Prenatal classes in 1968 at the hospital in Margate, Kent. Photo: Hulton Archive/Getty
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Don't call the midwife: why we're obsessed with “natural” childbirth

A new history of the Lamaze technique is balanced and impressive, but, like almost everything connected to childbirth, it is not entirely neutral or impassive.

This article first appeared on newrepublic.com

The typical birth narrative that you read online is a tale of harrowing disappointment. The mother had “spent months – if not years – dreaming” about her baby and her pain-medication-free birth. Often, it’s at home, where the mother fantasises that she will be “surrounded by my family, in an environment where I was free to walk around.” Ideally, the mother would even be able to reach down and pull her baby into the world herself. But, by dint of fate and unhappy circumstance, these moms are forced by medical professionals – sometimes even midwives or doulas – to have C-sections or epidurals. They are “treated disrespectfully or without compassion at that most vulnerable time.”

Read enough of these narratives and you’ll be convinced that the baby-industrial complex is a cold and harsh machine, where epidurals are pushed like marijuana from an aggressive street vendor and individual agency is dismissed.

But the reality is quite different. A new book, Lamaze: An International History by the historian Paula A Michaels, explains that the vast majority of modern American women are satisfied with their birth experiences. She doesn’t get into specifics on this particular matter, but she notes that according to a 2013 national survey of women’s childbearing experiences, “Mothers generally rated the quality of the United States maternity care system very positively.” 47 per cent said it was good, and 36 per cent said it was excellent.

Indeed, it’s my experience that even at big, impersonal city hospitals, the language and protocol surrounding maternity care is sensitive and catered to a woman’s desires. I recall the birthing plan that I was encouraged to fill out before I delivered at NYU Hospital. Would I like to move around during labour? Did I want pain medication offered to me immediately, or never? Did I want to delay umbilical cord clamping? (Studies show that this has benefits for the baby.) I remember looking at the crisp white sheet of paper with its cheerful check boxes and being mystified. Before receiving it, my “birth plan” consisted of going into the hospital when I started having contractions and leaving, at some point, with a baby in arms.

“We invite you to participate in the planning of your birth,” the NYU hospital’s website warmly announces. “We ask you to consider your preferences and beliefs that will make your birth experience meaningful to you and your family.” That’s a long way from the birthing gulag conjured up by disappointed new moms, and it’s a result, in part, of the adoption of Lamaze techniques in the US in the 1970s.

Michaels’s book offers a fascinating and detailed history of childbirth over the past century-plus and how what we refer to as Lamaze, but what is more technically known as “psychoprophylaxis,” fits into it. Michaels defines psychoprophylaxis as “a way of giving birth that attempts to manage labour pain primarily through psychological conditioning and without reliance on drugs.” The patterned “hee hee hoo hoo” breathing that is a staple of sitcom depictions of a Lamaze birth is intended to relax and distract a woman from the pain signals in her brain.

Though Lamaze was spread widely in the late ’60s and early ’70s by American feminists who were pushing back against a medical establishment that they saw as paternalistic, its roots go back to the 1930s, when a British physician named Grantly Dick-Read published a book called Natural Childbirth. Dick-Read’s Natural Childbirth was itself a kind of reaction to the established norms for middle- and upper-class birth. In the late nineteenth and early twentieth century, new state regulations about who could attend a woman during childbirth placed the majority of pregnant women in hospitals when they gave birth. Once birth became a formal, medical process, middle- and upper-middle-class women began asking for pharmacological pain relief. In 1915, Michaels notes, first-wave feminists were not agitating for a return to the home birth; they were arguing for twilight sleep during labour, because they thought it would liberate women from the discomforts of childbirth.

In Natural Childbirth, however, Dick-Read stated that childbirth is not inherently painful. “Women’s minds, not their bodies, were at the root of pain in childbirth and fear was ‘the greatest evil,’” Michaels writes of Dick-Read’s beliefs. The way to help women get out of their heads was through childbirth-education classes and greater support from husbands. Dick-Read promoted some insanely retrograde ideas – that birth pain is psychological; that women of the upper classes should be the ones having lots of babies – but other parts of his philosophy sound like they could have been cribbed from crunchy mommy blogs. Birth, Dick-Read wrote, is “an ecstasy of accomplishment that only women who have babies naturally [i.e., without anesthesia] appreciate.”

While Dick-Read’s methods were proliferating in the US and the UK in the ’40s and ’50s (though they never defined the dominant approach), a similar technique was devised in the Soviet Union. But there the impetus was different: a shortage of pain meds and a concomitant, statewide push for fecundity in devastated post-war Russia. There, psychoprophylaxis was developed and encouraged to improve the experience of the working classes. Like Dick-Read’s methods, psychoprophylaxis also relied on education for expectant mothers as a way to cut down on pain, which was, of course, all in their heads.

A French obstetrician named Ferdinand Lamaze picked up psychoprophylaxis when it was presented by Russian doctors at the 1951 International Congress of Obstetrics and Gynecology. Lamaze promoted, on an international scale, the trained muscular relaxation and patterned breathing he learned from observing women giving birth in Russia.

When Lamaze was first imported to the US, it wasn’t synonymous with zero medication. In the mid-’60s, “a little Demerol or morphine to take the edge off pain and tension did not stand in the way of claiming success in achieving a ‘natural’ birth,” Michaels writes. It was only when countercultural ’60s values, which prized authentic experience above all else, took over Lamaze methods that pain medication was eschewed completely.

Also gone was the notion that childbirth pain was all in a woman’s head. Pharmacology-free childbirth was framed as empowering because the male medical establishment pushed drugs, and those drugs “desensitised women’s bodies and clouded their minds” during an experience that should be wholly natural. Despite the shift in framing, the language of Lamaze moms in the early ’70s was curiously similar to the language of Dick-Read. They wanted an experience that was “near ecstasy”.

Exclusive use of Lamaze without pharmacological pain relief fell out of fashion in the early ’80s as epidural anesthesia became widely available, and as scientific literature began showing that those complex breathing patterns didn’t really help mitigate pain. But Lamaze helped usher in a lot of birth practices that we now think of as commonplace, including childbirth-preparation classes, allowing the birthing mother to have a supportive partner of her choosing in the room with her, and the rise of hospital birthing centers, which provide things like hydrotherapy tubs and homey furnishings along with access to the regular maternity ward should anything go wrong.

Michaels's book is balanced and impressive, but, like almost everything connected to childbirth, it is not entirely neutral or impassive. Even as she admits that most women are happy with their childbirth experiences, she still pushes for systemic change in her conclusion. She believes that maternity coverage should be ordered by the “logic of care” instead of the “logic of choice”. Care is an open-ended process without boundaries, Michaels says, while choice is a matter of assessing the limited products on offer. The latter, she argues, gives women a false sense of empowerment. According to a “logic of care,” women would be able to have a doctor or midwife with whom they’d developed a rapport deliver their baby, instead of whoever is on call; doulas, a kind of birthing assistant, would also be available to whoever wanted them, instead of just to women wealthy enough to afford them. Doula rates vary depending on geographic location and level of experience, but range from a few hundred to a few thousand dollars.

I don’t know that those measures are practical, or that they would even prevent the blogosphere from being “perennially abuzz with chatter of disappointing childbirth experiences,” as Michaels puts it. How do you guarantee that a certain obstetrician is available for every woman in labour? What if two women covered by the same doctor go into labour simultaneously at different hospitals? Isn’t a midwife allowed to have her own family emergencies that might supersede her job? What if your doula disagrees with your choices? Or the doula fights with the midwife? Will you still feel cared for and empowered?

I don’t mean to discount the bad experiences that women have during childbirth – those experiences are real and painful. But perhaps those are individual issues, rather than national ones, stemming, in part, from the unreasonably high expectations that we’ve put on the birth process. Our expectations are high because we choose to have children, and we have fewer of them. Before the pill and the sexual revolution, having children was socially expected and more difficult to prevent. As Jennifer Senior says in her new book, All Joy and No Fun: The Paradox of Modern Parenthood, “Adults often view children as one of life's crowning achievements, and they approach child-rearing with the same bold sense of independence and individuality that they would any other life project.”

But the other part of our high expectations may have to do with all of the new information we have about pregnancy and how our actions and environment could influence our fetuses. In her wonderful book, Origins, Annie Murphy Paul discusses the burgeoning scientific field of “fetal origins”. Paul writes that the discoveries of these researchers “have been cast as one long ringing alarm bell, one long line of doctors in white lab coats, shaking their fingers at pregnant women: No, Don't, Stop!” Your diet, your stress level, the air you breathe, and yes, how you give birth, can all affect your child. No wonder we are so concerned with how our children come into the world; we're told we could be screwing it all up just as they take their first breath.

As a result, we now emphasise our preparation in the run-up to the birth – all those birth classes to take and cord-clamping decisions to make – and yet, we leave the hospital almost entirely clueless about the mewling, fragile little bundles we’re spiriting home. Just like parenthood itself, birth is not always going to be something “ecstatic” or something that you can control, no matter how many boxes you’re allowed to check on your birth plan.

This article first appeared on newrepublic.com

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Andy Burnham and Sadiq Khan are both slippery self-mythologisers – so why do we rate one more than the other?

Their obsessions with their childhoods have both become punchlines; but one of these jokes, it feels to me, is told with a lot more affection than the other.

Andy Burnham is a man whose policies and opinions seem to owe more to political expediency than they do to belief. He bangs on to the point of tedium about his own class, background and interests. As a result he’s widely seen as an unprincipled flip-flopper.

Sadiq Khan is a man whose policies and opinions seem to owe more to political expediency than they do to belief. He bangs on to the point of tedium about his own class, background and interests. As a result he’s the hugely popular mayor of London, the voice of those who’d be proud to think of themselves as the metropolitan liberal elite, and is even talked of as a possible future leader of the Labour party.

Oh, and also they were both born in 1970. So that’s a thing they have in common, too.

Why it is this approach to politics should have worked so much better for the mayor of London than the would-be mayor of Manchester is something I’ve been trying to work out for a while. There are definite parallels between Burnham’s attempts to present himself as a normal northern bloke who likes normal things like football, and Sadiq’s endless reminders that he’s a sarf London geezer whose dad drove a bus. They’ve both become punchlines; but one of these jokes, it feels to me, is told with a lot more affection than the other.

And yes, Burnham apparent tendency to switch sides, on everything from NHS privatisation to the 2015 welfare vote to the leadership of Jeremy Corbyn, has given him a reputation for slipperiness. But Sadiq’s core campaign pledge was to freeze London transport fares; everyone said it was nonsense, and true to form it was, and you’d be hard pressed to find an observer who thought this an atypical lapse on the mayor’s part. (Khan, too, has switched sides on the matter of Jeremy Corbyn.)

 And yet, he seems to get away with this, in a way that Burnham doesn’t. His low-level duplicity is factored in, and it’s hard to judge him for it because, well, it’s just what he’s like, isn’t it? For a long time, the Tory leadership’s line on London’s last mayor was “Boris is Boris”, meaning, look, we don’t trust him either, but what you gonna do? Well: Sadiq is Sadiq.

Even the names we refer to them by suggest that one of these two guys is viewed very differently from the other. I’ve instinctively slipped into referring to the mayor of London by his first name: he’s always Sadiq, not Khan, just as his predecessors were Boris and Ken. But, despite Eoin Clarke’s brief attempt to promote his 2015 leadership campaign with a twitter feed called “Labour Andy”, Burnham is still Burnham: formal, not familiar. 

I’ve a few theories to explain all this, though I’ve no idea which is correct. For a while I’ve assumed it’s about sincerity. When Sadiq Khan mentions his dad’s bus for the 257th time in a day, he does it with a wink to the audience, making a crack about the fact he won’t stop going on about it. That way, the message gets through to the punters at home who are only half listening, but the bored lobby hacks who’ve heard this routine two dozen times before feel they’re in the joke.

Burnham, it seems to me, lacks this lightness of touch: when he won’t stop banging on about the fact he grew up in the north, it feels uncomfortably like he means it. And to take yourself seriously in politics is sometimes to invite others to make jokes at your expense.

Then again, perhaps the problem is that Burnham isn’t quite sincere enough. Sadiq Khan genuinely is the son of a bus-driving immigrant: he may keep going on about it, but it is at least true. Burnham’s “just a northern lad” narrative is true, too, but excludes some crucial facts: that he went to Cambridge, and was working in Parliament aged 24. Perhaps that shouldn’t change how we interpret his story; but I fear, nonetheless, it does.

Maybe that’s not it, though: maybe I’m just another London media snob. Because Burnham did grow up at the disadvantaged end of the country, a region where, for too many people, chasing opportunities means leaving. The idea London is a city where the son of a bus driver can become mayor flatters our metropolitan self-image; the idea that a northerner who wants to build a career in politics has to head south at the earliest opportunity does the opposite. 

So if we roll our eyes when Burnham talks about the north, perhaps that reflects badly on us, not him: the opposite of northern chippiness is southern snobbery.

There’s one last possibility for why we may rate Sadiq Khan more highly than Andy Burnham: Sadiq Khan won. We can titter a little at the jokes and the fibs but he is, nonetheless, mayor of London. Andy Burnham is just the bloke who lost two Labour leadership campaigns.

At least – for now. In six weeks time, he’s highly likely to the first mayor of Greater Manchester. Slipperiness is not the worst quality in a mayor; and so much of the job will be about banging the drum for the city, and the region, that Burnham’s tendency to wear his northernness on his sleeve will be a positive boon.

Sadiq Khan’s stature has grown because the fact he became London’s mayor seems to say something, about the kind of city London is and the kind we want it to be. Perhaps, after May, Andy Burnham can do the same for the north – and the north can do the same for Andy Burnham.

Jonn Elledge edits the New Statesman's sister site CityMetric, and writes for the NS about subjects including politics, history and Daniel Hannan. You can find him on Twitter or Facebook.