A Passion for Birth
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What episiotomy is, how it came to be a standard part of an obstetric delivery, its benefits and risks as a routine practice, and women’s accounts of episiotomy and its short and long term effects. A discussion on how routine episiotomy can be avoided, and of how more women can be enabled to give birth without perineal trauma.
Traditional rites and symbols in childbirth
The implicit meanings of ceremonies and symbols in traditional birth practices, and the relevance of these to childbirth today.
Change in childbirth
Recent developments in childbirth, how these are perceived by childbearing women, and how birth may be in the future.
Instinct and culture in childbirth
The relationship between biological and social elements in childbirth, and how the physiological process may be affected by the psycho-social context within which birth takes place.
Sex in pregnancy and after childbirth
The woman’s changing body, emotions and relationships.
The psychology of breastfeeding
How a woman’s ability to breastfeed spontaneously and in a satisfying way for both her and her baby is influenced by emotional factors, by social pressures, and the importance that the help and advice she is given should be empowering rather than lowering her self-esteem.
The rebirth of midwifery
How obstetrics has changed the role of the midwife and the way in which midwives perceive themselves. The rise of the childbirth movement and the midwife’s reclaimed identity: an international view. A discussion of what will be needed for the midwifery renaissance to become a reality.
New Zealand – Maori Birth Traditions
When I go to other countries to lecture, there may be book promotion as well, and I fit in a period of research if I possibly can. I did this with the Maori in New Zealand in 1990 when I was invited by seven women elders to learn at first hand about Maori traditions of childbirth, which are ‘tapu’ (the Maori word for taboo which has a layer of supernatural meaning). Younger Maori women are not allowed to learn about them. I had been with the Maori before, and it was as a result of this that they invited me to come and be initiated into the secrets. They said that then I would have responsibility to write and speak about them. Traditions differ between the North and South islands, but are very similar to those in the islands of the Pacific, in Fiji, for example. These people travelled in their boats all over the Pacific – and the Maori are part of the greater Pacific culture.
Carved over the entrance to every ‘marae’ (place of worship) is a vagina. Access to the Maori culture and to the values of Maoridom is only through a woman. In the same way, in formal religious rites a man speaks only when called by a woman. Women are the ‘callers’. They enable men to express themselves.
The marae itself is constructed in the form of the human body. The lintel over the door depicts the way into the womb of an ancestor through the body of a woman who conceives the Maori members, nourishes them during gestation and gives birth to them. She is the portal to birth, life and death. Any person stepping over the threshold under this lintel becomes ritually cleansed.
I entered the marae of Papakura through a door that depicted a woman with carvings of people of the northern tribe on her left and right side. Her arms were raised to either side of her as if clutching beams and she squatted, feet firmly planted on the ground, whilst two carvings of the people of the tribes fanned out on either side of her.
Traditionally, at sunrise a Maori pregnant woman gets up, faces east and breathes slowly and fully as the sun rises. At sunset she turns to face west, and breathes slowly as the sun sinks
The God of the Universe formed human beings, and afterwards created the lesser gods, including Kamaro the God of the Sea, who in turn created marine life. Uemoko shaped the plates of the earth, then shifted them, moving America away from South Africa and New Zealand away from Australia, for example. Pakeamarktir was the God of the elements, wind, rain, lightning, thunder and storms.
When a woman gave birth she went with other women into the bush and they made a warm nest. It is called ‘Korama’. She often delivered the baby using another person to support her as she knelt forward. This might be one of her other children. A man told me, with pride, ‘I myself helped to bring my sister into this world when my mother was giving birth. I went before her and knelt down and she leant over me.’
Patient Advocates
I met the first patient advocate to work at a large women’s hospital in New Zealand, Lynda Williams. Her brief was to give all women using the hospital information about their rights, help them understand how the medical system works, ensure that they had access to their medical records, deal with complaints, and be readily available to listen to them. She was independent of the Area Health Board and directly responsible to the Health Commissioner (like our ombudsman) and so could be effective.
Her appointment followed a scandal that rocked the country in the 80s. In 1988 the Minister of Health revealed that for more than 20 years women at the National Women’s Hospital had been used as guinea pigs in research on cancer of the cervix. This type of cancer was not treated, in spite of the fact that since the early 60s it had been known to be a precursor of invasive cancer. Judge Silvia Cartwright said that Professor Herbert Green had ignored virtually all the existing research by withholding treatment from women with early changes in cervical cells.
These women did not know they were being used as research material, had no opportunity of withdrawing from the study or of giving informed consent to it, and believed the many investigations and the surgery they had for research purposes were actually methods of treatment. In fact, even when malignant cells were multiplying quickly, some women were told there was nothing wrong with them.63
The judge called for the appointment of a patient advocate in the hospital to be a voice for patients on ethical committees and in the development of information about treatment protocols, make sure that information was available in a woman’s own language, and heighten awareness of emotional, cultural and social needs. She called for a ‘human link between the medical and administrative services and the patient’. In a damning indictment of the medical system, she said, ‘I accept that individual doctors, nurses as a group and the medical superintendent all believed that they put the patient first. But I also have ample evidence that this is not always the case. Nurses have been conditioned to protect patients by stealth. They cannot, therefore, be effective advocates who will act bravely and independently.’
Lynda had been a childbirth educator for 12 years, was on the Auckland Women’s Health Council, and had four children herself. ‘One of my main goals,’ she told me, ‘is to empower women in a system that is continually disempowering us. I don’t want to become yet another crutch to be leaned on, but to empower women to take back control of their own health care.’ She said it was hard not to be worn down by hospital bureaucracy, ‘In an institution like this the rights of the patients get lost in other kinds of issues such as staffing, which assumes more importance than the needs of individual women.’
Her appointment led to the development of a system in which advocates had the difficult task of confronting and challenging an entrenched medical position. Some members of staff believed that the advocates’ job was really to make work easier by getting patients to obey instructions. They expected her to sweet-talk women into believing what had been done to them must be for the best because doctors are experts.
At that time there were some patient advocates in the UK in places like Hackney, where there was a large immigrant population. They helped women who did not speak English. The patient advocate in Leeds told me that in theory she could help anyone, but in practice her work was limited to ethnic minorities.
A real patient advocate is quite different from interpreters employed in hospitals. Interpreters translate what doctors and nurses are saying, helping women to conform to hospital protocols. Advocates take an active part in policy-making.
Since that time advocacy has become established as vital wherever power is unequal – in mental hospitals and the mental health services, for example. My daughter Polly was actively involved in the training of advocates for users of the mental health services and in setting up services.
In the 90s Polly worked voluntarily with Rape Crisis and with Lesbian Line in Oxford, and out of this grew wider advocacy work and her appointment as Co-ordinator of Volunteers in the Oxford area for women with mental health problems, most of whom had been sexually abused. Then she went to Wales and was responsible for co-ordinating all statutory and voluntary mental health organisations in the South Wales valleys, Merthyr Tydfil, the Rhondda and Cynon Taff – an area where there was extreme social deprivation since the closing of the mines, and where services were severely underfunded. Her task was described as ‘service user involvement and development’, making sure that routine services took into account the needs of people to be involved in the design and working of all agencies, and ensuring that individual voices were heard. Mental health patients need help with building confidence and self-esteem, but were often considered unable to make choices for themselves and were simply treated with drugs, and stigmatised when they did not comply with plans made for them.
Islands Of The Pacific
On my first visit to Fiji in 1993 Uwe joined me from Harvard, where he was a Visiting Scholar from then until 2003. We stayed in a beautiful hotel on the tiny island of Vatulele. There was a communal table in the restaurant, a personal pool through the glass wall of our room onto the heath that stretched to the sea edge, and wild horses galloping free. I met a waiter who took me to his village to learn from the local midwives and talk to women.
Talking to the traditional village midwife in the open just outside the village, we were discussing her work. You couldn’t interview anyone without a crowd gathering and taking part – a definite advantage – more to be learned. So every question I asked, every subject I raised, stimulated a response from the women who stood around us. At first the midwife was keen to show that she conformed with the bio-medical standards imposed by the hospital system. She sought approval. I represented, whether I wanted to or not, the American technocratic way of birth. It was difficult for me to make it clear that I was not testing her. So I talked about birth ways of women around the world – having other women to help them, for instance. It was quite hard going. She couldn’t trust me yet. The conversation got more lively and the bystanders helped. Then she started to explain how she managed the second stage of birth: ‘When the woman lies down …’ she said. My eyebrows shot up and I exclaimed, ‘Oh, they lie down! In many countries women don’t like to lie down. They kneel or squat or stand.’ At that point the crowd of women suddenly burst into activity. ‘Of course we don’t lie down!’ They exclaimed. ‘We stand. We stand. We swing-along!’ First one, then another, then all of them broke into a pelvic dance, slowly rotating and rocking their hips. The midwife laughed and danced, too, and I joined them. We understood each other exactly. The children joined in. It was an instinctive birth dance shared across cultures. We didn’t have to talk about it. We knew. Birth is movement. Birth is a dance!
An invitation to lecture and do research in Hawaii in 2003 presented an opportunity to interview midwives and mothers and explore childbirth for the second time on the islands of the South Pacific.
On this visit we stayed on the island of Maui. It was a good base from which to fly in a single engine plane to the scattered islands and get an idea of birth traditions and the problems presented by a medicalised birth system in which heavily pregnant women were directed to fly to the big hospital, either already in labour, or to wait, isolated from family and friends, until labour could be induced. This is a model similar to that in the Canadian far north when in late pregnancy women were flown to a hospital in Winnipeg, and where at that time midwifery units had not yet been created on the reservations. As a result important birth rites were not enacted and the children born far from home were deprived of tribal membership.
Fiji has a rich birth culture. When the Chief’s wife gives birth members of the community blew on conch shells four days after to welcome the baby and the mother and baby’s first week are passed in complete seclusion. The mother and maternal grandmother massage the newborn baby with coconut oil, a tradition that continues now.
Adiseru was a 52-year-old Fijian midwife who had been working for 33 years, and was apprenticed with her mother. She learned from her how to massage the pregnant woman with oil twice a week from when she was two months pregnant. She gave her advice. She should never wear tight clothing around her neck, or a necklace, lest the cord twists round the baby’s neck. In the second stage of labour she told the woman, ‘Slowly, slowly, … Gently, gently.’ Native midwives never did episiotomies, and might guard the perineum with the flat or side of their hands when they thought it necessary. She told me she could tell in pregnancy whether a baby is a boy or a girl, because girls are on the left. Then she slapped me on the shoulders and roared with laughter. Other women joined in. How gullible can you be?
Research in Hawaii was preceded by my addressing a large gathering of US-trained midwives in Honolulu, in dazzling light facing huge windows and brilliantly sunny gardens, when the air conditioning had failed. Unfortunately I passed out at the podium. The result was dramatic. I came to with midwives surrounding me offering a wide range of skills. They massaged my feet, shoulders, head and back, gave instructions about breathing, and engaged in meditation and chanting. I felt in safe hands, though there were rather too many of them! An incident like this has an amazing uniting effect on a crowd, and we became very merry afterwards. We all moved out into the garden and sat on the grass, where the meeting continued.
These midwives were a lively lot, with sympathy for local cultural traditions that had proved their value, and I enjoyed learning from them. In the nineteenth century Hawaii was Japanese and until the Second World War Japanese midwives gave childbirth care and worked alongside native midwives. On the rural western side of Kauai and Lanai the old language was still spoken, and native midwives used the hula during childbirth to ‘help move these babies down’. Yet on the small islands women were flown to deliver in hospital in Honolulu and this was mandatory for first babies. Midwives say that many refused to go to the hospital because ‘birth is easier with midwives at home’. On Tara, where there was no doctor, nurses – not midwives – delivered most babies, but I discovered that there were four traditional midwives, who used touch and massage, and placed women in warm water to treat pain.
Grandmothers are enormously important in this culture, as in Fiji, where the first baby is given to the maternal grandmother, or sometimes an aunt, to raise. Grandmothers have the right to choose any child of a daughter. A woman who is barren can ask for a child, too. The practice of surrogacy is traditionally well established and if a woman cannot conceive by her husband she can select another man to be the biological father, while her husband remains the social father.
Pele is the grandmother goddess, Tutu, and Mother Earth is the goddess Papa, representing the female principal. Grandmothers sing sacred chants and lullabies to the baby, so that the child starts to learn cultural values early. A traditional midwife tells me, ‘We share. What is mine is yours. What is yours is mine. We all care for each other.’
Talking with Hawaiian midwives, I learned that before American missionaries came a man’s parents chose his wife, but that this changed with American influence.
As the time of birth approached the family gathered to help by
pooling their mana (vital life force). The mother knelt for the birth, with one or more female companions supporting her back, while the kahama, a male healer, or the midwife, knelt in front of her. ‘Men are always put away during birth’.
I talked to a fifteen-year-old Kauai woman who told me that her maternal grandmother massaged and rotated the baby into the right position at the end of her pregnancy, ‘So I had no troubles’. After the birth she said she went straight back to work. I said, ‘Oh, really?’ and told her that in most countries other women cared for the new mother, and she then quickly amended what she was telling me, and said that at first there was a 30 day period in which she was nurtured by women and no men were allowed in the house.
A midwife aged 86, who had started midwifery when she was 25 and retired at 70 because her sight was failing and her arms were no longer strong enough to hold a woman up in a good position for birth, described how she spread coconut leaves or grass on the ground and women helpers supported the mother’s shoulders and arms from behind. The mother held onto a stake in the earth. In pregnancy she advised women to have regular exercise and eat plenty of vegetables, special vegetable jelly, and hibiscus leaves, and avoid drinking much tea. Instead she should have tea made out of lemon leaves. She should not eat red foods, including crabs and lobsters, which ‘make the baby have tumours’ or any long fish such as barracuda. If labour was very slow she gave the mother herbs that were rich in natural oxytocin. One thing that these traditional midwives did not do was to inject synthetic oxytocins, a major cause of fetal death, uterine rupture and maternal death in countries where traditional midwives have adulterated their practice with powerful drugs that have been introduced by professional obstetricians and midwives. Oxytocin is useful in controlling haemorrhage, but when generally available at pharmacies in rural areas, and used in labour, it can be very dangerous.