The Enduring Power of Patriarchy in Birth
Within the realm of birth, two paradigms dominate: medical and physiological. Both sit on opposite ends of the birth spectrum and both posit their model as superior over the other.
middle ground: nature in hospital?
The medical model emerged in the early 20th century when physicians began to frame birth as a medical event necessitating medical interventions within a hospital setting. These physicians were predominantly white men and the transition to hospitals triggered the exclusion of female midwives from birth.
Whereas the medical model required formal training within a higher educational institution, midwifery was rooted in experiential knowledge and passed down through generations of healers, midwives, and witches alike. The modern-day physiological model is based off midwifery care and believes birth to be both normal and natural.
When I found out I was pregnant, I began a deep dive into pregnancy and birth preparation literature. My understanding of birth was largely shaped by the movies and shows I had grown up with: scenes of women rushed to the hospital after their water broke in a dramatic fashion, cutting to those same women in hospital gowns, screaming bloody murder, while pushing a 6 month-old baby out of their vagina.
I quickly learned that there was far more to a real-life birth than Hollywood would have you believe. The time I spent reading books, taking classes, and listening to the stories of other women who birthed before me were incredibly fruitful. I began to understand the physiological process that is labor and the more I learned, the less I feared.
As they say, knowledge is power.
But as my knowledge bank accumulated more information, the more I began to fear the medical model. And the more I feared the medical model, the more I idealized the “natural” physiological model.
My brain computed the following maths:
No medical intervention + uninterrupted labor = natural (read: good). Medical intervention + interrupted labor = unnatural (read: bad).
Ok, I thought. Just have the natural labor and you’ve done it right. Right?
Not so fast.
Detecting the Patriarchal Odor
The notion of “doing birth right” is inherently misogynistic. Any assertion of control over how, where, when, and why a woman chooses to birth a baby is the patriarchy speaking.
Feminism, on the other hand, is rooted in personal choice. It grants one the space to listen to their own body, make their own decisions, and carve their own path. Each path taken is “right” in its own way with no one way better than any other. Patriarchy, in its age-old way of thinking and operating, slips in to say, “Actually, there is a correct way of birthing. And anyone who does not follow it, has failed.”
While the physiological model is rooted in true feminist theory, the modern day natural childbirth movement associated with physiological birth is not. It in fact has more than a small tinge of patriarchal odor to it. Before you come for my head, let me explain.
Traditional midwifery care trusts the body’s innate ability to labor and birth a baby. Period. Modern natural childbirth movements have interpreted this statement of trust to mean that a “natural and normal” labor is one in which medical interventions are not utilized. Spontaneous onset, vaginal delivery, and minimal medical intervention are the key markers of a physiological birth.
Should a birthing person require the use of a medical intervention, like in the instance of a mother’s pain index exceeding a tolerable level and her requesting an epidural, the labor would be considered a twinge less than natural. The idea that medical intervention, particularly that used to electively minimize pain in childbirth, is somehow an indicator of a “less than ideal” labor is not new.
In fact, the belief can be traced back to the Catholic Church who promoted the idea that childbirth pains were a punishment from God for Eve’s original sin.
To the woman [the Lord God] said, “I will greatly multiply your pain in childbearing; in pain you shall bring forth children.”
To which I am sure she replied, How gracious of you. Thank you kindly, dear benevolent God.
Although Pope Pious XII legitimized the use of medical interventions for pain management in childbirth in a 1956 address, the damage had already been done. Both the modern day natural childbirth movement and the professionals who sought to medicalize birth were heavily influenced by the Church’s teachings.
Medicalization of Birth
Medicalization of birth was, and remains to this day, highly problematic. Obstetric medicine, almost entirely made up of white men, seized birth from homes and the hands of women under the guise of “safer” birthing conditions. Much to the horror of all birthing people and midwives, these hospitals were far more dangerous and resulted in higher infant and maternal mortality rates than home births. Hospital birth outcomes were largely due to sanitary issues. It wasn’t until the application of germ theory in the early 19th century that these morbidity rates began to decline.
Worsening birth outcomes was the increased use of medical interventions including forceps, scalpels, and anesthesia in births that “likely could have succeeded without intervention.” Where medical interventions did make improvements, however, was in cases of hemorrhaging and birth obstructions.
The Catholic Church’s influence within the medical model becomes no more clear than in the use of episiotomies. Episiotomies are surgical incisions made at the vaginal opening, through the perineum, for the purpose of widening the vagina during birth and preventing tearing. This practice, though far less common now as research has shown spontaneous tearing to be less severe, has its roots in the idea of female virginity.
As Jenine Ellis writes in her essay “What I Mean When I Talk About Patriarchy In Birth,” OB William Ray Arvey (1982) promoted the idea that episiotomies were ideal interventions for their ability to restore “virginal conditions” to female anatomy. In his book Power and the Profession of Obstetrics, he wrote “A properly completed surgical repair was considered to be one that restored the vaginal anatomy to a state considered sexually desirable by the obstetrician performing the repair.”
Objectifying women’s bodies for the male gaze and idealizing female virginity for the patriarchy? Sounds about right. The Church would have you believe that Mother Mary gave birth to her son without disrupting her virginal status by way of conception or during labor.
So repugnant is the idea that a sexually active woman could have been responsible for birthing the son of God, by way of vaginal delivery no less, they have proselytized the idea of immaculate conception for centuries.
Obstetric Violence through an Intersectional Lens
The assertion of control over a woman’s body within the medical system is even more obvious and cruel for women of color. Obstetric violence has a long history of dehumanizing black women by treating them “as expendable clinical material for its institutional needs,” writes Colleen Campbell. In her essay “Medical Violence, Obstetric Racism, and the Limits of Informed Consent for Black Women,” Campbell makes a direct connection between today’s disproportionately high infant and maternal mortality rates among black women to gynecology’s early days.
Black women’s position at the intersection of race and gender has led them to experience the harmful effects of medical racism and gendered violence, particularly in relation to childbirth. Black women’s bodies held value insofar as their ability to reproduce, which maintained the enslaved population, and work on the fields, which increased profit.
Within the realm of gynecology, black women did not have the political or legal protections to grant consent or refuse medical procedures. Their bodies were viewed as property per their status as slave and early gynecology took advantage by exploiting their bodies for medical research.
This form of early obstetric violence by male physicians was largely motivated by the desire to gain legitimacy for themselves while delegitimizing the midwives and healers that had dominated birth until then. Early medical interventions, such as episiotomies and cesarean, were tested on unconsenting black women before later being used on white women.
Early gynecology research also included the mass sterilization of black and brown bodies by government-funded clinics. The mass sterilization was part of a broader eugenics movement that believed blackness to be a less-desirable trait and aimed to reduce reproduction by black, and primarily poor, women.
Obstetric violence has continued into today’s medicine with women of color disproportionately affected. All women, regardless of race, face an increased risk of cesarean in the US due to physician pressure and insurance liability. Despite spending more money on healthcare than any other developed nation, the US has the highest maternal and infant mortality rates amongst its wealthier counterparts.
The Natural Childbirth Movement
Modern-day medicine has evolved with empirical evidence and more diversity among OB’s, which has led to improved outcomes in comparison with it’s early days. The long-storied history of over medicalizing birth, especially for women in color, left a black stain on our medical system that has proven difficult to remove. It is no wonder that in the wake of twilight sleep, a natural childbirth movement arose to fill the massive gap.
The early natural childbirth movement, however, was not led by the midwives and healers that had attended births for centuries prior. This might come as a surprise for you but the people spearheading both the medicalization of birth and the natural childbirth movement? Almost entirely men. Think Grant Dick-Read who promoted breathing techniques in labor as the only pain management needed. If pain reached an intolerable level, it was simply due to fear of the birthing process itself and a lack of adequate education during pregnancy.
In his book Motherhood in the Post-War World he wrote, "Woman fails when she ceases to desire the children for which she was primarily made. Her true emancipation lies in freedom to fulfill her biological purposes," as well as stating that tribal women who died in childbirth did so "without any sadness...realizing if they were not competent to produce children for the spirits of their fathers and for the tribe, they had no place in the tribe."
Hmmm…not quite the feminist hero I was hoping to uncover. If Dick-Read’s poetic writing reads of race and class, you’d be right.
As evidenced by Dick-Read, eugenics proved to be a major influence in not only the medicalization of birth but also the natural birth movement. Similar to those within the medical system, Dick-Read wanted to promote reproduction among white, upper class women who he deemed “over-civilized” and most genetically desirable. The problem as he saw it, was the fear these women had of the pain in labor.
Dick-Read’s primary goal was to discourage women from using pain management of the medical variety and instead experience birth fully embodied. The use or dissuse of medical pain management remains to be the separator between a “natural” birth and an “unnatural” one. Use an epidural? Unnatural. Rely on your breath and bodily positions? Natural.
The Value System Behind Birth
But what does it mean to be natural? And why is natural so important?
The answer to that lies in the socio-political landscape in which the natural childbirth movement was born. Around the same time as the medicalization of birth, the world began to see the damming effects of industrialism, capitalism, and over-consumption. In response to this, society rebelled against the idea of modern civilization and emphasized the need to return to nature.
This emphasis on nature extended to the birth world and promoted the emerging concepts of the natural childbirth movement. Nature is more strongly associated with the feminine and therefore carries values of love, nurture, and altruism. Medicine falls within the category of the masculine and instead carries values of logic, destruction, and apathy. The natural childbirth movement did not evolve in a vacuum. As scholar Ornella Moscucci states, “it is necessary to resist any attempt to regard natural childbirth as a universal, value-free category and look at the intellectual and political context in which it was embedded.”
The problem with both frameworks, medical and physiologic, is in the ascribed values and the meaning attached to them. One is clearly regarded as better than the other for its “natural” nature and the other is less ideal for its “unnatural” nature. This value system places an immense amount of pressure on women to perform in pregnancy and birth. As Dick-Read put bluntly, a woman who cannot successfully birth a child without the need of medical interventions has failed.
At the heart of the natural childbirth movement is a desire to empower women to birth without relying on medical professionals. Common statements like “Trust your body” and “I embrace the power of birth” are standard in natural birthing modalities. While there is no doubt that our country has had a large-scale issue with over-medicalizing birth, a lingering question of what it means for a woman who could not “trust her body” or “embrace the power of birth” remains.
What happens when a woman is unable to birth without medical intervention? When the “natural” course of her labor requires an epidural, an induction, or even a cesarean?
In some cases, medical interventions can be life-saving procedures. In others, they can reduce the possibility of postpartum depression. But often times the use of medical interventions creates long-lasting feelings of shame, guilt, and self-doubt for those hoping for a “natural” birth.
If empowerment in birth is the goal and bodily autonomy the means, both ends of the birth spectrum seem to be missing their marks.
A Feminist Approach to Empowered Birth
The patriarchal odor may be easier to see in the medical model, but do not ignore its presence within the physiologic model. Women have been fighting to take back the power of birth ever since the early days of gynecology when male doctors co-opted birth from midwives.
I cannot believe, however, that today’s polarization of birth is what our ancestral midwives, healers, and witches had in mind when they thought of empowered birth.
Empowerment in birth looks like flexibility of choice in which all pregnant people have the ability to choose their provider and birthing location, without being limited by insurance.
Empowerment in birth looks like informed consent in which pregnant people and their support persons receive comprehensive birth education leading up to labor.
Empowerment in birth looks like bodily autonomy in which a pregnant person’s desires for birth are listened to and followed to the best of the care team’s ability.
Empowerment in birth looks like access to contraception, the ability to family plan, and the option to safely terminate a pregnancy.
Empowerment in birth looks like culturally competent care, in which our medical system’s racist history and its pervasive influence on modern obstetrics is acknowledged.
Empowerment in birth looks like reproductive justice for all.
