Pregnancy & Birth
Recommended Books and Films About Childbearing
A History and Critique of Childbearing Books
Note from the author: The following article was written in the late 1990s. While some of the books listed are no longer in print, the article contains a brief history of childbearing and discusses a way of looking at books which I believe is still useful today.
The First Seven Books:
Choices in Childbirth
A Good Birth, A Safe Birth, and Sense & Sensibility
Your Baby, Your Way
A Wise Birth
What To Expect When You're Expecting
The Well Pregnancy Book
Stepping Beyond the System: The Last Three Books
The Birth Book and Spiritual Midwifery
Over the past thirty years, popular childbirth literature in the United States has attested to women's strongly felt need to understand pregnancy, labor and birth, and to know what choices they have, if any, in regard to practitioner, birthplace, and how they might give birth. In the early 1960s, the only books widely available were Dick-Read's Childbirth Without Fear, Karmel's Thank You, Dr. Lamaze, Chabon's Awake and Aware and Vellay's Childbirth Without Pain. These progressive physicians discussed alternatives to the routine surgical birth of our mid-century decades. Today scores of books written by women (and men), mothers, childbirth educators, midwives, social scientists and physicians provide information and advice about pregnancy, birth and parenthood.
Before the late nineteenth century, women learned about childbearing from other women. In colonial United States, friends and relatives brought food and stayed for days, even weeks, to help (Wertz & Wertz). Often mothers served as their daughters' faithful companions during the entire time of "confinement" (Leavitt). In the south, young African-Americans, after assisting their midwife grandmothers for years, later felt "called" to become midwives themselves (Smith/Holmes/ Logan/Clarke). Once physicians began attending births in homes, they too became a source of information. Once most women were moved into hospitals for labor and birth (by about 1950), it seemed as if the subject of birth literally disappeared from public discussion despite the efforts of some dedicated women to keep the subject alive (See Reclaiming Birth, Edwards and Waldorf). Indeed, the use of scopolamine meant that an entire generation of women shared a collective amnesia in regard to birth. In the late 1950s, birth reappeared as an issue. By that time, a significant number of women, having experienced the isolation and indignities of hospital practices, the dangers of general anesthesia and the obliteration of their memories, began to protest the situation. They wanted companions and support, and to be awake to see their babies born.
Although midwives in the United States did not attend many births during those years, many of the first nurse-midwives taught childbirth classes to a small number of women, some of whom helped to create groups like the original Childbirth Education Associations. By 1960, two national organizations were formed – the International Childbirth Education Association (ICEA) and the American Society for Prophylactic Obstetrics (ASPO) – built from the writings and teachings of dozens of women’s groups, writers and innovative professionals. "Family Centered Maternity Care" was their credo.
In the exciting open climate of the late 1960s, during the "second wave" of the women’s movement, middle-class women turned to each other again in greater numbers. They began to "claim" their bodies and their sexuality, analyzing their personal experiences in a cross-fertilization of facts, feelings and ideas. They discovered that they were not alone, that others had undergone similar events, and that male-dominated institutions had been responsible for minimalizing and suppressing their needs and desires. They discovered the heady power that comes from talking together, telling deeply-felt birth stories, sharing information and forming groups to organize and work for change.
Many women (and some men) wrote books advocating childbirth reform. These books replaced the old-fashioned community of knowledge, and created new communities and organizations. Some of the authors of the late 1960s and the 1970s included Niles Newton, Barbara Ehrenreich & Deirdre English, Doris Haire, Lester Hazell, Sheila Kitzinger, Suzanne Arms, Ina May Gaskin, Yvonne Brackbill, Tom & Gail Brewer, Nancy Shaw, Birgitte Jordan, Raven Lang, Dick & Dorothy Wertz, Catherine Milinaire, and the Boston Women's Health Book Collective). They spoke (or hoped to speak) for many women. Their books expressed dissatisfaction with prevailing medical practices, and shone as beacons of hope that practitioners and hospitals would become more responsive to their needs.
These authors described and critiqued modern obstetrics, locating the source of its philosophy, training and practice in several areas – in the aggressive development of nineteeth-century obstetrics, in male physicians’ desire to make money, and to have power over women by controlling the natural process of childbearing (see Horrors of the Half-Known Life, G.J. Barker-Benfield, for a history of early obstetrics – soon to be reprinted). They unearthed and gathered stories of pregnancy, labor and birth, collected and analyzed medical and historical data, and explored birth practices in the U.S. and other countries. Their work, implicitly or overtly, contained fragments of a vision of a woman-centered system of maternity care. That vision in its purest form located birth in the home and created a new generation of community midwives who learned through apprenticeship, home study, midwifery schools and nurse-midwifery programs. These newest midwives restored to this culture the phenomenon of positive births, developed midwifery schools and created local and national midwifery organizations.
In the 1970s, change seemed possible. People involved in childbirth reform hoped, even expected to alter the services that didn't meet their needs and to develop new ones. They worked hard to introduce midwives into hospital practices and to create freestanding birth centers. They continued the struggle of earlier pioneers to establish hospital policies that would encourage fathers, siblings, family and friends into birthing rooms and permit rooming-in, breast-feeding on demand and early discharge. But they met resistance in most places.
Advances were hard-won and difficult to maintain because most obstetricians (predominantly male in those days), at the hub of power, would not or could not deviate from the conventional view that women's bodies don't work well by themselves. The obstetrical philosophy holds that pregnancy and birth are "high-risk conditions," potential illnesses to be "managed" and controlled by physicians in hospitals with drugs and technology, inherently painful experiences which no woman should have to endure. While many women were learning about woman-centered birth and seeking to shape their experiences in personal and empowering ways, obstetrical ideology remained fundamentally unchanged. Most of the changes that did take place in the 1980s obstetrical world involved an intensified use of testing and technology -- the almost routine application of ultrasound, AFP screening and amniocentesis, the continued use of pitocin, fetal monitoring and epidurals, and the notable increase in cesareans. Then, as now, physicians utilized these procedures regardless of their necessity, effectiveness or safety (Brackbill, Inch, Marieskind, Cohen/Estner, Goer). Then, as now, strong pressures from medical industries selling everything from fetal monitors to drugs to surrealistic plastic birthing chairs reinforced this tendency to intervene. The very existence and availability of technology inevitably restricts the arena of choice. Small important gains have indeed been made – birthing rooms, increased nurse-midwifery services, shorter hospital stays – but always, the physician within the hospital institution retains power and control.
This intensified medicalization of pregnancy and birth results from an adulation of technology combined with obstetrics' historical imperative to "manage" and control the birth process. "What if something goes wrong...?" permeates the atmosphere, with many women increasingly fearful and worried. Almost everyone now accepts the purely medicalized description of pregnancy, labor and birth, expanded here and there with strictures about "lifestyle" -- no drinks, no drugs, eat well, exercise adequately, get a lot of rest -- almost as if the activism and analyses of the past three decades had never taken place. In the U.S., achieving some reforms has not fundamentally altered the maternity care system. But it has led many people to believe -- or to fool themselves into believing? -- that significant structural changes have occurred, that further reform can take place and that many real choices are available.
Most childbirth literature of the 1970s and early 1980s differs from that of the mid-eighties to late nineties, as it strongly expresses women's desire for change, for choice and for more control of the birth experience. The childbirth preparation books we read today, strongly affected by the continued medicalization of childbirth, confusingly combine these desires with a renewed dependence upon physicians and technology.
Modern books about birth seek to reconcile two concepts. Women-centered birth places women at the heart of the childbearing experience. This viewpoint affirms pregnancy and birth to be normal, healthy life events. It values women’s strengths and perceptions of their needs, paying careful attention to the language they use and to their life experiences. It trusts that women know, or can learn, what they need to know to be healthy, to give birth well, and have healthy children. It takes into account the whole picture of women’s lives. It involves the practitioner’s use of a whole range of midwifery stills (which exist in a different realm than obstetrical skills). It conceives of health as a means to an end – a life fully lived – rather than as an end in itself. In contrast, medically manipulated and controlled birth focuses upon the risks and pathology of childbirth, as well as the primacy of obstetrics (a surgical specialty) and of medical technology. It almost always ignores the social, economic and spiritual circumstances of women’s lives and health, and concentrates upon medical surveillance and rescue in time of crisis. Often it pits mother against child, treating her as a container for her baby. So many women going through the obstetrical system feel undermined, their human rights denied, their bodily and spiritual integrity violated, and their very health threatened.
These two concepts often conflict. Sometimes they seem (and perhaps are) irreconcilable. Despite our work these past decades as educators and activists, the medical view predominates throughout the country; the obstetrical system, a medical monopoly, is too firmly entrenched to be shaken. It affects all of us. As authors describing the ways in which these conflicts often play themselves out, we use the mindset, words and arguments of the system we criticize. We are locked within a system that tolerates only a little deviation, and dictates the priorities to be addressed. We become defensive. No sooner do we mention women's complex feelings, desires and concerns in our writing and teaching, then we must enter into discussions about discomfort, risk and technology. Unwittingly, we embrace the conventional obstetrical framework – its language, its categories of care -- in order to caution and strategize against it. It shapes our thoughts and feelings and struggles and bends us toward compromise and capitulation. We offer either-or dichotomies, and foster misleading expectations. We guide women through a medical obstacle course they should never have to confront in the first place (and that they have little or no power to change). We advise them to learn about their capabilities while zeroing in upon the coercive aspects of a physician-dominated system. We urge them to wield their amazing ability to give birth in the very atmosphere that stifles and mutes childbearing in all its depth and dimensions, and at the very time they are the most vulnerable. We ask them to split themselves into parts, to dilute their strengths, and, at times, to abdicate their powers of feeling and reason.
Childbirth advice books thus influence our choices. They inform and guide; they also indoctrinate in a subtle way. Often they are confusing and contradictory. We are told that we are strong and capable and then cautioned about all the things that might go wrong. We are advised to fight for that "natural" birth and at the same time confronted with long lists of tests and interventions to circumvent, somehow, if possible. Almost every mention of a woman’s desires and concerns is immediately followed by a discussion of risk and danger. We are counseled to work for change if we are not satisfied, and to do so coolly, politely, in a lady-like manner. We are well-behaved, taking care not to offend the powers that be, as if a medical eye and mind hovering on the horizon were monitoring every sentence. We end up doing women a disservice by claiming that they may avoid the strictures of our obstetrical system when most of their their babies must be born within its bounds.
In this critique, by analyzing the language, organization and content in selected passages from ten childbirth books, we will uncover the underlying messages women receive. The following seven books focus specifically upon the issues of choice and preparation for childbirth within the framework of the obstetrical system. Birth Reborn, the eighth book, serves as a bridge between two ways of looking at childbearing. The Birth Book (long out of print) and Spiritual Midwifery suggest a way of understanding women and midwifery that enables us to fashion a maternity care service that truly meets women's needs and enhances their lives and health.
Advice books proliferate and expire in the market quite speedily; only a few will last more than a few years. Some of the books mentioned and discussed are still in print. Others have been out of print for decades, and several excellent books are being reprinted. I hope that readers of this critique will use these pages as a tool for reading and analyzing current advice books, and those yet to be written.
THE FIRST SEVEN BOOKS
Choices in Childbirth (CC), by Dr. Sylvia Feldman (1979), demonstrates by its good will and its lack of critical sophistication the thinking of the general audience in the U.S. Its author, a psychotherapist, has encountered many women suffering from post-partum depression caused by difficult, even abusive, birth experiences and believes strongly that women must have choices that will strengthen and satisfy them. She makes an earnest effort to educate women and to dispel fear and ignorance, urging women to plan during pregnancy rather than be passive "patients," and to consider various "methods" of dealing with labor and birth.
At its best, the book raises important issues. But it immediately sets two kinds of care in conflict. It presents choice in terms of "the natural camp" vs. "the least involvement and responsibility possible" (xiv), "natural childbirth advocates" vs. "technologists" (21), and (extrapolating from a doctor's statement) "humanize(d) childbirth" set against the "benefits of modern obstetric care" (49). It is one thing to recognize that there are different ways to give birth and that conflicts between them exist. It is another to set them in such opposite camps that one seems to exclude the other totally, especially in a society that endorses technology and modern obstetric care and will lean toward it in theory and practice. Presenting such a dichotomy is good in that it suggests an alternative, but not helpful unless a woman can be sure that she and her practitioner can honor all the implications of her choices and help her to follow through with them. The first third of the book, apart from a chapter on nutrition and exercise, drops the "natural" side of the equation, and is taken up with information about medically managed and monitored birth, the Cesarean birth experience and the pros and cons of childbirth drugs.
Finally appears a chapter entitled "The Natural Way." "Natural" methods, defined as the opposite of "medicalized" include the Dick-Read, Lamaze and Bradley Methods. (Later on we read about "Leboyer births, babies, baths, doctors and midwives"). (182-186) This is significant because it reveals that the author has heard about only the more or less accepted "brand-name" alternatives (all devised by men), and that she knows little about midwifery and all the unnamed, deeply experienced, organic ways in which women labor and give birth. One method mentioned is actually called "Doctor-Centered Natural Childbirth." The description begins: "...more than with other natural childbirths, this is the doctor's show. Everyone must accept his obstetrical practices. (He) uses electronic fetal monitors routinely" (111). On the one hand this seems a contradiction in terms; on the other, it proves to be an accurate indicator of the fact that these so-called "natural" methods can be easily integrated into standard obstetrical practice.
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