The Culture of Childbirth
Childbirth brings a change in the state of consciousness akin, . . . . to that achieved by shamans and mystics. It is a time when a woman reaches beyond normal perceptions and may involve a vision of the universe which transcends ordinary reality.
--from Birth Traditions & Modern Pregnancy, by Jacqueline Vincent-Priya
It seems as if the experience of childbirth should be the same the world over. After all, giving birth is perhaps the most essentially human of all activities. And yet, as with everything else people do, we alter this biological event to fit our widely dissimilar cultural constructs. Thus, pregnancy and childbirth have their own associated rituals, beliefs, practices, and psychological ramifications. With little more in common than the eventual outcome: a tiny new person, women around the globe move through this inarguably significant life-passage in their own uniquely fascinating ways.
Sarah* is a direct-entry midwife in New York state. She practices in rural dairy country near the Canadian border among the many Amish and Mennonite families living there. Currently, Sarah attends more than three-fourths of the births that take place within these close-knit, insular groups of highly-religious families. In Sarah's own words, here is what is like to attend an Amish or Mennonite childbirth at the beginning of the new millenium:
"The women I work with give birth at home, almost exclusively. This is a matter of finances, for these folks mostly milk cows, which isn't a big money maker if you have a small herd and milk without machines, as they do. They do not carry health insurance because of their religious beliefs. Additionally, they feel very suspicious of the medical establishment not honoring their beliefs and treating them with respect. They prefer to remain at home, where they have control over such things as allowing nature to take its course rather than, for instance, trying to save a very premature baby.
When the time comes time for an Amish woman to give birth, there is always an older woman from the church community with [the birthing mother]. The mothers have their husbands present as well, but the whole thing is a big secret to their other kids. The Mennonites usually do tell their other kids. Many of the Mennonites prefer to birth with only their husband present. When a young woman in either of these communities gives birth for the first time, she has never really heard much about what the birth experience is going to be like. I usually tell first-time mothers what to expect and that's all the education they get, except for what their mothers tell them. The pregnancy is absolutely hidden until the baby is born.
I have never seen one of these women ask for medication for the pain of childbirth, but they sure do want Tylenol for the afterpains! I don't know why they don't use pain relief. The one time I asked, the woman acted as if she had never heard of the idea. They just don't seem to have terrible pain.
These women have between ten and twenty children each. They give birth well into their forties. The Amish seem to have as many babies as a human can, spaced according to how long they can go without having another child, usually one per year or year and a half. I have personally delivered the sixteenth baby of a forty-six-year-old. The Mennonites--some of them--use birth control.
The women almost always give birth in a semi-sitting position. . . . They wait until the baby is about to crown to even lie down. They stay clothed the entire time, but the women have special dresses that they wear at birth where the belly can be exposed so that the baby can be immediately placed on the mother's belly after birth.
The Amish women in the community who attend births are called "catchers," but since Amish religion prevents anyone from getting an education past the eighth grade, the catchers are not formally educated, carry no equipment or drugs, and generally do not know how to treat most serious complications, although they are very well-versed in herbal medicines and I have learned a lot from them. Their main role when I am there is taking the baby immediately after birth and wiping it from head to toe with baby oil, binding its belly, and dressing it in a special dress and bonnet. The young brides seem to take great pleasure in sewing the dark blue baby dresses and caps and quilting a baby blanket. They like to get the baby dressed as soon as possible, with his belly bound and feet wrapped, and covered with many blankets.
One thing the Amish believe is that there is no breastmilk at first, and some don't feed the baby until the next day. Some give the baby things like jello water or watermelon seed tea, which is supposed to be good for preventing jaundice.
For postpartum women, they use sheperd's purse tea for bleeding. For a month after birth, the new mother has a 'hired girl': an Amish neighbor who, for $15 per week, lives there and does all the household chores including cooking, child care, canning, and quilting. Occasionally another one will stop by to help with laundry.
In my practice, the C-section rate is five percent. In fifteen years, I have never done an episiotomy. My rough estimate would be that, unattended, these communities have a maternal death once in every ten years or so, maybe less. For women who have so many babies well into later age and have the worst varicose veins you have ever seen, they have almost no complications."
*"Sarah" is a pseudonym because the practice of direct-entry midwifery is illegal in New York State.
THE NGAANYATJARRA OF AUSTRALIA
In Tjirrkarli, in the Ngaanyatjarra Lands of western Australia, Ngaanyatjarra women now often leave their remote communities many weeks and sometimes months before their babies are due, to give birth in regional hospitals. This has also become the case for most other Aboriginal women living in remote parts of Australia. However, a strong and unique birthing culture continues to survive among the Ngaanyatjarra, passed through a kinship network of sisters and daughters, grandmothers and aunts, even as aboriginal women face increasing encroachment from homogenous Western medical influences.
The Ngaanyatjarra prepare for birth with the understanding that it is both a natural and sacred part of life. Girls are present and involved when other women in their family and social circle give birth, and pregnant and postpartum women are given an elevated status within their extended family and larger community networks. Among the Ngaanyatjarra, the care of a pregnant or birthing mother is almost exclusively the domain of other women.
Although spouses play a limited role, the pregnant woman seeks out other women for medical advice and care, as well as for friendship. These supportive women see themselves as serving several purposes for the expectant mother: to make sacred the process of birthing, to build the confidence of the pregnant woman, and to ritually protect both the woman and her unborn child.
Spiritual ceremonies recognize that pregnancy is a particularly vulnerable time for the woman and her baby at both a psychic and emotional level. The father often has a role in these rites to ensure that his loved ones are kept free of any negative influences. As a rule, pregnancy is considered a time when a woman is expected to surround herself with only positive sights and sounds, and often great care is taken to avoid anything that may cause tension or distress. Moments of heightened intensity such as altercations of any sort, being with other women during their own childbirth, or sighting the body of a deceased loved one are generally considered taboo during pregnancy. It is also considered unthinkable to speak to pregnant women about birth as something which is traumatic, physically painful, unpredictable, or unbearable. Birth is represented as deeply profound, mysterious, and culturally and spiritually affirming.
An aboriginal woman knows long before she gives birth who will be present when she delivers and what each person's role will be. In most cases, she will have had a longstanding relationship with all of her birth attendants, including the one who acts as her midwife. The guiding rule is for the birthing woman to be attended only by those who will make her feel totally at ease and loved throughout the birth process. Anyone or anything which may distract or distress a birthing woman is consciously kept at a distance. A minimum of conflict is said to contribute to a quick and easy delivery.
Sometimes, the husband will also be present at birth to physically support his partner. More often, however, his role is to perform specific rites some distance away from the birthplace. Those women who are in attendance at the birth may also perform particular rites, such as chanting, singing, dancing, or drumming.
The Ngaanyatjarra consider the burial or preservation of the placenta of the utmost importance. They also place great emphasis on seeing that the umbilical cord is cut at what they believe to be just the right place. These two birth practices are believed to be fundamental for the social, psychological, and spiritual future of the child and its family.
Following the birth, new mothers and their babies are thought to be in need of extra-sensitive treatment for some time. Various rituals are undertaken and prohibitions are observed in the weeks following the baby's arrival to ensure that the mother regains her strength and develops a good supply of milk. The baby will also have rituals performed to protect it from evil spirits, as well as to ground and guide it throughout its life.
Written with the assistance from birth researcher Linda Rawlings. Much of the information herein was adapted from Rawlings' presentation, "In the Spirit of Birth."
CHINESE MOTHERS LIVING IN HONG KONG
As with other elements of their personal well-being, many pregnant Chinese women look to the Taoist theory of Yin and Yang with regard to their childbearing. Both forces must be in balance in order to have a comfortable pregnancy and a healthy baby. Pregnancy is considered a joyous time because children are thought to be a blessing and a way of continuing a family's lineage, an important Chinese value.
When a woman gives birth, her body is thought to be depleted of the "hot" element: blood, as well as her inner energy, called "chi." This places her in a "cold" state for around forty days followiing childbirth, a period assumed to be needed for the uterus to heal. This period is commonly known as "the confinement period" and during this time, the woman is expected to observe specific restrictions in her diet and activities. She is advised to rest as much as possible, and to wear socks and sweaters in order to warm her body. Some families even keep all the windows in their home closed during this time to keep heat from escaping. Additionally, new mothers try to avoid having any air or wind blowing in their immediate direction. The new mother rarely, if ever, leaves home during the confinement period.
Certain ritual activities are observed by the new mother and those caring for her in order to restore her body heat and chi. These include:
* Washing her clothes separately from the rest of the family
* Feeding her many spicy and ginger-laden foods
* Offering her special tonic wines
* Not washing her hair for one month
* Celebrating the baby's twelfth-day and one-month
* Making a special occasion of the baby's first haircut
The postpartum woman typically has several helpers during her confinement period. These may include her husband, her mother or mother-in-law, or a "confinement maid." The attitudes of these helpers toward breastfeeding has been found by researchers to have the strongest impact on whether the new mother decides to breastfeed or not. Breastfeeding rates are quite low among Chinese women living in Hong Kong today because postpartum women are viewed as weak and in need of rest and rejuvenation. Breastfeeding is often viewed as something that will sap a mother's energy and prevent her from returning to a state of balance and good health.
Written with assistance from Doris Fok, BASocSc, GradDipEd, IBCLC.
TRIBAL WOMEN IN NIGERIA
Josephine Enang is a nurse, midwife, and Internationally Board Certified Lactation Consultant. She left her home country of Nigeria several years ago, but while there, she practiced midwifery in the rural communities of southeastern Nigeria among several tribal groups, including the Efik, the Ibibio, and her own kin group, the Ekoi.
Enang says that in her experience, tribal Nigerian women today give birth in small health clinics which are located within their agrarian communities and are managed by local nurses and midwives. Midwifery continues to flourish in Nigeria and most low-risk women never see a doctor during pregnancy or childbirth. The midwives refer patients with potential complications to regional hospitals and the physicians found there. When no trained midwife is available, traditional birth attendants assist women during pregnancy and childbirth. These attendants are generally older women from the community with a lot of hands-on experience. It is considered a serious taboo for a young woman to give birth without having undergone a ritual circumcision ceremony, which is thought to initiate her into womanhood.
According to Enang, Nigerian women do see labor as a painful process, but don't believe that it requires the use of narcotics or other analgesia. Women who endure pain in labor with quiet dignity are considered "strong." She says that during her six years of practice in Nigeria, she never once used any pharmacologic pain relief measures for a birthing woman. Women do receive childbirth education from other women and they learn to depend on natural pain relief measures during labor such as breathing, movement, and distraction.
No men are ever present during childbirth, explains Enang, because birth is considered to be solely a woman's domain. Older women of the family are usually there to assist the birthing mother. Other family members are rarely allowed in the delivery room. Women most often give birth in a squatting position because it is believed to be most comfortable and because gravity facilitates descent of the baby. Episiotomies are sometimes done by the midwife, and sutures are completed with the use of a local anesthetic. If a woman gives birth before twenty-eight weeks, no special lifesaving measures are taken with the baby because this is believed to be a miscarriage or a spontaneous abortion.
Newborns are considered extremely delicate and are handled with the utmost care. Mothers begin breastfeeding within an hour of birth and it is considered very strange if a woman chooses to bottle-feed. Most mothers breastfeed their babies for several years. In the weeks after birth, mother and baby are never separated: the baby sleeps with the mother or in a small cot at her side.
Women are usually discharged from the local clinic within twenty-four to forty-eight hours of delivery, and are then cared for at home by family and community members. These support people assist with household chores, meal preparation, and teaching the new mother basic baby care. When the baby loses the stump of his umbilical cord, it is used to plant a family tree. Baby girls generally have their ears pierced within a week or so of coming home.
AN AMERICAN BIRTH
Many mainstream, middle-class American women learn that they are pregnant within the first week after a missed menstrual period. Comprehensive prenatal care usually begins during the first trimester of pregnancy, with monthly or even bi-weekly visits made to an obstetrician's office. At these visits, the woman is weighed and has her blood pressure taken. The doctor's office nurse usually listens for the baby's heartbeat, and in many cases, the pregnant woman is able to learn her baby's sex by the sixth month of pregnancy with the use of ultrasound or amniocentesis.
American women choose their birth attendants based on factors such as what hospital the doctor is affiliated with (ninety-four percent of American births take place in a hospital), where his office is located, and whether he is recommended by friends or family members. Often, the woman has a very cursory relationship with the doctor who will attend her at birth. Office visits are often extremely brief and in group practices, the woman may see a different phsyician at each visit with no idea who will actually be with her on the day she goes into labor. A woman's partner, if she has one, usually accompanies her to some or all of her prenatal visits.
Many women take a special class to prepare for childbirth since very few have ever seen a baby born before giving birth themselves. Some childbirth classes are geared toward teaching a woman how to achieve what is known as a "natural" birth--generally thought to be a birth free of pain-relieving medication. A much greater number of classes, however, are offered through hospitals and are more general in nature. These hospital-based childbirth education classes give a broad overview of what a woman can expect from a hospital birth, and a good deal of attention is given to what sorts of medical pain relief is available, as well as what sorts of complications might arise. Again, a woman's partner usually attends these classes with her.
Increasingly, pregnant women use what they learn in childbirth classes to draft what is known as a "birth plan": a written script of how they would like their birth to proceed. Often, the birth plan consists of a laundry list of common medical interventions--such as a routine IV or an episiotomy-- that the woman would like to avoid. When the woman takes her birth plan to one of her later prenatal visits in order to discuss it with her doctor, she is often told that the plan is acceptable, but that she needs to be "flexible" and understand that the doctor can't do his job properly if he is hampered excessively by a written plan. The doctor generally agrees to "try" to help the woman achieve the birth experience she envisions.
A great number of births in the United States today (some estimates put the number as high as seventy percent) are either induced or augmented with the use of medical practices--such as rupturing the membranes--or medications like pitocin. Many women check into their hospital birthing suite early in the morning and are hooked up to an IV with pitocin in order to get contractions started. This is especially true for women who go more than a day or two past their estimated due date. Hospital birthing rooms are often quite comfortable and homelike, and the woman's partner and mother or friends are able to wander in and out of the birthing room at will. Whichever nurses happen to be on duty monitor the woman's contractions and progress with the use of various technologies which include a fetal monitor strapped to a woman's belly or an internal monitor inserted into the birth canal and attached to the unborn baby's scalp.
Greater than fifty percent of American women (and as many as ninety percent in some hospitals) choose to have medicinal pain relief during childbirth. The most popular form of pain relief is an epidural, inserted into the woman's back by a highly-trained anesthesiologist. Epidurals frequently slow the progress of labor, so pitocin is often given to the woman at this point if she isn't receiving it already. The many wires and tubes attached to the laboring woman, as well as the fact that epidurals make walking impossible, mean that the mother is confined to her hospital bed, usually on her back or side.
When the baby begins to descend down the birth canal, the nurse on duty pages the woman's doctor, who arrives in the room in time to assist her with the actual delivery. The woman generally pushes while on her back with her legs supported with stirrups attached to the bed or by her partner and nurse or other birth helper. Nearly seventy percent of first time mothers in the United States receive an episiotomy when the baby crowns, making this one of the most common surgical procedures performed in the U.S.
After birth, the cord is cut quickly and the woman is often given another shot of pitocin in order to assist her in quickly expelling the placenta. Many women never see their placantas and the great majority of placentas are disposed of by hospitals as waste.
In the United States today, nearly one in four women experiences complications that prevent her from giving birth vaginally and cause her to require a Cesarian section. Approximately one in ten hospital-born babies requires a stay in the hospital's neonatal intensive care unit, making the NICU experience a fairly routine part of the American birthing culture.
Written with assistance from the books The American Way of Birth by Jessica Mitford (Plume, 1992) and A Good Birth, A Safe Birth by Diana Korte, Roberta Scaer (Harvard Common Press, 1992)
THE JU/'HOAN WOMEN OF SOUTHERN AFRICA
Among the Ju/'Hoan women of Botswana and Namibia, birth is seen as a transformative experience. A woman attains a much higher status when she has successfully completed the life passage of pregnancy and childbirth. Unlike most other cultures around the world, the Ju/'Hoan do not have traditional midwives in their communities. Instead, women and their partners place a very high value on the ability to give birth completely alone with no one at all present for the event.
Although solitary childbirth is the cultural ideal, a young woman may choose to have female relatives present for her first birth. However, even with others present, the woman herself is considered completely responsible for whatever happens during and immediately following her birth. An easy delivery and a healthy baby are said to reflect a woman's full acceptance of birth.
Women sit quietly during labor and do not make noises in response to any discomfort they may feel. Fear of childbirth is thought to be extremely dangerous for both mother and child. The Ju/'Hoan believe that a woman's fear of labor might lead God to decide that the baby is unwanted and thus, He might take the newborn back to the spirit world. Women who are thought to have behaved with cowardice during childbirth are ridiculed by the entire community, while women who face the experience calmly and bravely are held up as an example to other young girls. Postpartum care by the community is also more attentive and loving toward those new mothers who gave birth full of stoic joy and without complaint.
The Ju/'Hoan women have, on average, four or five births during their lifetime. Extended breastfeeding promotes natural child spacing. With each new birth, a woman attempts to move closer to the ideal of giving birth completely alone and without assistance of any kind.
When the woman is ready to give birth to her second or later child, she walks a few hundred yards away from her village without telling anyone and prepares a cushion of leaves under a tree. She may lean on the tree during labor for support. Births occur close enough to the village so that other villagers are able to hear the baby's first cries. This is often the community's first indication that their partner/sister/daughter/friend has just delivered a baby. At this point, assistance is often welcomed and other women may go to the new mother and help her with cutting the cord, delivering the placenta, and cleaning the baby. The afterbirth is known as "the older sister." Women who take care of even their own postpartum cleanup without any assistance and then return to the village carrying their new baby achieve the highest status of all.
Complicated birth is rare among the Ju/'Hoansi. When a birth is exceptionally difficult, a traditional medicine man may assist or a woman may walk several miles or more to a local clinic or hospital. One of the greatest hazards to birthing Ju/'Hoan women are the lions and other predators who may attack when they leave the village alone at night to give birth.
Written with assistance from the chapter, "Hunting, Healing, and Transformation among the Kalahari Ju/'Hoansi", by Megan Biesele, and included in the anthology, Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives, Robbie E. Davis-Floyd and Carolyn Sargent, editors (University of California Press, 1997).
Katie Allison Granju is a contributing editor of Minnesota Parent. Her book, Attachment Parenting: Instinctive Care for Your Baby and Young Child (Pocket Books) will be available in bookstores in August, 1999.
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