A Passion for Birth

by Sheila Kitzinger

  Caring for patients was trivialised and gynaecologists only began to learn how to talk with and listen to them when competing for private patients, and probably did not acquire it at all if they worked with women in clinics. Interaction with patients was often depersonalised. Norma describes some doctors as ‘surgical seducers’ who listened to women ‘pretending an emotional involvement and interest, and many women responded to this by offering OBS their trust’, the trust that later meant they accepted whatever advice and judgements were pronounced.

  Scopolamine reigned. It had been the standard treatment for pain since the 1950s and was called ‘Twilight Sleep’, because women could wake up and be presented with babies they did not know they had because it removed all memory of birth, almost as if it had happened to someone else.

  Dr Guttmacher promoted a three drug mix that should be given to all mothers. ‘In favourable cases, under the influence of the drug triad, the patient falls into a deep quiet sleep between pains, but groans and moves about in a restless manner with each pain. The somnolent stage continues into the second stage of labor and frequently for several hours after delivery. When the patient awakes, the obstetrician is rewarded by hearing her ask, “Doctor, when am I going to have my baby?” The quickest way I know to prove that the child is already born is to have her feel her own abdomen. A newly restored waist-line soon convinces even the most sceptical.’10

  In fact, women did experience birth, but it was often like a bad dream and they had no control over it. When a woman had been ‘scoped’ she screamed and tossed around helpless to do anything about it. Maternity wards sounded like torture chambers. The management solution was to corral patients in high barred cots, thickly padded so that they could not harm themselves, and with canvas fixed over the top to prevent them climbing out.

  Introduced by a woman, Bertha Van Hoosen, an obstetrician who reported in the Wisconsin Medical Journal that it ‘solves the problems of child-bearing’,11 the most enthusiastic advocates of Twilight Sleep were feminists, who saw it as the answer to birth pain to which every woman had a right, together with obstetricians who used it as a way of asserting their professional domination of childbirth.

  The American College of Obstetricians and Gynecologists (ACOG) was established in 1951. The uterus was treated as an organ that could be whipped out without any problems (and still is today). It was just a useless little bag. By the 1980s more hysterectomies were performed in the United States than any other surgery – with the exception of caesarean sections. Data from the National Centre for Health Statistics shows that more than a third of American women will have a hysterectomy by the time they are 60. Statistics from the 1990s showed that women aged 40–44 years were more likely than any other age group to have a hysterectomy.12

  Diana Scully’s ground-breaking study13 of the training of ‘OBS’ and ‘GYNS’ in two Boston hospitals was published a few years after I visited Boston and revealed that obstetricians were trained to prefer politely submissive patients. One explained, ‘The main thing is that she understands what I say, listens to what I say, does what I say, and believes what I say.’

  Diana Scully also looked at the medical literature about female psychology and sex. Women have, for example, a pre-menstrual phase in which ‘an oppressive, cyclic cloud … stops them functioning in a logical, male fashion,’ according to the prestigious American Journal of Obstetrics and Gynaecology, and one text book stated that a wife ‘should make herself available for the fulfilment of her husband’s sexual drive’.

  In her interviews with obstetric residents in training she learned that ‘medical judgement’ and ‘surgical skill’ were the most important elements: ‘You know what you are doing, you take it out, and the patient gets better.’ She asked students how they learned about female sexuality. Answers ranged from Playboy to the army. Though women expected gynaecologists to be able to counsel them sexually, few in the profession had read any parts of Masters and Johnson’s classics.14 One doctor who was about to give sexual counselling said that he had not actually read them but had seen the authors on television.

  In their first year residents used forceps for delivery more frequently than later on, since this was the special skill they wanted to learn then and were required to have as part of their training. As one put it: ‘I use them a lot to gain the experience of using them. There is almost no time when you can’t use them, unless the woman delivers before you get the forceps on.’ They gained status with colleagues as surgeons, not ‘baby catchers’. They were not interested in normal birth because they didn’t think they learned anything from it and used women as teaching material. They were concerned to gain experience in doing hysterectomies and caesareans and to repair injured organs: ‘I need more hysterectomies … I thought I would never have enough sections, but eventually I said I had enough. … I have to see an injured bowel and injured bladder.’ So they negotiated with colleagues and developed techniques for talking women into having unnecessary operations. One resident described what he would tell a patient with small fibroids: ‘I would explain to her … that these fibroids may sometime in the future grow bigger, may get symptoms, may cause her trouble; she may need surgery at some point in time, and if she would like to have surgery done now, it can be easy surgery … She won’t have any more children, but she won’t have any fibroids, and she won’t have any potential for disease.’

  With the Boston Women’s Health Collective Norma and her sister activists challenged the male monopoly of women’s health and in the first edition of a remarkable book, Our Bodies, Ourselves, urged women to be responsible for their own bodies, demand genuine informed choice, and the opportunity for undisturbed birth in an emotionally supportive setting. I was privileged to be part of that movement.

  In a recent communication, Norma kindly said of that time, ‘You were a breath of fresh air, and sophistication – almost as if you came from another planet! As I told Uwe, I still remember the dress you wore not only to a public lecture in the church we used but also to an afternoon tea reception for the doctors held in someone’s house. It was a black crepe dress, and had large ladder faggoting all down the long sleeves from the shoulders, making a dramatic effect each time you gestured, which you did often and expansively. The doctors who came were drawn to you like some kind of sexual magnet, could not take their eyes off you, and crowded around to have a look and press flesh (your hand, I mean), leaving the rest of us to languish in our usual frumpy respectable Boston “meet the doctors” get-ups, otherwise reserved for church. Nothing of that dramatic impact had ever happened before, and it put me, and BACE, on the map, so to speak.’

  How Not To Push A Baby Out

  While I was teaching prenatal classes in Cambridge, Massachusetts, in 1969–70, Uwe was Visiting Professor of Government at Harvard, replacing Henry Kissinger who had gone to work in Nixon’s White House.

  All the fathers turned up for the classes because this was expected of couples who were doing Lamaze training. In France a woman’s obstetric physiotherapist guided her. When psychoprophylaxis crossed the Atlantic the male partner took her place. Elizabeth Byng adapted French psychoprophylaxis and produced a new equally rigid American version.

  The male partner managed the breathing training, and supervised it during labour, in a way that struck me as highly intrusive. Men came to classes with stop-watches, to time contractions and regulate breathing with precision – so many breaths at precise ‘levels’ in the first stage, and in the second stage commands to the woman to hold her breath for at least 30 seconds. In order to push effectively, the longer she could hold it, the more ‘successful’ she was. At that time birth education classes, and above all the Lamaze method, put strong emphasis on strenuous pushing and prolonged breath-holding.

  Women were also taught to contract their abdominal muscles while they pushed. Yet a woman who pulls in her abdominal muscles usually simultaneously tightens her pelvic floor muscles, resisting the descent of the baby’s head, and causing hers
elf unnecessary pain. For these muscles are completely released only when the lower abdomen is allowed to bulge out, the opposite of a sucking-in movement. It struck me that women were being trained to do something which was quite unnatural. Our home in England was on the edge of the Cotwolds – sheep country. Walking past fields in which ewes were giving birth at the peak of lambing time, I was fascinated to see how they breathed. They pushed their young out with short, rapid breaths and open mouths. Cats and dogs do the same. They do not go in for all the huffing and puffing and breath-holding that women are taught to do. Nor do they get into the extraordinary positions which are often required of women in labour, lying flat on their backs with their legs in the air. They are in a semi-upright position and, with the pelvis tilted, move around and often shift position during the expulsive stage.

  When a woman does what comes naturally she is likely to breathe in the same way as other mammals. It is a breathing pattern like that of sexual excitement and orgasm.

  In orgasm breathing is at least three times faster than usual. As a woman reaches a climax her breath is involuntarily held and she gasps, groans, sighs or cries out. When it fades her breathing gets slower again. If it is a multiple orgasm (waves of desire and fulfilment, with intervals between each) her breathing speeds up with each new wave and she holds her breath for a few seconds. She may do this up to five times at the height of orgasm. Her breathing slows down as it passes.

  This is how a woman breathes when she acts spontaneously pushing out a baby, too. If she is not told what to do, she usually breathes quickly, holds her breath for a few seconds, breathes out, continues to breathe fast, holds it again for a few seconds, and so on, until the contraction starts to fade. And just like a woman having an orgasm, she wants to hold her breath like this between one and five times at the height of each contraction.

  In conferences around the world I demonstrated this on stage, lying on my back on any table that was handy. I remember doing it in Milan lying on a judicial bench in the council chamber under the gaze of portraits of city notables and local saints.

  How not to push the baby out

  I was always fully dressed with a cape and jewellery of course. I might be wearing long boots, and often a hat. I admit it produced a comic scene. But that was my intention. The performance often brought the house down. I huffed and puffed and strained and blew. I groaned and gasped with gaping jaws. At this point I adopted the role of the encouraging midwife, who admonished me sternly, ‘Close your mouth! You can’t push with your mouth open!’ So I clamped my jaws together and did it again, drawing a huge breath and hanging on to it, and blew out my cheeks, went red in the face, and my eyes popped. There was a fresh wave of laughter, because midwives had seen it all before, even though they hadn’t realised how ludicrous this frantic pushing was.

  I saw this enacted in real life in delivery rooms, ‘Push! Push! Don’t waste your contraction! Take a deep breath and hold it. Now come on, you can do better than that! Push as if you were constipated! Take another breath and hold it for as long as you can!’

  A male physiological model was, and often still is, imposed on women. The characteristic pattern of male orgasm – stiffen, hold, force through, shoot! – (I usually accompanied this with dramatic arm movements!) distorts our spontaneous psycho-sexual behaviour. Instead of the wave-like rhythms of female orgasm, bearing down is treated like a mighty ejaculation. A woman must carry on as long as she can and then sinks back, exhausted.

  There is an endocrinological connection between sexual arousal and the intense sensations of childbirth. Identical hormones pour into the woman’s bloodstream. Endorphins, the body’s natural opiates, are not only pain-killers. They make us feel good. Pleasurable athletic activity, sex and birth all involve the release of endorphins. In the 70s, Niles Newton explored the action of oxytocin, which she called ‘the psychoactive hormone of love and breastfeeding’ in sexual arousal and childbirth. A rush of oxytocin pours into her bloodstream when a woman is sexually excited, when she has a passionate urge to bear down in the second stage of labour, and when the milk ejection reflex occurs during lactation. But this ‘psychoactive’ hormone is easily inhibited.

  Women who have had a distressing labour often tell me that sexual excitement and feelings during birth can have no possible connection with each other. Yet the energy that flows through the body in childbirth, the pressure of uterine muscle that is contracting spontaneously, the downward movement of the baby, and the fanning open of soft tissues, can be erotic. A woman who is enjoying her labour swings into the rhythm of contractions as if birth-giving were a powerful dance. She waits for the contraction, and focuses on it, like an orchestra following its conductor. When she pushes it is an expression of sexual energy, of longing and fulfilment, and if she has the loving support to achieve harmony between mind and body, it can be a psychosomatic experience of transmutation and metamorphosis.

  Many women never have a chance to experience this because the second stage is managed as a battle to get a baby born, under instructions from their attendants. It is turned into a contest in which a woman struggles to push the baby down through the barriers of flesh, spurred on by everyone present. In hospitals around the world I have seen cheerleading teams urging a mother to greater effort, more sustained and deeper breaths, more energetic strainings.

  This not only makes her feel that she is falling short of a standard impossible to attain, but imposes stress on the second stage which sometimes adversely affects the baby. When a woman is exhausted with straining, bursts blood vessels in her face and eyes, and tries to hold her breath for as long as possible, there is a risk of cardio-vascular disturbance that affects the baby’s heart rate, oxygen supply, and acid base balance.15 If a woman holds her breath and strains for a long time her blood pressure drops. This reduces the oxygen available to the baby. Then, when she can push no longer, she gasps for air and her blood pressure shoots up above normal. But long before this stage is reached the flow of oxygenated blood to the fetus may already be reduced. What often happens then is that the dips in the fetal heart rate which persist after the end of the contraction are taken as a signal for her to push still harder and hold her breath longer. This has the effect of cutting down the baby’s oxygen supplies further.

  For me the power of birth is like the strength of water cascading down the hillside, the power of seas and tides, and of mountains moving. There is no way of ignoring it. You cannot fight it. Techniques cannot enable a woman to control it as she might be in control of a car or a computer. I believe that whoever is helping should aim not to manage, conduct, or coach, but to give her strength and confidence as she allows her body to open and her baby to press through it to life. Midwives can help use this powerful sexual energy to keep birth normal.

  Decca Mitford

  I spoke at exciting conferences in America in which mothers and midwives got together to explore the possibilities of birth in a setting where women were free to do their own thing, learn about recent research, and plan campaigns in their communities.

  I first met Jessica Mitford when I was lecturing at a conference in support of midwives in Oakland, California, and she joined me on the platform. Decca was no feminist and seemed surprised by the feminist fervour of the meeting. She always loved jokes, and indeed, her way of coping with distress and tragedy in her life, of which she had a heavy dose, was to laugh. This wasn’t a joke. She opened her talk by turning to me and saying, ‘I didn’t know that I was going to be at a revivalist meeting.’ Information about birth was not really her metier and she contemplated it with something approaching horror, and midwives, I think, with suspicion.

  Decca and her fellow Communist human rights lawyer husband Robert Treuhaft later visited me following the enormous success of her book The American Way of Death, which described funeral homes, the mortician industry, and the whole ritualised monopoly of dying and being laid out in the United States. She was researching a book on birth.

  We discussed poss
ible titles and I suggested ‘The American Way of Birth’ because, in much the same way, it was an exposure of the obstetric system. Kenneth Galbraith, the economist, a close friend of hers, was doubtful about this because it was ‘hitchhiking’ on the earlier book. I introduced her to ‘the empathy belly’ designed to involve expectant fathers in pregnancy – a heavily weighted inflatable apron that a man should wear to learn what it was like to be pregnant, and how it slowed a woman down, caused backache, and made it hard to get comfortable at night, or even to sit and walk. I also told her about ‘the intra-uterine university’ to start early education of the fetus, which involved listening to its heart beats and playing music to which the baby could respond.

  Subsequently I sought her advice about publishing and getting an agent, and she put me on to a woman who had been like an adopted daughter to her, Mary Clemmey, who remained my literary agent for some years.

  When Decca died of a rapid cancer she faced it with huge courage and planned her funeral in San Francisco with a glass antique hearse pulled by six plumed horses. A marching band, led by a saxophonist friend, followed the cortege, blaring out rousing hymns, including ‘When the Saints Come Marching In’. We celebrated her life in an upbeat way in London. Her friends gathered in a theatre to extol her and focus on her colourful personality with a party afterwards.

  Palo Alto

  At a big International Childbirth Education Association conference in Palo Alto, California, in 1979 I spoke about rites and ceremonies in childbirth. My joy in acting was expressed in my style of lecturing. I didn’t want to stand at a lectern and orate. I aimed to use my body to bring to life the different scenarios of birth in various cultures and draw dramatic contrasts. At Palo Alto I acted how women in Jamaica gave birth with strong pelvic movements, chanting with cries to the Lord, and drew on the passionate experience of ‘getting the spirit’ in revivalist worship up in the hills with dance and song.