Paradigms of Birth

From the beginning of human existence, birth has been a necessary part of the continuation of our life form. The history of childbirth and the practices around it have changed dramatically, shaping and reforming in a multitude of ways. Physiologic birth is the innate function of mother and infant in navigating the birthing process. This kind of birth is the natural form of childbirth and has been with us since humans first evolved on this planet, yet in many ways has been lost through modernization and the development of the medical system. In this paper, I outline the functions and benefits of physiologic birth, the medicalization of birth in the United States, and the re-integration and evolution of physiologic birth in maternity care practices within postmodern society. 

Physiologic birth begins at the spontaneous onset of labor, goes through the three stages of labor, and ends about an hour after the birth of the placenta…and ripples far beyond that. Birthing people have the freedom to move instinctually, with no interruptions. During this process, the baby is making its way down the birth canal by going through the cardinal movements of labor. These are the instinctual movements the baby makes as they are navigating the birth canal. When labor extends longer than what is deemed normal, physiology understands that this is usually because the baby is getting into an optimal position. When left alone, the baby is able to navigate through cardinal movements into an optimal position for birth (Roberts, 2002, p. 10).

The second stage of birth is defined as full dilation which is when the cervix has opened to ten centimeters. In the medical model, this is when caregivers are taught to coach women to push. In the realms of physiologic birth, coached pushing once a mother is fully dilated can cause harm to the mother and child. If the birthing person does not have the instinctual urge to push at ten centimeters it could be because of the position of the fetal head in the pelvis. Forced pushing can cause periods of prolonged bearing down and can potentially cause long term harm to the mother and lead to the use of further medical interventions (Roberts, 2002, p. 2-4). 

The third stage is the birth of the placenta. It is birthed freely, with no coaching or pulling the cord. The cord is left attached to the child and placenta until the mother feels it's time for it to be cut. Often in physiologic birth settings, the cord-cutting is delayed until the baby is notably acclimatized. At this point, the cord will become limp as important nutrients and oxygenated blood have been distributed back to the baby. A lotus birth is when the cord is let to separate from the baby and placenta organically. This process can take three days (Department of Pediatrics, 2016, para. 1). 

An interesting phenomenon found in completely undisturbed birth is the moment between the birth of the child and the mother picking them up. Paciornik and Paciornik’s (1979) Birth in the Squatting Position is a short film documenting several women giving birth in the traditional Brazilian method. During these births, a much slower transition is shown from the moment of birth to skin-to-skin contact. The mother takes a moment, looks at her baby, and then slowly picks the baby up. It appears to be a very gentle method in the calm environment. 

Hormones play a big role in how birthing people navigate labor, birth, and the postpartum period. The length of the postpartum period varies between cultures and personal experiences, however, it is understood as the time after birth. Six weeks is the common understanding of this period in the United States, however, in some cultures, it can last for multiple months, and for some women up to two years. Undisturbed birth allows for normal hormonal processes during childbirth to occur and can have positive impacts on the postpartum period and beyond for families (Buckley, 2015). 

After nearly three centuries of medicalized birth in the United States, a movement back to the roots of birth has been reintegrating itself into postmodern society. The roots of birth–physiologic birth– is the most natural and innate form of birth. In the United States today, there are a number of different options for maternity care, each utilizing a different model of care. The level of knowledge and focus on physiologic birth varies, and while each option is unique, each model of care has a deeply interwoven history with the others. The two most known care options today are midwifery and obstetrics. Obstetrics was developed within the medical model to offer women clinical care during pregnancy and birth. An obstetrician is a physician specializing in maternal care. Midwifery, on the other hand, has a long, complex, and diverse history across cultures and times. The Old English roots of the word offer the aspect of it that has remained the same: with woman. The technical definition is a person who assists women in childbirth (Merriam-Webster, 2022) 

Today the main options for midwifery care are certified nurse-midwives (CNM), certified midwives (CM), certified professional midwives (CPM), and traditional or lay midwives. While all of these differences fall under the defined scope of midwifery, there is much to know about these different kinds of midwives. The level of education varies between CNMs, CMs, and CPMs,  however, each of these certifications guarantees academic training. Traditional midwives are normally unlicensed and do not have any official academic credentials. The knowledge these people carry is passed down from generations, learned through experience and community members. 

A new model of care has been revealing itself into society. This model is most similar to traditional, or lay, midwifery and is most simply put as the practice of woman-centered care. Different words have been dawned to name this new–yet simultaneously ancient–practice. Some of these include the birthkeeper and traditional/independent birth attendant. My understanding of this kind of care is based on my own education and experience as a becoming birthkeeper. These practitioners have a broad education and knowledge of birth, however, are not licensed or academically certified by accredited sources. Because these practitioners are not tied to an accredited institution or licensure, they are able to fully focus on woman-centered care. There is controversy over this kind of practice, its safety often questioned by both families and practitioners (Mendoza, 2002, para. 13-14). 

In the United States, midwifery laws, requirements, and regulations vary from state to state. Twenty-three states have midwifery licensing laws that have serious restrictions on practitioners and birthing women’s rights to choose, while only four states license midwives without restricting individuals' choices (Campbell, n.d., para. 4-5). There are thirteen states that do not license midwives and allow midwives to practice freely and seven states that do not license but have criminalized homebirth altogether. The remaining states are in the process of changing and are not yet public knowledge (Campbell, n.d., para. 5). As Campbell states, [required licensure] is educational elitism[, and requiring] additional education was just one way that the U.S. regulated [lay] midwives out of existence” (Campbell, n.d., para.6). 

Before the 1920s midwifery was not regulated by the government, traditional and lay midwives were the norm. However, through series of modulations, the medical system gained control of these midwifery practices (Rooks, 2014, para. 3). The medical model was developed in the late 19th and 20th centuries. It gained popularity alongside the advancement of science and rationalism in mainstream society (van Teijlingen, 2017, p. 1). It was first developed mainly as an attempt to manage the risks of childbirth. 

By the end of the 20th century, the majority of maternal care moved from the home to the hospital and the use of interventions such as forceps and anesthesia became commonplace. In the medical model, pregnancy and childbirth are viewed pathologically as a disease instead of a normal processes. Objective measurement of symptoms and clinical observation has been historically the primary focus in this model of care. (van Teijlingen, 2017, p. 2). Because birth has become publicly viewed in a disease-oriented manner, physiologic birth is not deemed acceptable in everyday practice. The management (versus the facilitation) of pregnant women has become the standard in maternal care. 

Research done by Marian McDorman shows that out-of-hospital births began to increase between 2004 and 2017, homebirths specifically increasing by 77% ( 2018, para. 3). Her findings suggest a growing movement away from in-hospital births starting in the early 2000s. This research found that a lack of medical coverage was a prominent limiting factor for women that desired out-of-hospital births (2018, para. 4). However, McDorman said, “despite [...] the substantial out-of-pocket costs associated with these births, an increasing proportion of women are choosing to give birth outside the hospital” (2018, para. 32). She believed that the reason for this is that women may “feel that it is safer, with lower cesarean rates and fewer interventions; [as well as] feel more empowered and in control of their experience” (2018, para. 33). She continues to suggest that those who endorse hospital births would have the most success in creating a more supportive in-hospital environment and experience for mothers and their families (2018, para. 33). She concludes by stating that “society might be better served by a maternity care system in which mothers, wherever they give birth, feel empowered, engaged and safe. In such a system the emphasis is less on place of birth and much more on how best to serve the needs of mothers, infants, and families” (para. 35). McDorman is advocating for the model of women-centered care. 

There is a clear need for a more standard practice among medical practitioners that promote physiologic birth due to its safety and health benefits. The value of standard maternity practice is that it creates more interdisciplinary and reliable access to particular birthing practices women desire. However, reducing maternity care solely to the medical model–whether an obstetrician or a licensed midwife– strips women’s rights to choose where they feel most comfortable, and are therefore only encouraging physiologic birth when in the hands of the medical system. Birth is multidimensional, many different aspects influence the orchestration of a birth, and the models of care accessible to women must reflect this. 

Whapio D. Bartlett, better known as Whapio, is a seasoned independent midwife adept in both the realms of both ancient and modern birth practices. She is also my teacher. Bartlett said:

…we are on the verge of having a monoculture of birth where there is only one way for birth to unfold in the system. [Women] are not going to be satisfied by one approach, one style, one right way to give birth. (n.d., para. 14)

Whapio’s point is that it does not matter if every practitioner has access and knowledge in facilitating physiologic birth, there is a deeper question of a women’s individual power and right to birth on her terms. There is a question of deeper ethics of the involvement of the medical model and women’s bodies, as well as their choices around them. The successful unfolding of physiologic birth is reliant on the mother, birth attendees, and environment. Thus, it is important that the mother has the autonomy to choose both her attendants and environment. While standardizing practice among institutions and licensing agencies is important, standardizing this care in an attempt to criminalize other forms is problematic.

References

Bartlett, W. D. (n.d.). The Whapio wire. The Matrona. https://thematrona.com/the-whapio-wire/

Campbell, A. (n.d.). Midwifery Licensure Restricts Women's Birth Choices. Birth Services. https://www.birthservices.net/news/52-midwifery-licensure-restricts-women-s-birth-choices

Department of Pediatrics (June, 2016). Lotus Birth/Umbilical Non- Severance: What to Expect. Michigan Medicine | University of Michigan. 

MacDorman, M. F., & Declercq, E. (June, 2019). Trends and state variations in out-of-hospital births in the United States, 2004-2017. Birth (Berkeley, Calif.). 46(2), 279–288. https://doi.org/10.1111/birt.12411

Mendoza, M. (2002, November 25). Midwives At Center Of Controversy. CBS News. Retrieved May 27, 2022, from https://www.cbsnews.com/news/midwives-at-center-of-controversy/

“Midwife.” Merriam-Webster.com Dictionary, Merriam-Webster, 

https://www.merriam-webster.com/dictionary/midwife. Accessed 20 May. 2022.

Paciornik, C., & Paciornik, M. (Directors). (1979). Birth in the squatting position [Film]. Polymorph Films.

Roberts, J. E. (2002, January-February). The “push” for evidence: Management of the second stage. J Midwifery Womens Health, 47(1), 2-15. doi: 10.1016/s1526-9523(01)00233-1. 

Rooks, J. P. (2012, May 30). The history of midwifery. Our Bodies Ourselves. https://www.ourbodiesourselves.org/book-excerpts/health-article/history-of-midwifery/

Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, 

MANA, and NACPM. (2013). The Journal of perinatal education, 22(1), 14–18. https://doi.org/10.1891/1058-1243.22.1.14

van Teijlingen, E. R. (2017). Editorial: The medical and social model of childbirth. Kontaki, 19(2), e73-e74. DOI: 10.1016/j.kontakt.2017.03.001