Ever wonder WHY it's so hard for human beings to give birth? I mean, why does it have to be so difficult and carry on for hour after painful hour? Why have we worked hard to devise methods of pain relief and surgical procedures to "deliver" women from this burden? Is it something to truly be "delivered" from, as the term originally indicated?
One thing that is helpful to know, is that as Homo sapiens, we have a difficult time birthing because our pelvises are so narrow. Any wider, like our chimpanzee cousins, and we'd be knuckle-scraping. Most mammals for that matter have a much easier time birthing simply because their pelvises can accommodate a baby more readily. But another side effect of our Homo sapien physique is a large cranium. Big head, big brain. So, as we got smarter and started to walk upright we had a conflict of larger head and smaller pelvis - thereby making birth difficult, yet certainly not impossible.
For centuries, birth was something women did either on their own, or with the help of womenfolk...sometimes a specific woman known as a midwife, which literally means "with woman". Midwives were revered, and/or feared, in societies all throughout Europe. They were often said to be witches and sorcerers and thousands were burned alive during witch hunts. When a baby was born in the middle ages, even up until the 18th century or so, its outcome, good or bad, was the responsibility of the midwife delivering the baby. So deformities, what we know as birth defects, and so on were the fault of the midwife, for which she would be blamed, or driven out of town, or sometimes executed. On the flip side, if she did something remarkable, like when midwife Louis Bourgeois delivered Marie de'Medici, the Queen of France, the first male heir to the throne in more than eighty years, she became a luminary in Parisian society.
But even then, in the 17th century, a celebrated midwife like Bourgeois was at odds with the physicians of the day. Birth was something you could count on, and delivering a baby without killing it or, more importantly, the mother, could be a lucrative business. Midwives often worked for bartered goods, or returned favors, or sometimes a small amount of money. A doctor, on the other hand, promising a safer setting and medical experience would charge usually triple the amount of a midwife in the late 19th century. Physicians had the ability to spread bad word concerning midwives. Tales of botched births and maternal deaths drove those who could afford it to chose a doctor over a midwife, who certainly had no medical training.
However, a skilled midwife's knowledge came to her from years of practice and from traditions handed down from generations of women. Doctors in the 19th century were teaching other doctors birthing techniques when they had never even witnessed a birth before. They were frequently taught on dummies, and birth was seen as mechanical and required aggressive intervention. Use of forceps and butchering women's perineums, among other things were common practice. So was the notion that lying flat on her back with legs strapped to stirrups was a good idea. But far worse than mere inexperience was that during this century physicians knew nothing of bacteria and contamination. It was entirely common for a doctor to examine a corpse then go straight to an internal exam of a laboring woman. As a result, women frequently died of septic bacterial poisoning, or "puerperal fever". Midwives in contrast, never did internal exams. There was no point...a baby is either IN or it's out. In the mid-19th century doctors considered it an insult to suggest that they wash their hands at all. There was one genius I must mention here, however: Ignaz Semmelweis of Vienna - who as far back as 1847 - discovered microscopic proof of the origins of the disease causing these deadly fevers. He wrote, "Puerperal fever is caused by conveyance to the pregnant woman of putrid particles derived from living organisms. Consequently must I make my confession that God only knows the number of women whom I have consigned prematurely to the grave." No one believed him. Semmelweis died in a state-run insane asylum.
Even into the 1920s not all physicians washed effectively or wore gloves, so childbed fever remained a killer, accounting for as much as 40% of maternal fatalities in American and European hospitals. So, it's not so long ago that birth was still considered a dangerous affair. Again, dangerous mostly because of a medicalized approach to labor. Midwives were still having good luck at home births, with rare fatalities overall. Yet, homebirthing was really for the very rural poor. In fact, by 1949 most states, including California, had outlawed midwifery completely. So for a few decades in the 20th century birth became a standard hospital procedure, where women were often knocked out by drugs in what's known as "twilight sleep", delivering unconsciously, then waking to a swaddled baby they had no memory of birthing.
It wasn't until the women's movement in the 1970s that birth came back into the hands of women. Home births and midwifery became popular again in certain circles - most notably in California. Ideas came from European doctors like Fernand Lamaze, that our notions of pain and birthing were in our heads, so to speak, and that through breathing techniques and support, women could manage their labor pains and be present and active.
At one point in the US there were hundreds of thousands of midwives and that number has dwindled to a mere 6,000. Less than 10% of American births today are delivered via midwifery, where in Europe almost the opposite is true. In Germany, it is a law that a midwife be present for all births, even those where a procedure like a Cesarean section is being performed. Yet, American women feel safer in a hospital setting with a physician presiding. "Oh, birth is dangerous," they say. "You never know what might happen." And just as in the 19th century, doctors meddling with things they didn't need to meddle with (i.e. internal exams) we have the same sort of intervention that goes on in a more sophisticated way.
As a result, more births in this country are done by Cesarean section than any other country in the world (except maybe Brazil, which runs a close race with us). The C-section rate is going from 30% to about 50% in many hospitals. Why is this bad? Why not eliminate the difficult part and cut straight to the chase, as it were?
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Five hundred years ago, in a little Swiss town, a woman labored for days, to no avail. The thirteen midwives who had been called in to assist could not help. Her desperate husband, an illiterate pig-gelder (that's one who neuters pigs) approached the local authorities and asked permission to slice open her abdomen to retrieve the baby. After first saying no, they finally said yes. And so Jacob Nufer went about his dangerous business, delivering a large healthy son. Not only did both patients survive, but the child lived to be seventy-seven and the wife had several more children, including twins, all vaginal births.
The tale is believed to be the first written record of a mother and child surviving a cesarean. There is a common assumption that the cesarean section was named after Julius Caesar who, legend has it, was cut out of his mother's womb. However, that act at that time would have surely killed her. Caesar's mother, we know, survived his birth and died only after he invaded Gaul. The more likely explanation is that the surgery was named generically after the rulers of Rome…as the operation in Germany (during the First World War), for example, is called a Kaiserschnitt, after the ruling kaisers.
Today, cesarean sections are such a routine operation that nearly one out of every three babies in developed countries arrives in this manner. One of the highest C-section rates on earth is in Rio de Janeiro, where 90 percent of wealthy women would rather pay for the operation than put their vaginas at risk. Pregnant women who schedule surgery even if there's no medical reason for it are now known as "too posh to push." (This unfortunate term was popularized by none other than "Posh Spice" Victoria Beckham, for electing a C-section for no particular reason other than convenience). This notion, of scheduling an unnecessary C-section is becoming a popular trend. Once doctors had to invent a reason for performing this operation when there was not a medical imperative, but now it's starting to become almost as routine as scheduling a pedicure.
I was discussing the topic of C-sections with a med-school student. We considered the nagging issue about why it is controversial that so many births, especially in America, have gone in the surgical direction and why that is considered, only by some, to be negative trend. She, as a future doctor, wanted to understand if there was a concrete medical argument against C-section and for a good old-fashioned vaginal birth.
I have to answer this in two separate ways: Medically speaking, if a C-section is not warranted (as in the case of a life-threatening emergency), is this really a bad thing for mother and child?
There is not enough evidence to show that a baby, being born via a surgical incision straight to the uterus, is at any long-term disadvantage in a physiological sense. This reminds me of a film I saw once where a group of chicks were shown hatching from their eggs. In one group, a human stepped in and peeled away the shell for them. In another group the chick was left to its own devices…pecking, resting, struggling and pecking some more. The process is slow and laborious. But in the group where the shell was peeled away for the bird, 7 out of 10 chicks died. The conclusion is that there was a specific benefit for a hatching chick to go through the process in this manner: whether it was an issue of lung maturity or a final stage of muscle development or avoiding general physical defects, the fact is: "Yes, there is clearly an evolutionary benefit for this birthing process to unfold as it does."
Could it be, that human babies too, benefit in some way from the process of birth…from the compression to their malleable cranium, from the squeezing of their lungs which must be prepped in order to take their first breath of air, from any number of factors that are too difficult to measure, like perhaps a tendency for disorders such as asthma or allergies?
These are open-ended questions that we won't know answers to until the medical community decides to truly study the effects of C-section on our population. What is known, however, is that babies born via C-section are at risk of being nicked by the scalpel and sometimes do have a more difficult time with initial breast-feeding attempts. Mothers too are more likely to develop postpartum depression and serious placental abnormalities which can impact future pregnancies. Just the risk alone of enduring major abdominal surgery puts the woman in a compromised position for the same reasons that ALL surgery is risky. Recovering from a C-section is far more rigorous than recovering from a vaginal birth, where women tend to feel better after just a few days, or sometimes the following day. Full C-section recovery, in contrast, takes about six weeks, frequently with some complications involving infection and difficulty healing.
On the other side of the argument is what a normal vaginal birth gives the mother. There are many women who feel that their ability to birth is in some way indicative of their success and power as a woman, in her most primal sense. (Much the way some men feel their ability to impregnate a women is a symbol of their prowess and strength.) When women are denied this opportunity they often feel they have failed. Many women I have spoken to who have ended up with a C-section have a sense of disappointment or sorrow about the event. While women who have felt in control of their birth (with little or no medical intervention) are conversely empowered by the experience. <b>What is significant about being empowered by birth is that this often sets the tone for how confident one will feel as a new parent – arguably, the most trying time of self-doubt and confusion.</b>
This is what natural childbirth hinges on: The sense of profound accomplishment in a very arduous endeavor. Birth, in a natural way, can often be ecstatic in the true sense of the word, "out of one's body", and that probably is how most women might describe their birth experience. And that experience is one that can change your life forever.
That seems to be what many doctors forget as they typically attempt to "deliver" the woman from her suffering. Physicians are trained to respond to pain as a state which must be treated; pain is a natural response to crisis, to physical abnormality. In this way, the medical community does not value the pain that is inherent to labor. Once a doctor said to me, at a dinner party, "I don't get it…if you broke your leg you'd want morphine to get you through….why on earth would you want to endure pain during labor, when we have drugs to take that away?"
The issue is one of understanding that birth is not a medical emergency. It is a physical process; it is something that women "do", not something that has happened to them, like a puncture wound or fractured bone. For over a century doctors have tried to come to the aid of, and "rescue", women from her terrible station in life to "suffer through labor" (see the bible for that one).
In the early 20th century "twilight sleep" which actually made a woman forget her labor, became incredibly popular. By administering a drug called Scopolamine, which was basically an amnesiac with morphine, a woman in labor could be made to fall into a semiconscious state and emerge hours later with a baby in her arms – remembering nothing in between. However, once under the spell of Twilight Sleep, the doctor would bandage her eyes with gauze and stuff oil-soaked wads of cotton in her ears so her own screaming would not wake her up. Later on, it was acknowledged that giving a woman any drug, whether a gas or a narcotic would render her baby equally anesthetized. These newborns did not always breathe immediately, and there was a great risk of postpartum hemorrhaging.
With the advent of "spinal" anesthesia and later "epidural" anesthesia (the difference between the two is just how much of the body they numb) women seemed to have the perfect answer to removing the pain of labor, remaining completely awake, and not affecting the condition of their baby in any way. Today more than 90 percent of American women call for the needle in the back when pain becomes too intense. The woman remains completely conscious – though often she feels relaxed enough to nap during labor.
God's gift to women? Perhaps. But once again, there are drawbacks. Women hooked up to epidurals are more likely to need artificial hormones (such as Pitocin) to keep contractions strong. They are also more likely to have their blood pressure drop; develop a fever and have greater risk of needing episiotomy or vacuum extraction to get the baby out. If you can't feel your extremities, it makes pushing difficult. No one wants to admit that epidurals lead to more cesarean sections, but the fact is, they do…. mostly due to many other complications which cannot be directly connected to the epidural alone. For example, if you are numb from the waist down, you cannot move around and are generally lying on your back. This position does not assist the baby in moving through the birth canal. When the baby stalls, things get complicated and C-sections are often called for.
Nevertheless, epidurals have a virtual lock on hospital pain relief in the US, anyway. Somehow, women all over the rest of the globe manage to give birth without them. In Japan, the epidural rate is about 1 percent. In the Netherlands, doctors do not offer epidurals because such pain relief is not part of the natural process.
In North America, pain relief is so socially acceptable that it is virtually expected. Even if a woman has refused an epidural in a typical hospital setting, nurses will continue to push for her to get one so that basically she can rest comfortably, watch television, talk on the phone and generally not be pacing, moaning or otherwise being a high-maintenance patient.
"Why do they push epidurals?" asks Kate Bauer, of the National Association of Childbirth Centers. "It makes the patient easier to manage. At the root of everything, there's money to be made. I'm sure many think they're doing a great service to women by offering the epidural and relieving them of pain, but it also helps them to cut back on the nursing. You've gone from the human touch to this: Give them the epidural and watch the monitor."
Almost no one is complaining….but I come back to my earlier point: Taking the experience away from the woman has its distinct drawbacks, though many women are more than happy to be 'delivered' from the rigor of birthing. In the end it becomes a very personal decision and more about a psychological comfort level - whether that's fully-loaded medical intervention, or the comfort of home and your bathtub.