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

Photo: Getty
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Germany's election isn't about who will win, but who gets to join Merkel in government

Even small changes in vote share could affect who rules with the chancellor's CDU.

The leaves are falling and the ballot boxes are being given a final polish. It should be peak Wahlkampf. (Trust us Germans to have a word for "campaign" which sounds like something that should be barked by a soldier in a black-and-white film.)

Yet, instead of "peak campaign", with just days to go before polling day, we have an almost deadly dull one. Europe’s largest nation is being gripped by apathy. Even the politicians seem to have given up. Four years ago the then Social Democratic (SPD) challenger for chancellor, Peer Steinbrück, was so desperate to grab attention that he posed on a magazine front cover pulling the middle finger.

Instead Chancellor Merkel’s strategy of depoliticising the economic and social challenges Germany faces, and being endorsed as the steady mother of the nation, seems to once again be bearing fruit. Her Social Democratic contender has simply not been able to cut through.

So much so that for most voters the differences in policy agenda between Merkel’s Christian Democrats (CDU/CSU) and her main challenger Martin Schulz’s SPD are hard to detect. Not least because the SPD has spent the past four years serving under Merkel as the junior partner in a so-called "grand coalition". It doesn’t make it easy to distinguish yourself when you have just spent the last four years agreeing in cabinet.

This is dangerous and careless in an age of economic and political insecurities where voter volatility has reached new heights, and the radical right-wing AfD is forecast to get a vote share in double figures – a tally that would make it the third strongest party in the Bundestag.

It’s business as usual for Merkel who has copied the playbook that so successfully delivered three victories: picking no fights and managing expectations. Why change a winning formula? She wants to carry on chasing the political legacy of her hero Helmut Kohl by securing a fourth term in office.

Once again the "safety first" strategy is paying off. Her CDU/CSU is on course with the polls showing a solid 17 per cent lead over Martin Schulz and the SPD.

Merkel may be cruising to victory, but Germany’s proportional electoral system means that she won’t be able to govern alone. Which means the most exciting question in the German election isn’t who is going to win, but with whom is Merkel going to form another government. All eyes are on the different combinations of parties that would provide the chancellor with a new majority.

As it stands, it is very likely that for the first time ever, the Bundestag will be host to six political parties. More dauntingly, it will also be the first time since the Second World War that members of the radical right-wing will be sat in the chamber. Arguably, this political setback may be seen as a failure of moderate forces to find the right political solutions for the refugee and financial crisis – the AfD is essentially the offspring of both – but it is also part of a wider populist surge in Europe and North America.

This fragmentation of the party system in Germany will make it a challenging task for CDU/CSU to form a coalition. However, with the return of the liberal, and pretty unashamedly neo-liberal FDP, Merkel can potentially revert to a traditional centre-right ally. This would please those in her party who have been sceptical of her socio-economic move to the left, and blame her for the rise of the right-wing populists.

A report by the University of Mannheim provides us with a useful, if firmly scholarly, political version of those dating compatibility quizzes we all like to do in idle lunch hours. It finds that a coalition between the CDU/CSU and the FDP would be a natural match. They would agree on 20 out of 38 of the main policy issues in German politics. 

On which issues would coalition partners agree/disagree?

Only the other traditional “bloc coalition” between the SPD and Greens, which lifted Gerhard Schröder into the chancellery in 1998, would do better, matched on 24 issues overall. The study matches preferences on key economic, social, domestic and foreign policy of all major political parties and maps potential areas of conflict for all realistic coalition options. But polls currently show that neither of the naturally fitting centre-right or centre-left blocs would have enough seats to make a coalition work.

Which leaves three possible scenarios. The most intriguing would be the "Jamaica coalition" of the CDU, FDP and Greens (so called because the three party colours are the same as the Jamaican flag). Such an option has never been tried before at the federal level but is currently in power in Schleswig-Holstein. Alternatively, Merkel could follow the example of Saxony-Anhalt and try governing with her own CDU/CSU alongside both the SPD and the Greens. However, the new study finds that a three-way pact would be more prone to conflict and harder to negotiate than any of the two-party options.

More than two parties in a coalition would be an interesting novelty at the federal level, but disagreement on individual policy areas is expected to be considerably greater. The so-called "traffic-light-coalition" of the SPD, the Greens and the FDP would agree on 11 topics, yet disagree on 20 issues. And on top of issue-specific conflicts it would be more difficult to bridge ideological differences between parties at the different ends of the left-right dimension, as such between the SPD and FDP.

In the end it will all depend on how the numbers play out on election day this Sunday. The fact is that even minor shifts in voting behaviour from the current poll predictions would make a major difference to the options for government formation.

So, what should you look out for on election night? I would suggest keeping an eye on the liberals. What happens to the FDP’s vote share is crucial for whether they can return to their role as coalition queenmaker, after failing to jump the 5 per cent hurdle in 2013 and ending up with no seats. If the business-friendly liberals cannot deliver a majority for Merkel, the ball will be firmly back in the SPD’s court.

Gerhard Schröder used to say that a chicken is fat at the end (it makes more sense in German).

But if Schulz’s campaign does not pick up momentum in the closing hours of the campaign, and the Social Democrats' vote share collapses to around 20 per cent, its leaders will find it difficult to justify another grand coalition to SPD members.

They will likely be once again asked to endorse any grand coalition with the traditional conservative enemy in a one-member-one-vote ballot. Many inside the party fear that another four years as junior partners to the strategically astute Merkel could be the end of the road for the Social Democrats.

Florian Ranft is a senior researcher and adviser at Policy Network