Who controls childbirth?

Who controls childbirth? That’s the title of an insightful, beautifully written piece in the July issue of the magazine Self. As the subtitle explains:

A holistically minded movement says women should—and that doctors are going about it all wrong. An expectant mom [author Taffy Brodesser-Akner] reexamines which side she’s on.

Brodesser-Akner begins by explaining that her current second pregnancy reflects either extreme optimism or profound amnesia since she was so traumatized by her first birth. She had a serious adverse reaction to the medication Stadol, an arrested labor, a variety of interventions, a C-section and a healthy baby.

The author’s “holistically minded” friends and acquaintances were quick to blame her everything that happened:

… [P]eople who hear my story ask about [doulas and birthplans]. Did I consider a home birth? A midwife instead of an obstetrician? How about The Bradley Method, childbirth training designed to promote unmedicated, spontaneous vaginal births? The answer is no…

The women who ask me about my preparations for my first son’s birth—who imply with these questions that I could have prevented what happened to me if I’d been more diligent—are part of an informal movement of women who are trying to “take back” their birth—take it back from the hospital, the insurers and anyone else who thinks he can call the shots…

But that view represents a profound misunderstanding of childbirth and of history.

As Judith Walzer-Levitt explains in Under the Shadow of Maternity: American Women’s Responses to Death and Debility Fears in Nineteenth-Century Childbirth, until very recently, women did not wonder who controls childbirth. They wrote their wills and hoped not to die.

Maternity, the creation of new life, carried with it the ever-present possibility of death. The shadow that followed women through life was the fear of the ultimate physical risk of bearing children. Young women perceived that their bodies, even when healthy and vigorous, could yield up a dead infant or could carry the seeds of their own destruction… Nine months’ gestation could mean nine months to prepare for death. A possible death sentence came with every pregnancy.

Childbirth was deemed a glorious success if both mother and baby survived it and neither was permanently damaged in the process. Those bad old days were not so long ago, but with the striking success of modern obstetrics, the reality of childbirth has receded from women’s lives. Instead of viewing childbirth as the inherently dangerous process that it is, some women pretend that it is controllable. Of course if you’ve convinced yourself that childbirth can be controlled, it is only a small step to demanding that women exercise that control.

Once you believe that you can control childbirth, your expectations can be unlimited. All birth plans are really nothing more than a mother’s expectations writ large. The author of a birth plan expects to have a vaginal delivery, minimal interventions, and no pain relief. That’s possible because the author also expects to have a relatively short labor, an optimally position baby, an optimally sized baby, a perfectly functioning uterus, and a baby who wouldn’t dare suffer from lack of oxygen during the process. And evidently, merely thinking positive will make it so.

The author explains:

I told four doulas my story. One spoke of how I had to “vindicate” my last birth. Another extolled aromatherapy and how it might have helped me dilate. All four agreed on one thing: What had happened was partially the fault of the doctors and nurses, but it mostly happened because I didn’t trust that my body would be able to give birth. “When you trust yourself again,” one said, “you’ll be able to dilate.”

To understand the why such a view is absurd, it is worth examining a related question: who controls pregnancy?

Imagine a woman who writes a “pregnancy plan” specifying her expectations as follows: she expects to get pregnant the first month she tries, will have no morning sickness, will not have a miscarriage, will not get gestational diabetes or develop pregnancy induced hypertension. She will not have premature labor, an excessively small baby or an excessively large one, go into labor on her due date and give birth to a boy.

Crazy, isn’t it? Why is it crazy? Because we know that these things are not under the control of anyone. We know that “trusting yourself” will not prevent miscarriage; fully one in five documented pregnancies end in miscarriage and “trust” has no power to change that. “Trust” can’t prevent morning sickness, pregnancy induced hypertension or premature labor. And, of course, “trust” cannot determine the baby’s gender and no amount of wishing will make it so.

No one asks “who controls pregnancy?” because pregnancy is not controllable by anyone, let alone the mother. And childbirth is exactly the same. No one controls it, so it is worse than pointless to debate who ought to control it, far worse. Pretending that childbirth can be controlled is a recipe for disappointment, because the disappointment stems from failed expectations. And when your expectations are unreasonable, you are bound to be disappointed.

It is a curious fact, never acknowledged by natural childbirth advocates, that the “disappointment” of a C-section or the “failure” to avoid pain medication are not universal responses. As research has shown, both are profoundly dependent on race, class and national origin. A sense of disappointment or failure is almost exclusive to white, middle class women from first world countries. Most women around the world and most women in the US don’t feel disappointment in having a C-section or take away a sense of failure from choosing pain relief.

Indeed, most women have no expectations beyond giving birth to a healthy baby. The route does not matter to them, and the particulars of how labor progresses do not matter, either. They don’t view birth as a piece of performance art, with a predetermined script, and shame the only appropriate response for those who flub their intricately choreographed parts.

Merely asking “who controls childbirth?” indicates a view that ignores reality. For the reality is that no one controls childbirth, not mothers, not doctors, not insurance companies, no one. Just like pregnancy, childbirth is uncontrollable.

How would we react to a woman who blames herself for morning sickness or a provider who counseled that “trusting” pregnancy is all that is needed to prevent a miscarriage. We’d be shocked, saddened and possibly angered that anyone could blame a woman for a her own morning sickness or for the miscarriage of a deeply wanted pregnancy. And if offered the opportunity to comfort such a woman, most of us would assure her that she should not blame herself; it was not her fault; there was nothing she could have done to prevent those things.

Similarly, when natural childbirth advocates insist that “trusting” childbirth will obviate the need for pain medication or will prevent a C-section, we should also be shocked, saddened and possibly angered by the impulse to assign blame when no blame is warranted.

Who controls childbirth? No one, and if we want to protect women from disappointment and a sense of failure we’d do better to acknowledge that reality and stop pretending that wishing can make things so.