ru have alternatives, that youk that pregnancy and birth are: to womenP Looking back onr have had the chance to make,k back on pregnancy and birthdid x. "'en talk about the pregnancy;terested in talking about thelives, and I consider that reallylearn so much about people."e way how I handle prenatal:stions. A lot of people rvho ask

ley're doing; they've done a lotave, and what I mainly do is

: sure of. . . . Some people willand then I will have to find

,e said before, go in this avenue:ally ansrvering their questions,:eir mind, and building up a

ically what it is."

rapport probably loom so largell as the lay midwives becausemd risks they take on in agree-

Childbirth:

The Social Construction

of Birth

l[ first thing to remember is that obstetrics is asurgical specialty. The management of childbirth within hos-

pitals is essentially the same as the management of any othersurgical event. While obstetrics is a patriarchal institution,that fact becomes almost irrelevant in the management ofchildbirth. Certainly women in labor are treated in a dehu-manizing way, are condescended to and ignored, patted andpunished. But that treatment is hardly unique to obstetricalpatients. It is part of the way in which hospital patients ingeneral, and surgical patients in particular, are treated.

In surgery the ideology of technology is dominant. Perhapsmore clearly than anywhere else in medicine, the body is a

rnachine, the doctor a mechanic. In the typical surgical situa-

tion the unconscious patient is waiting, like a car upon ahydraulic lift, rvhen the surgeon arrives, and is still in thatcondition as the surgeon leaves. The surgeon and the rest of

IN i,ABOR

the medical staff may care about the person whose body liesbefore them, but for the duration of the surgery, the mind-body dualism theorized by Descartes is a reality. It scemsgenuinely diflicult for surgeons to respond to patients as con-scious human beings at the same time they are working ontheir bodies. Marcia Millman reports, from her observationsof surgical wards, that when patients have been given localrather than general anesthesia for an operation and are thusawake, their serious remarks about the operation or theirattempts to take part in the doctors' conversations as thesurgery is underway often bring the staff to laughter.t Tothem, the talking patient is incongruous, almost as if a car hadsighed while one of its ffat tires was being replaced.

When women are sedated through labor and made uncon-scious for delivery, as the obstetrician Delee outlined in hisrgzo article in the American !rurnal of Obstetrics and Ggne-cology,2 then the only possible description of birth is as an"operation" performed by a surgeon on a patient. Delee'sarticle, "The Prophylactic Forceps Operation," set the stan-dards for obstetrical management of birth, routinizing suchprocedures as forceps extraction, episiotomies, manual ex-traction of the placenta, and the lithotomy position (flat onthe back with the legs up in stirrups). Although in recentyears the use of heavy sedation and anesthesia has been lessfrequent because of the dangers they pose for the motherand the baby, the surgical nature of the event remains con-stant.

Nancy Stoller Shaw described the physician-directed, in-hospital deliveries she observed in the rgTos in Boston as allfollowing the same pattern. The patient is placed on a deliv-ery table that is similar in appearance to an operating table.The majority of patients had spinal anesthesia, or its equiva.lent, the epidural, which numbs the woman from approxi-mately the waist down but leaves her conscious. She is placed

l16¿l

The Social Construction of Birth

in the lithotomy positio^n and draped; her hands may bestrapped to prevent her from contamináting the ster,e fierd.She cannot move her body below tf," "t.rt, and ..Her

activeparticipation in the birth is efl.ectively oro..,,

This does not mean that the woman becomes unimportant,only that her body, or more specifically, the birth canal andits contents, and the almost Lor" UoUy'rre the only thingsthe doctor is really.interested in. Thi fart of her and, inparticular, the whole exposed pubic area, visible to thoseat the foot of the table, is the süge o, *t,i"f, the drama isplayed out. Ilef«:re it, the doctor,"it, or, "

small metal stoolto do his work. Unless he stands ,O ¡r" "ur.,rt clearly seethe mother's face, nor she his.

^St " i,

"up*"ted as a persorr,as effectively as she can be, frcm th*'fart of her that isgiving birth.3

The Birth Process

The medical litcrature cleffnes childbirth as a three_stagephysiological process. In the fi.rt,trg" ihe cervix, the open_ing of the uterus into the vagina, Aiiotu, from being nearlyclosed to its fullest dimension of rpprn*irnutely ten centimeters (almost four inches). This is referred to as ..labor,,, an«lthe contractions <¡f the uterus tf,-t prli rpon the cervix, ils"labor pains." In the second stage the UrUy r, pushed thro,g'the opened cervix and through ifro urgñ or birth canal, anclout of the mother's body. firis is tf,e'..aálirery.,, The thirtlstage is the expulsion of the pracenta, the ..afterbirth.,,

I. any situation the possibility exi.sts for alternative defini-tions of the situation, differeni vcrsioru ol. what i, ,rrtighappening. Which version is accepted and acted upon is areflection of the power of the parüip;n;;. Those with more

lr6s l

IN LABOR

power can have their deffnition of the situation accepted as

reality. Often this involves sorne bargaining or negotiatingbetween the people involved.'fake, for example, a child witha sore throat who doesn't want to go to school. The parentmay say the throat is not thot red, and the child counterswith "But my head hurts too." Might the child be experienc-ing some soreness and pain? Certainly. Rut is it bad enoughthat the child should stay home from school? That depends.Medical authorities may function just like the parent in thissituation. Patients recovering from tuberculosis, for example,may claim that they really are well enough to have a week-end pass,a and patients and doctors in mental hospitals nego-tiate over the patient's mental health.s lrrequently, pregnantwomen come to the hospital claiming that they are in labor,but by medically established judgments they are not. Thestate of being in labor, like illness or any dcviance, is an

ascribed status: that is, it is a position to which a person isassigned by those in authority.6 But one can also negotiate,to try and achieve that status or have one's claim to it recog-nized.

not yet begun to dilate. Whether she is or is not in lalror willdepend on whether she tht-.n begins to dilate" or the contrac-

self to the hospital claiming that she is in labor, and by weep-ing, pleading, or just because she seems educated and mid-dle-class, she is admitted, the medical acknowledgment thatshe is in labor will have been established. If she does notbegin to clilate for twenty-four hours, and then twelve hours

t us take as an example a woman at termpaínful contractions at ten-minute intervals, who has

I 166]

The Sr¡cial Construction of Birth

after that-thirty-six hours after her adrnission*she delivers,that woman will have had a thirty*;l1.r.labor. The medi_cal authorities wi' sec it as a^thirty-six-hour rabor* and so wi,she.'fhat reality whic.h tt "yñ-ñI[6á]uhen labor began,becomes-the only reality tfr"y t *i". O"ih* otlr._, hand, if she

i.^*:l::, or delays admissiln _".1 ;;;;r;"ts hersetf ro thehospi ta I twe n t y- fou r h ou r s il ;; ;;;; il;,;il1 ]Il ;:#:labor, she will have nra ,,Jr¡¡,rl"Jr,¡.'i,ffi?rfrom the time of her admissior,, ttu toiio is preferable, thelonger labor being easily percei*¿

", i".r,itutional misman-agement. E_tr* the point of view of th. r¡,^ñ,rñ &I_^

.ññ ;ttf r"me st,-¿nge conliáEti,o,rrffin requiring hospi_talization, but at the same time wants tc¡ avoicl prolongecllabor, "'real" labor is defined ,-,,rt i,u i".nrs ol the scr¡setir¡nsthe wr¡man cxperiences, but i, terms of:.:o..,u.rrrr,.*_cr,r-1, ic;,iidilatation-

'fhe pregnant rvoman therefore wants to be accuratr-, (inmedical terms) about defining the ,"r"i áf Unor. Otheru,,is,l,if she gains early admission, she r.vill have helped to deíir¡ethe situation as an overly lo,g labor. l, uaaitio., to the strr:ssinherent in thinking oneself tá be in labor for thirty_six lror¡rs,the medical treatmánt she will,u""iuu p.usents its own ¡rrob-lems. Laboring women are r«rutinely confined to becl in hos_pitals, a situation that is.as disturbing ;ry"frolngi"*lly as it i.sphysically. Not only is the labor n"."Jl"=¿ as being longcr,but,the horizontal position rhu *urt orrr_" in bed physicallyprolongs labor, as may the routine oa.rri.riot.rtion of secla-tives during a long hospital stay. In u.l,ti;i;, to the variatio,s

l16zl

IN LABOR

in treatment during the first hours of labor, the treatment shewill receive is different in the last hours, when the woman is

hospitalized in either case. Women who have been in a hospi-tal labor room for thirty hours receive different treatmentfrom women who have been there for only six hours, evenif both are equally dilated and have had identical physicalprogress. Which woman, after all, is more likely to have acesarean section for overly lonq labor-the one who gotthere just six hours ago, or the one who has been therethrough three shifts of nurses? What the woman experiencedbefore she got to the hospital-how strongly, how frequently,and for how long her contractions have been coming-doesnot enter into the professional decision making nearly as

much as what the medical attendants have seen for them-selves.

It is also important for the pregnant woman to be accuratáin iderrtifying labor, because i[ she presents herself to thehospital and is denied admission, she is beginning her rela-tionship with the hospital and her birth attendants from a

bad bargaining positio4. [Ier version of reality is denied,+leaving her with no alternative but to lose faith in her ownor the institution's ability to perceive accurately what is hap-pening to her. Either situation will have negative conse-quences for the eventual labor and delivery. That is whychildbirth-education classes frequently spend considerabletime on the defining of labor and so-called false labor.

The same issues arise when a decision has to be made aboutwhen a woman should be moved from a labor to a deliveryroom. In American hospitals, unlike those in most of the restof the world, the first and second stages of labor are seen as

sufficiently separate to require different rooms and, fre-quently, different staff. Women attended by nursing andhouse staff thoughout their labor may not see their own ob-stetrician until they are in the delivery room. p.ts-aryn

I 1681

The Sr¡cial Construction of Birth

nd then apply that distinc-ü

Ionger viewed as laboring urt o, a"iiu;;;."rffi'Jffi,";missed, and the womar delivers, .ry, in ifr. nril "; tl;;;to the delivery room, then she ir;";';;;ving..precipped,..having had a precipitous delivery. iflf," prir, is called toosoon, if the staff decides that the wo*r, ,, ready to deliverand the physical reality is that .h" h;;;rother hour ro g«r,then concern is aroused about il; led; of second stage,because she has spent that

"*t.u hor, ?n a delivery ratherthan a labor room

Why rnust the hosp-ital make arbitrary clecision.s in deffninglabor and its stagesp [lecause tf," ur. oítfre facilities requiressclie9uling. The staff has to r."o* *rr"r,'" lrbo, room wiil befieed and a delivcry room needed. It It herefore, p"rrái"r,r t u

""o-i.," ;n;' ;fi# iir,Xiiliii?;judge cervicar diratation and to pruai"t derivery time. This isusually done by the nursing staff. Some examinations may benecessary in order to evaluate the physical condition "Itt.laboring woman an. her f.tus, bui i""rl, examinations ofcervical dilatation are equally

""".rory-fo. r"h_J;i;; ;r;:poses. Still others are done for teaching purposes. Süch ex-arninations are usuaily quite pairfur, ,o ihrt here we see theinstitutional demands in/t ic t itg,utfr", tfr"., alleviating pain.There is one more reason for the examinations. The staffffi ,[, Jlffi : ;'-:X Hf ilni ..},?ing its prestige as, in this instance, , fJy-_r¡ing institution,¡rrocessing or "treating" the laboring *á_".,. The labor pro-cess is usually self_contained; left t"o hu. own devices thewoman can produce the baby, in nine cases out of ten, with

lr6el

IN LABOR

absolutely no pr«rfessional assistance. Not only may the exam-

ination, at its most useful, locate the rninority of womenneeding assistance; it also constitutes "treatment" of all la-

boring women, thus justifying the existence of the institu-tion. The woman can therefore be seen, and see herself, as

being in the hospital for the purpose of such treatment, or"medical care."

Nancy Stoller Shaw, in her study of maternity care, ForcedLabor, notes that for a woman giving birth in a hospital,childbirth involves a "continual inability to protect herselfand control the access of others to her body."z Standard"piepptng" procedures, like admissions procedures to thearmy, jail, a mental hospital, or any total institution, reinforcethe idea that the individual loses control over her body andself, including a "systematic removal of all personal effects as

well as parts of the body (hair, feces) and its extensions (eye-

glasses, false teeth)."8 'lhe custom of shaving the perineumhas been repeatedly demonstrated to serve no medical pur-pose at all, having developed, with the invention of the dis-posable razor, from the clipping of any very long pubic hairsto a full shave.s While it is a pointless, humiliating, deperson-alizing, and irritating experience, it is explained to thewoman and staff as being necessary, r.vith the latter beingbest equipped to provide this "service."

The Impact of Prepared Childb¡rth

Prepared childbirth has tried to humanize medical manage-

ment-not to do away vi,ith the medical approach, but tomake it more pleasant fo¡ wornen, more responsive to theirneeds. Many corrrpromises have been rnade even with this

modest goal. The American Society for Psychoprophylaxis inObstetrics, ASPO, as the first (and ftrremost) source of child-

Itzo]

The Social Cr¡nstntction oJ'Birth

birth preparation, has supported the way rnedical proce-dures are viewed, as is made clear in an unpublished ..Cuide_

lines for ASPO'feachers" (c. r97o). The guidelines state, forexample, with regard to exarninations:

It should be pointe«l out to patierrts that internal examina-tions during labor in the hospital can be performed by thepatient's own physician, by a resident physician, an intern,or a nurse. This depends on the procedures established byhospital policy. Examinations will be given either rectallyor vaginally, again depending on hospital rules or individ_ual physicians, but it is not for the parturient to decide whoshould or should not examine l-rer «luring labor.

This is far from being a consumer-oriented approach andis in fact in direct opposition to the legal rights of the woman.The American Civil Liberties Union Ilandbook The Ríghts ofllospital Patients, states, "All patients have a right to refuseto be examined by anyone in the hospital setting.,'ro g¡*,-Iarly, while the patient has a right to refuse any treatment orprocedure,r t ASPO guidelines say, with regard to the ..prep_

ping" procedures, "It is not worthwhile to make an issue outof this."

ASPO has not supported childbirth outside of the hospital,and home-birth advocates have been denied acceptance intoASPO teacher-training programs. The hospital is unchal-lenged as the location for birth, and the training the preg_nant woman receives usually does not teach her to under-stand and rnanipulate the hospital environment. For themost part, rather than teaching in detail about hospital facili-ties and person,el, the childbirth-education classes instructthe woman in ways to avoid clealing with external events.The laboring wornan is taught to take a ..focal point"_apicture or flower she brings from home, or simply a spot on

lr7rl

IN LABOR

the wall-and focus on that alone, blocking out all othq:happenings during a contraction. Rather than being alertehto which hospital procedures are arbitrary or might be un-náiers*ry in her case, the woman is taught instead how toignore-"breathe through"-enemas, perineal shaves, re-peated examinations, transfer from bed to stretcher, and so

on. The focusing technique is thus one for dealing with thehospital, and may not be directly related to the birth experi-ence itself.

The cues available to us in a situation include not onlyphysical objects and sensations, but also perceived behaviorand even the way we see ourselves acting. The cues we getfrom our own behavior are an important part of how weunderstand what is happening. This has interesting implica-tions for childbirth.

All of the childbirth-preparation programs teach the use ofbreathing techniques for labor. Margaret Myles, author ofone of the most widely used textbooks of midwifery in theworld,r2 has said that it has been her experience that nornatter what childbirth-prcparation breathing techniques a

woman used, as long as there was a regular pattern of breath-ing, it worked. Whether it was L¿rmaze puffing and pantingin rhythm, or plain puh-puh-puh, they all worked. The usualexplanation for the effectiveness of these methods is that theconcentration on breathing blocks out sensations of pain. Yetwornen practice their breathing exercises while driving orwatching television or reading-all activities that requiresome level of concentration. Anything that won't take one'smind off the road, or away lrom a TV program, is unlikely todistract a womon from the sensations of labor. I believe thereal reason that breathing exercises rvork so well in the con-trol of pain in childbirth is that they present the woman withpositive cues regarding her situati<ln. If she were not doing

ItTz j lrzsl

The Social Co¡tstructir¡n of Birth

the breathing, she might very well be crying or calling out.I{er ability to evaluate hcr own situation, taking "u.r"frn*her own behavior as wr:ll as that of others, b*áo_e, ,r".},important. T'he woman who has just gotten through a con_

t¡action- without crying out has presc,nted herself with evi-d.:":. that the pain is bearable. fi.it were not bearable afterall, she knows, she rvould be crying. The woman,s perccivcdpain and perceived cornposure are conflicting elements. Aslong- as the composure can be maintainect, thln the r:onflictcan be resolved by the sensations being defincld as bearable.In a sense, it is a more structured version <¡f

..Whenever I feel

afraid, I whistle a happy tune."When a laboring woman is lying in a hospital bed, an in-

travenous needle in her arm (as is st¿rndarj hospital proce-clure), listening to doctors being paged, with strangers com-ing in and out of the r<¡om, then the cues available to her areolrjectively no diffcrent frorn the cues she could expect if shewc,re dying. People cannot bc placed in hospital go*r, onhospital tables under hospitar rights rvearing rittrc braceretsthat will identify them, whethei consciously present or not,witho_ut there being createcl for therr¡ as well a.s for those whocare for them, the image of patierrt. All that the birthingwoman can rvork for in that situatio¡t is control over pain anJ.her expression of pain.

. In emphasizing pain and its control, the chilclbirth-educa-

tio¡¡ grou¡rs reinforce the medicar model of childbirth as acrisis situation. The, substitution of self_hypnosis, breathingtcchniques, and the Iike for control by drugs does not chal-lenge the essential rnoder of what is áccurring in the birth.Iloth the educators ancl the physicians are in accorcl thatchildbirth pain requires proflessional a.ssistance in its control.The two groups are, or rnore accura tely uere, vying for clr¡rni-nance or political control over pain relic.f. The resoiution thatwas reachecl can be secn, certainly in the case of ASpO, as

IN LABOR

cooption by the medical establishment of the childbirth edu-cator. Withdrawing all fundamental challenges to the medi-cal profession, ASPO worked toward having breathing tech-niques seen and used as one of a potentially escalating seriesof analgesics.

To Be Deliuered or to Cioe Birth

The messages that the woman picks up from the cues availa-ble to her ¿rre not limited to the normality, health, and rela-tive painfulness of her condition. The definition of the situa-tion goes much deeper than that, to the very heart of theprocess and who controls it. This is best exemplified by theuse of the word "deliver." Both mothers and birth attendantsare said to deliver babies. When the mother is seen as deliver-ing, then the attendant is assisting-aiding, literally attend-ing. Ilut when the doctor is dclivering the baby, the motheris in the passive position of being deliuered. The rvords areof course the least of the cues that the laboring woman re-ceives regarding the importernce of her contribution to theevent taking place, the delivery of her baby.

Three basic patient-practitioner relationships-ways doc-tors and patients c¿rn deal rvith each other*have been iden-tified.t3 The ffrst is the actiae-passiue relationship, particu-larly applicablc to the unconscious patient in an emergencysituation. 'Ihe doctor makes all decisions, and the patient is"worked on," rnuch the samc way as mechanical repairs aredone. In childbirth this relationship is typified by the doctorusing forceps or surgery to pull the baby <lut of an uncon-scious mother. What is particularly important to note is thatthe doctor not only has complete control once the mother is

unconscious, but it is also the physician who has the authorityto dcfine norrnal, variations from norrnal, and obstetric

[rl q)

The Social Construction of Birth

emergencies, as well as the ..state,,of the patient. The physi_cian in a hospital birth alway, t ola, tf,. power to create anactive-passive relationship by t ruirrf tnu mother anesthe-tized.

The original ASPO teacher-training course states:

If your doctor himself suggests merlication, you should ac-cept it willingly_even if you don,t feel the neecl for it_as he undoubtedly has veri guoa..ru*s for his clecision.ra

The rgTo teacher-training guiclelines statc that ..the final cle_cision on the use of dr,,g, hás to n" *,itf,ihe individual physi_cian," a statement again contradicting the legal rights ofpatients, as outlined by the A.C.L.U., iJ..fur" ..any me<licalor sur¡1ical procedure [from] being perforrnecl on thern re-

:ilfli:1;I,',|;;ll:,,""' or thli r a," t"^,., to th e advi sabli iyThe second possible practitioner-patient relationship isone of guidonce_coo¡terotior:. T,he practitioner guides anddirects the patient, who, if ,h. ;;g','l.o}patient, takes guid_tnce and direction easily.. In chiklbirih, if,l,, best typified bythe in-hospitar "prepared" birth. T,lru

-irt o.ing woman isthere to be "coached,".a u,ord r*r;ñ;'u;ecl in childbirth_prerparation classes. AII- the preparatiá she has had hastaught her to work within th* ira_"rr,r.t of institutional

:rfr tsp.o reacücr guiclelines hrr;ih;;;; say abour docror_¡ratient relationships:

'l'he patient should be encouragerl to have a good ..ra¡r-port" with her physician. tf her do"to. i, not acquaint.rlrvith the Larnaze techniclue, l;t. ,fr"rla try and gct hisco,fidence, show that shels not "f;;;;;;,;á;;il;;;:if he rvill read the ASI,O ..Irhysician.s

dornrru.rlque,.or tht.ASPO training rnanual. It shoulcl ü" r>oüri"O out that, r¡rritt,

Irzs l

IN I,ABOR

obviously, physicians do not cherish to be told by their

patients how to tn"¿J"t ir''t:,,t-*:^:::rd"l:HlflX;patrents lr.,w tu l"i'*ü. t'"tfully discussed' ancl from ourever, it can certarntY

ilH;;;.a ár"* á"'l cu" be gained rrorn this'

Note that physicians cottduct labor-and delivery' and if the

"patient" tttot" tooit'";;;;;""" of the oatient role for the

laboring wornan) "'"ft"'-tt clear that she is not fanatic' her

I labor rnav be """;;;;;á i" u""o'd rvith some of her wishes'

' i ffiil;";;';;,* ñ;;l'* be tactfrrl' and thc suggestion

ii is pointedly not *"áJii-t she select u"oihu' physician' The

legitimate u"ri, oi*tt. authority of the physician is not ques-

tt"iT3'tnrru possible relationship is one of mutual participa-

tion, inwhich practitioner and patient work together toward

a common goal' Ine#,nle';;Ja ¿elial of the "patient" role

and thus of medical "á"trof' But the institutionalization of

childbirth works'*J;;;-t;; development ":tl'i ;:'::ffi;:lill'+# ##^i?1;;;; in no iosition to be an equar

oarticipant irr her uitit'i"g' She is outnumbered and over-

pow*,"d she maY üffi ;;J ;::::::'I3;":,1"iffi:Xálpowered' sne mav :-.:'i:-':, :,

--,t;..,t advocate (husband,'nr.,i"tn*,, even bringing a patient a<

coach) *,,t, t-,"',^ot" litoltdl{S'i ,P 'H

difficult, or

only as long as

:::l':H:'L l"il'iln"';;;'; '" accord with institutional

.rf"r. ft " ASPO teacher guidelines state:

ASPO very much encourages "F-amily Centered Mater'

nity," i.e., a husba"tl;;;ñ team during labor and deliv-

ery when possible' ;';;;á"tstood' however' that only

husbancls who have i*ftl'-' " lornral cour-se with their wife

in rhe Lamaze ,""#;;;;;;" of real help to the wife'

l rz6l

The Social Construction of Birth

Rather than demystifying childbirth, this sentime.,t ,nou.flbirth further into the sphere of medical activities, too co¡n- ¡

plex for a lay person to understand with<¡ut special training. r

It is perhaps for these reasons that so much emphasis is puton control of both pain and the expression of pain in prepara-tion for childbirth classes. According to the rules of the game,if the laboring woman chooses to deal with her pain by crying ,.n/

or calling out, she has entirely forfeited hcr right to rnake S ,'''decisions. Much is made in childbirth-preparation circles ofthe woman's being in control during labor, but all t.haq is

neant by that is control over her expressions of pain.tAwoman vvho maintains a fixed, if somewhat glazed, cheerfulexpression and cont'inues a regular pattern of breathing is

said to be "in control"" as she is cartcd from one roorn toanother and literally strapped flat on her back with her legsin the air.

Certainly a woman who was unconscious, semistupeficd,amnesiac, or simply numb from the waist down cannot haveexperienced giving birth as an accomplishrnent, sornething \Aover which she had control. IIuTEñátñ[TñEl,voñran who is

encouraged in childbirth-prcparation classes to see herself as

a rnember of a "team" delivering her baby? Though she rnayhelp and watch in a mirror,@'

-Positioning and draping her in such a wáy that she cannot -ldirectly see the birth, not allowing her to touch her genitals Ior the forthcoming bal:y, tells thc mother that the birth is Isomething that is happening to her or being done to her, not

Isomething she hcrself is doing. The birth is managed, con- Iducted, by the other members of the tcam, those who are \tc'lling her rvhat to do, and physically manipulating hcr and )her baby.

more exciting-Ind rhi'illing thíñ§-to dr.r. F)ncouragiñg. a

r DaDY. I l,l

I UtÉI-ryaexciting, thrilling thing to sce, !q-§_qn _e_y.r, ffi ryw ohlir--Tó-úlall6E h c r sZ' I fl iñ- a i nir r o r g iv' rñ [ 6 i r t h rn o v e s h e rfrom being a participant to an observer ol'the Uirth. TIJ

[ttz ]

IN LABOR

-<:-rh nñrnes out of the context of i

cmphasis on "seeing" the birth "":"r'tJ, r'r'.,"Ñ;, i"-r'"piii' ¿"-*l'-iit'"Tl#li1 H:;r"qi19':) ffi:;::::tl-;;;il;ü suggestions and taking direc-

tion. Rut the n*oltal *";;:" II'n" team have had most

of their **pt'i"""";il;;;** babies without the active par-

ticipation ^"d h*I;;;ti"''"*n"t Jh"'t

know that thev will

\ seithat uuuv d"lil"l;;til;; withouí the rvoman's cooper-

\ Itior,, rhat is ,h;";;;;se in bcins there' If the mother

I wants to b" "wui"'"";;;;;'"" for the birth' theltlg 9n]y-. m*¡,i¡iir

u**X;gi*H:ffi,, *ii:Hi:: ;l?'lÜti?jiiiüÑt:s:;:lti":r'I I I was to hau*v i.t't'*""i'inis miracle"-spoken by the

' V *uth"r!'5In o'"';;;;;;üu*n,o less than in the pre-rg5os

medical *oatr"ff,""'1*"'"t"i"tent in the ability to make a

baby is shifted frorn it't birthing'woman to the medical pro-

fession' In the ""*^;;;areJbirth' the "coach" becomes

a member of tt'" *"¿ical ttam' u'álni"' it in teaching the

woman to *tnt""i;;ñ institutioJ demands' keeping her

in her Place'

The Role of the Birth Attendant

rnrr,",",,r*f ñuf 'r'u":T:"-l:i'^3:::;:tiT:li"$l?J1;:lá::'ffi ::ll,'""j.il:'tili""lqq:f:::::,:,X",:1J,:ff "i:;i",#::"ü'"il'r;;J...............#:,:;"*i*;::#:'J::i:'i§i:kes them

-'prores§rer¡; ii"ü other workers-the

they obviously contr.. f,,,nnrinn rrnder thearound, they obvrousl] currrrv' "" --- ^:nction under the

"r*"r,'*aerlies, and aides. ilt 1i-'."-:"^lt-*,"r the patients.

around,nurses' ot'ott"'f iLll".'i; ,ney also control the patients'physician's supefvrsn

^-r ^rr L;rrh means the managementphysician's supervlsrolr 'L"^r ir--" rnoans the managementifi. *.ai"al management of birth means

Irz8]lrzgl

The Social Cc¡nstruction of Birth

of birthing women; to control or to manage a situation is tocontrol and manage individuals.

The alternative to physician and institutional control ofchildbirth is childbirth outside of institutions, and, most

important, outside of the medical model. In this alterna-tive. birth is an activitv that women do. The woman mav.----_nee4-_loms_bSJp bU!_tte help i&-[e{ the. [glt par!,- j¡- lhetA!@ &r-bel§glf As important as

fñc word "deliver" is in understanding the medical modelof childbirth, so too the word "birthing" clariffes themidwifery model. Qitüt"g, like sw.i41ming, singin_g, and

dancing, is somethifi]"rfla-,fá, "ói'-n"¿ve

lóñe for#--I(lr.cy Mills is a contemporary lay midwife and an impor-tant figure in the home-birth movement. She began as a

midwife by visiting a friend in labor, and has since attendedover 6oo births. Her r.vords are the most eloquent statementavailable of the midr.vifery appronch to birth:

I see myself going in and being a helper, being an attend-ant. Sometimes I play with the kids, or I do some cooking.Sometimes I sit with the woman. Sometimes I help thehusband assist the woman. Some families need more helpthan others, but it is easy to go in and see where you are

needed and how you can fill that role.r6

It is important for that wornan to be able to look at you, toknow you are there, to hold your hand, to be reassured. Iknow it helps when I say to a woman, "I know how you

feel. I know it's harder than you thought it was going to be,

but vou can do it."I7

IN LAtsOR

. Similarly, the lay midwives of the F'remont Women's Birth

\ t:tl"i" say, "Wc feel that people should be in control of theirJ experience, and we'll lit in accordingly,"ta and a lay midwife

from Madison, Wisconsin, says, "People come to us not so we. will care for them but so we vyill help them care for them-Lolrn..""I

I asked the nurse-midwives I intcrviewed what they saw as

their role in a birth, and what they did when they got to thehome:

-"ltJothing, Iirst. Which is very important, because they

expect me to clo sornething, like I'm supposed to do some-thing. Ilut they'rc doing it already and that's what we'regoing to bc doing, so I find it very important to just comein and sit down."

-"If I go in and I firrd the mother is agitated, I'll say 'I{i,'and go straight to the mother. If I find that she's not agi-tatcd, I'll take a slorver 'hi,' you knorv. . . . If she lookscomfortable, I clon't feel there's any rush, and I let hercontinue to feel that she's doing okay."

-"I try to get the main supp<lrt person involved in doingthe birth because it's really their birth and not mine.. . . My role is to listen to what's being said."

-"They see rne as a consultant, that I do have special skills

and know I ecl ge, nui-iñIi-iñ§]"artici pate in the <lecisionstoo, and except fbr sornething really outrageous most deci-sions are made collcctively. They're not giving me theirbody and they have to undcrstand that."

And rnost clearly of all:

-"My aim is that rvhen I leave that family feels theybirthcd it. I was there and t helped, but they did it . . .

that in their whole rccollection of the experience I willvery minimal. That's rny goal and that's my aim."

I rt]o l Ir8r]

The Social Construction of Birth

Iloth this sociar rore and this goar are u".rffit from the::,::|:i:j.,.:nlr 1."

a hospitat birth, a áre th,r sh.,,, .,.__up_as being "tr,e ail."tri";"á',i'J'I;:,|,o,," that shaw sumsChildbirth, in the *";;;:'i:'i'1'' ""

performed bv ,. ^ff1::l].*odel, is a surgical procedureperformed br r.,.,nbrt;il,#;, il T:flij, L:ffi:rf

mmmm. ch ird;; ü * iil';d;,*lf,;lt j: :*{"''-of' women

""¿ ,r,",. famiries. Birthin"rl.]_.", iT the rives f

lromen can do, but u,suarry;;o;;;,;i;:J,TlIH:H I Oteaching to do weil_that ii ,;ú;;il;,.r., o*n satisfaction. t t

, . In this chapter ,

lur.u focusecl prirnarily on the role of ,n*-J

-

l¡irth attenclant vis-á_vis,h";*ñ;;;"1«'a n rake the acti ve

i:r.: r, d ;i;.,:n:".ffi:;Hifil.r#birth, as in the -"d,"11..:,r;i.i;;^#ii.tr,i,g woman can::,1. ll" active role, with ,t" r,r".ali Ltit¡n; then the l¡irthi r a supportive posi-

r¡,onsi bir*y r..-;;;'tf, ,;';:il ils [::ffi,# :mlH:lirrmer is based on the ideologf "ilü.",.gy, in which thelxdy is viewed as a machin",;i;;;;._rr".

of which ca¡¡lx' irnproved by o competent ,ru"f,urri". -fhe

latter is basedttn an integration of mind *d ñ;,;;thut phy.t"rl events:;:f il:T ;:Ji:l?y

d.;;; ffi ;:""ü ome is,,o, d.,, ¡ u.