring woman to apply the fetal monitor tends to slow the progress of labor. This may result in the use of pitocin to speed labor. But remaining in one position and using pitocin both increase the pain of contractions and can contribute to fetal distress, which in turn can result in the need for pain medication and ultimately lead to a Cesarean section. The greatest irony of this "cascade of interventions"' is that both the birthing woman and the physician are likely to conclude that medical technology saved this mother and baby from childbirth complications, never considering that the interventions themselves might have been responsible for the complications in the first place.

The belief that the natural process of giving birth is too risky and unpredictable to be allowed to proceed without medical management has robbed women of the ability to experience childbirth with confidence and trust. Unrealistically and unnecessarily fearful of childbirth, many women view the process of their bodies as undependable. presenting a threat to their babies, a threat that only technology can reduce. This kind of attitude contributes to the troubling trend of seeing the mother and baby as being at odds with each other, as if the wellbeing of one were in conflict with the wellbeing of the other.

A HIGHER STANDARD

A popular bumper sticker that reads "Birth is as sate as life gets" captures the idea that, while there always will be some unpredictability in childbirth, this is true of most areas of life. We accept this fact, take reasonable precautions and, tor the most part, do not dwell on unavoidable and unlikely events. Yet we seem to hold childbirth to a higher standard of safety than any other life experience. The same person who would condemn a woman for choosing a home birth on the mistaken grounds of the risk involved would probably have no objection to that mother strapping her newborn into a car scat and driving to the mall on the freeway — subjecting the baby to a completely unnecessary and avoidable risk. Even with irrefutable scientific evidence of the safety of out-of-hospital birth, many women are greeted with alarm when they choose this option. The implication is that the woman is somehow catering to her own selfish wishes for a quality experience and subjecting her child (and herself) to unacceptable risks. The perception of the risk is much greater than the actual risk to either mother or baby and technology does not reduce that risk for low-risk women and infants.

Dispelling the climate of fear and replacing it with accurate information about the birth process would give women the ability to make truly informed decisions about the kind of birth they want. In this way, more women could give birth in an atmosphere of trust and confidence -- in their bodies and in their own ability to make responsible decisions tor themselves and their children.

Teresa Rust Smith, PhD, is an assistant professor and chair of sociology at Salem College, a women's college in Winston-Salem, N.C. She serves on the board of directors of the NWHN and on the advisory board of the Florida School of Traditional Midwifery in Gainesville, Florida.

REFERENCES

1. Maternal and Child Health Bureau, http: mchb.hrsa.gov. '

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8. Butter I. "Premature adoption and routini/ation of medical technology: Illustrations from childbirth technology." Journal of Social Issues 1993; 49(2): II 34.