Midwives are called the ‘grandmothers of the umbilical cord’. They have a lasting relationship with each child whose cord they have cut, are highly respected members of the community, and take an active part in planning women’s health care.
In other Latin American countries I visited I was in huge maternity hospitals where I saw women lying petrified with fear, alone and completely unsupported emotionally. A doctor leaned heavily on the woman’s abdomen to forcibly expel the baby as quickly as possible. Following delivery of the placenta, the routine practice was for him to push his fist up into the uterus and sweep his hand round to ensure that no placental fragments remained. All this was without anaesthesia, or even caring words. In these countries, white women had private obstetricians, American-style, and dark skinned and peasant women were treated like animals.
There were hospitals like this in Nicaragua, too. But the important and hopeful thing was that nurses and midwives had come in from other countries, including North America and Britain, and were working side by side with local midwives, learning from each other, and had developed a system where there was a strong emphasis on the voice of the people. A Chilean midwife, Susanna, moved to Nicaragua and trained midwives, helping them to ask searching questions about their practices, and consider alternatives to interventionist obstetrics.
Yeshi Newman, an American midwife who helped with this work, said, ‘The job that women have done for centuries – guiding the entry of new life – has been recognised, and the dignity of the women who do this work shines like the sun’.
In Leon, Sophia, a Colombian-born exile married to an Italian doctor, started working with women giving birth in the big hospital, but conditions were horrific, and she was so outspoken that she could not continue her job there. So she switched to the street markets, set up a screen and arranged benches prior to giving talks illustrated with slides to anyone who gathered round. These covered all aspects of women’s health and sexuality, contraception, abortion and birth. It was ventures like these, going out to the people rather than expecting them to come to you, which were at the heart of the enormous social and political changes in Nicaragua.
Canada
In the 80s Canada was the only industrialised nation within the World Health Organisation not to recognise midwifery. Midwives were classed as amateurs, remnants of an old wives’ past tainted with witchcraft and ancient herb lore, and potentially dangerous. I was active in campaigning for midwifery in the different provinces of Canada. I knew excellent midwives in Toronto, and we planned a march on the College of Physicians while I was on one of my lecture tours there. Official recognition of midwifery rested with doctors. The decision was in their hands.
Michael Dickson, Registrar of the Ontario College of Physicians and Surgeons, was reported in the Toronto Globe saying, ‘I do not consider it proper for midwives to be involved in births, either at home or in a hospital. It would certainly be our position that midwifery is part of obstetrics and is therefore part of the practice scene of medicine.’44
The police told us that our march must keep on the move and there should be no standing around and proclaiming. This presented no problems. I was leading the march and would give birth performing my own birth dance, followed by all the other marchers behind me. When the day came I swayed, rocked, walked, breathed, held my breath, grunted, panted, circled and swayed with excitement and passion, birthing a life-like flexible baby doll through my box pelvis and foam rubber vagina and through the vagina out into my cradling hands.
All this was recorded by TV cameras. We must have been fairly persuasive, since Ontario was the first Canadian province to register midwifery. The Midwifery Act was passed in 1991, and in 1993 the Baccalaureat in Midwifery started.
Birth In A Soviet Time Warp
In 1989 a group of us – doctors and other specialists in birth and babies – were invited by the UK-USSR Medical Exchange Programme to meet for the first time a group of Russian specialists in order to share ideas – glasnost in action. My friends Wendy Savage, who was Senior Lecturer in Obstetrics and Gynaecology at the London Hospital, and Professor Norman Morris of Charing Cross Hospital Medical School, were also members of that group.
Following the two-day conference, I found it easy to escape the official programme of visits to showplaces and instead discover what it was like to have a baby in two Moscow hospitals, one a high-risk centre and the other a district maternity unit.
Birth education had been initiated and was firmly controlled by professionals, whereas in the West it was started by lay women: and classes were run by independent childbirth organisations such as the International Childbirth Education Association in the United States and the Active Birth Movement and National Childbirth Trust in Britain. These organisations began to come into being in the 50s, first in Britain and then in the United States and other European countries, set up by women who were themselves mothers and who resisted the increasing medicalisation of birth. They sought to provide emotional support and friendship in pregnancy, information about non-pharmacological ways of handling pain, and preparation for childbirth in small, friendly groups.
When birth education was introduced in the USSR in the 1960s, attendance at antenatal classes was compulsory from the thirty-second week of pregnancy. Most Russian obstetricians were women, but there was still heavy emphasis on their role as birth technicians and employees of the State, rather than on their understanding of birth as women and mothers themselves. I discovered that in psychoprophylaxis classes they had to follow the rules set down by a central authority: ‘Women must be … immunised to labour pain. Physicians must normalise and reorganise the minds of women poisoned by erroneous ideas.’ The language was authoritarian and didactic. The objectives of birth education were ‘to teach the pregnant woman proper conduct during labour so that she may follow instructions properly.’ ‘By understanding all the medical measures conducted in the institution the pregnant woman will be disciplined.’ ‘The physician should emotionally emphasise motherhood’s high social virtues confirmed in the Soviet Union by the establishment of government awards – orders and medals – and honorary titles to mothers of many children.’45 Russian psychoprophylaxis stressed control over the mother and her correct behaviour as a patient.
Preparing Women And The Political System
I have found that wherever birth education is not under the control of women themselves, but is promoted by large hierarchical institutions, it is dogmatic, authoritarian, inflexible – even punitive – towards women who do not conform. Women were told, ‘Here is what will happen to you.’ They were taught to relax so as not to be a nuisance. They were supposed to lie in bed tidily under the sheets, to be quiet so as not to frighten other women or interfere with the smooth running of the labour and delivery rooms, to breathe in order to suppress the desire to scream out in pain. What this adds up to is that the woman was taught to control herself so that she could be more effectively controlled by those caring for her.
Within the Communist system education for childbirth took the form of pregnancy gymnastics based on psychoprophylaxis, instruction about the Pavlonian psychology of conditioned reflexes, and basic anatomy and physiology. ‘Breathe in, 1, 2, 3, 4 – stop – breathe out, 1, 2, 3, 4, 5, 6 – breathe in! Breathe out! Relax!’ Commands were rapped out as if by a drill sergeant. None of it bore much relationship to what the woman actually feels during childbirth. The idea behind it was to control her behaviour so that she was quiet and disciplined. Communist values regulated women’s behaviour in childbirth. This last bastion of individuality, the intimacies of psycho-sexual life, inter-relationships between a mother and her baby, and between the couple and their child was made to conform to norms which each woman attained or failed to fulfil.
Fifty years earlier in the English speaking world ritual cleansing had been the norm. In Exploring the Dirty Side of Women’s Health two research midwives describe how, in 1920s New Zealand, ‘the aseptic technique reinforced the focus on the v
agina as a passage of dirt, requiring aseptic measures as stringent as for surgical operation. Midwives wore gloves, masks and sterilised overalls, and the woman’s body was shaved, bathed, emptied by enema, daubed with disinfectant and swathed in sterile drapes.’46 This was still the case in Russia in the 80s.
Being with a Russian woman in childbirth in the 80s was like being stuck in a time warp. No fathers were allowed inside the hospital, let alone in labour wards. A huge enema apparatus was on a stand just inside the labour ward door. First a ritual enema and shave transformed the woman into a patient. A complete pubic shave and enema were routine. The implicit message was that the mother was dirty and birth was polluting, so the entire pubis must be shaved bald as a hard-boiled egg and her bowels emptied of their filth.
Then she was left alone, lying on a hard, narrow, high bed to ‘get on with it’. She was expected to be quiet and disciplined, and if she had attended psychoprophylaxis classes to use these techniques to control herself and not make a fuss. So she lay biting her lip, moaning quietly, or writhing in silent agony.
When the baby was about to arrive she had to climb on a table and there was a hurried, often violent delivery. She could not hold or often even see her baby, which was given vigorous resuscitation and whisked away to the nursery. Mothers were left on trolleys with ice-packs on their tummies in the corridor for two to three hours or more before they set eyes on their babies. In one hospital I noticed nurses nipping off for a quiet smoke in the rooms where the babies were lying ‘under observation’. It was firmly believed that mothers could harm and contaminate their newborns if they were allowed to be with them. Before a woman was permitted to touch her baby, her fingers had to be painted with iodine to avoid conveying germs to the cocooned infants.
Midwives, nurses and doctors did not have to undergo this rite, though in any hospital it is the staff who are mainly responsible for cross-infection, as Semmelweis, the doctor in Vienna who taught his colleagues to wash their hands, pointed out long ago.
Bacteria that mothers transferred to their babies were perceived as the primary source of the epidemics of infection in hospital nurseries. These in turn threatened the staff of the institution. One professor of neonatology told me, ‘I can remember when other staff of maternity hospitals would not shake hands with neonatologists because they considered them a source of infection.’ In this way the medical system reflected the same dread of external contamination that was expressed in the Communist political system.
In Moscow babies were fed according to the clock, a regime that had been the rule in the West 30 years before, and which caused great misery for both mothers and babies.
Watching this, helpless to do anything to comfort women, I realised how dramatic the changes being made in Western hospitals since the 50s were because of the strong voice of the childbirth movement. I often felt that we were making no progress in humanising birth, but only had to see what Russian hospitals were like to be aware of advances.
For every birth in the USSR a woman had between two and six legal abortions. In the UK at that time there was one abortion for every five births and anaesthesia was used routinely. For every legal abortion in the USSR it was estimated that there was one illegal abortion, too. I don’t know how they worked it out, but experts guess 30 per cent of the illegal abortions ended in the woman’s death.
I got the impression that abortion was the model for childbirth. Birth was simply evacuation of the uterus. Women endured it in the same way they had to put up with all the other hardships – living in flats shared between three or four families with only one kitchen; having to queue for nearly all food; sometimes having three jobs – doing demanding work, moonlighting (one of our interpreters turned out to be a neurologist) and stuck with all the housework without any help from the men. This is why pregnancy could be a disaster.
Abortion was on demand up to the twelfth week of pregnancy, usually consisting of dilation and curettage without anaesthesia. Contraceptives were often unobtainable, but there was a great deal of suspicion about them too. A young doctor said she would never take the pill because it was ‘dangerous’, and condoms were ‘horrible’. Abortion she considered safer, cleaner and simpler. So that was the favourite method of birth control. Many Russian gynaecologists did nothing but abortions.
Some obstetricians were making efforts to give birth more personal significance for women. In one hospital I visited the admission room was like the entrance to an abattoir, with a huge enema apparatus, an open lavatory, and two women being ‘prepped’ at the same time without any privacy. But in that hospital, too, there was a ceremonial room – it looked like a parlour in an American funeral home – where the new mother met her husband and family and introduced the baby to them before she was discharged. A whole wall of this room was a stained glass picture of a mother and child, lit from behind.
First the woman went to the adjoining swaddling room where she was taught how to bind her baby and the resulting package was tied with pink or blue ribbon. Then to the background of music she emerged and the father saw his child for the first time, flowers were presented to her, and photographs with the new baby were taken. The music softened and a lyrical female voice announced: ‘Now the new life is in your hands. The baby is your dream and when you get home it will grow up and take care of you. Good luck little baby! We want your parents to take care of you so well that you will grow up to take care of them in the future. Good luck, little citizen!’ – and the national anthem blared out.
The meeting of a father and other members of a family with a newborn baby, treated as a private and intimate event in Western countries, was in Communist society a formal ritual entry into the culture, one in which the baby was symbolically exhorted to be a good citizen, and in which the parents were reminded of their duties to train the child well. Ceremonies of this kind served a similar function to those of baptism and christening for members of the Christian faith.
To enter another culture in the way I did is always to intrude and to risk violating deeply held beliefs. I was warned that when I lectured to doctors I should be methodical and unemotional, because that is what Russians like. Yet our interpreter was getting tired (he could not translate the word ‘sex’ so I had to improvise in actions) and I felt I could only make the points I wanted about a non-violent, rhythmic way of conducting the second stage of labour by acting what happens when women are surrounded by cheer-leaders yelling, ‘Push! Push! Push!’: how this makes muscles go tight, and eyes pop out, and results in exhaustion.
I demonstrated the difference between this and birth when there is no rush and no commanded pushing. I was amazed by the doctors’ ready laughter. They understood exactly what I was saying and we discovered that we shared the same sense of humour. These women obstetricians turned out to be warm, funny and passionate.
The USSR was largely out of touch with what was going on in the rest of the world. Even so, it was on the brink of change and we had an opportunity to affect the way that took place. While we were there a Vice-Minister of Health signed an order that hospitals must allow visiting of patients. There was a fluttering in the dovecotes as staff worried about how they were going to cope with that, in the same way that years before it was thought in the UK that if fathers were allowed in the delivery room they would faint and cause chaos.
An experiment was reported in Riga, where husbands could accompany their wives to hospital and stay during labour and birth, and described in a popular weekly magazine illustrated in colour. The rate of infection did not rise, (the reason given for the exclusion of all visitors), and the Ministry of Health said that men should be allowed into maternity hospitals. ‘Birth perestroika has begun!’ Wendy Savage exclaimed.
Other experimental projects held hope for the future too. I met a doctor who, in an effort to reduce the amount of cross-infection in hospitals, was giving antenatal and postnatal care to women at home, and who planned to do home births later.
I got to know the doctor respons
ible for all childbirth education in the USSR – a vivacious, glowing woman who was dissatisfied with their rigid methods of training for birth. It consisted mostly of lectures by obstetricians, paediatricians and even a lawyer, to obedient classes of listening women. We hoped to collaborate and she wanted to come over here to work with me. Unfortunately, she was never able to get permission to leave Russia.
Yet women were hungry for change. For the first time there was open criticism of maternity hospitals in lively correspondence in a Moscow newspaper. Obstetricians and paediatricians were shocked by what they saw as an attack on good practice.
Campaigning For Midwives
The Tao Te Ching described the midwife 2,500 years ago. ‘Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say: “We did it ourselves!”’47
Since the first recorded accounts of birth, and in countries all over the world, mothers and newborn babies have depended on midwives. They are the experts in normal childbirth, and giving care so that the abnormal does not develop. Midwives in traditional cultures describe their work to unblock, open up, release and free the woman so that she can give birth. ‘Midwife’ is from the Anglo-Saxon meaning ‘with woman’. She is also the wise woman, the ‘sage femme’ who has insight into women’s rhythms and the mysteries of birth and death.
A Passion for Birth Page 30