March 29, 2008

Childbirth and Choices

WHILE THE FEMINIST movement may have focused more on the right to abortion than other reproductive rights, there is a growing acknowledgment in the US and elsewhere that women’s right to safe, natural childbirth is being severely threatened by the imposition of the medical model. In the medical system, pregnant women are treated as ‘sick’ and childbirth as a dangerous event deserving of any and all intervention designed to make the process as ‘safe’ as possible. A spate of blogs and books written by moms, midwives and other reproductive health advocates indicates that women aren’t taking this lying down. (Pun intended–research has shown that giving birth while lying on one’s back is detrimental to the labouring woman). A couple of books are: “Birth: The Surprising History of How We Are Born” by Tina Cassidy (see her blog here), and “Pushed: The Painful Truth About Childbirth and Modern Maternity Care” by Jennifer Block. On the movie front, there’s Ricki Lake’s “The Business of Being Born,” “Home Delivery,” and “What Babies Want.”

Ironically, in this time where the use of technology is at an all time high, maternal mortality rates in the US are also abysmally high largely due to the increase in c-sections. Not only are women questioning births attended by doctors, but by midwives or any trained person. To quote an excerpt from “Pushed”:

Unassisted birth isn’t new. In the 1960s and 1970s it was often the only alternative to a hospital birth—a strapped down, separated from husband, guaranteed episiotomy birth—and the women who did it also gave birth to organized midwifery. “That’s what we were doing in the 1970s before there were any midwives,” says Peggy O’Mara, editor of Mothering. “It was part of the whole back-to-land movement and commune movement.” It was also a natural extension of the early feminist, grab-a-speculum-and-mirror-and-reclaim-your-body ethos, she said. “And I consider it a really legitimate response to certain environments. Where I lived in southern New Mexico, for instance, the choices were so poor that we just wanted to figure it out ourselves.”…For O’Mara, unassisted birth was the best women could do under the circumstances.

Until recently, most women in India had homebirths, usually assisted by a dai (traditional midwife) or other woman experienced in childbirth. But now, urban middle-class women are expected to birth in hospitals and the rate for c-sections among this strata is virtually the same as that of the industrialised countries. Still, dais do deliver 70% of India’s babies, given the fact that the same percentage of the population is rural. Yet the role of dais is ever-changing due to the state’s insistence upon training in medical standards of care, and their traditional knowledge is not respected (see the book “Birthing with Dignity” by Diane Smith and Jagori). has just published the story of Reba Daniel, who chose to give birth with only her husband present. Unassisted birth must happen all the time here to women who don’t have other options. But this is the first story I’ve found where an educated, professional woman did this of her own accord. Equally as impressive is that the article’s author is appreciative, and not critical, of the mother’s choice, since that is not how unassisted childbirth is being portrayed in Western media. The website Ms. Daniel got her idea from is here:

Yes, it is true that India has the highest rate of maternal mortality in the world, the main reasons being poverty, hunger and disease. But to those women who are physically fit and considering a hospitalised birth, I ask: why not give a thought to unassisted childbirth or homebirth with a dai?

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18 comments to Childbirth and Choices

  • Becky, while I agree in principle that childbirth ought not to be so medically invasive, and am whole-heartedly with you on the ‘we are not sick; just pregnant’ bit, I’m wondering how this back to basics approach would deal with medical complications if one didn’t do the hospital thing.

    I had a c-sec because my son was a breech baby. The hospital where I went to didn’t have these folks they now have for turning the baby in utero (and it still might not have worked had they had the people even then).

    Most doctors don’t take you on if you don’t go to them at least by the second trimester. It’ s a racket (the tests and medication that they so freely prescribe). But if you don’t, you might not know if there is a problem.

  • ggop

    Most midwives will rush you to a hospital if they perceive complications necessitating surgery. In rural India that may be a challenge.

  • Hmm, I’m not as sure as these people seem to be.

    For one, traditional knowledge isn’t necessarily accurate, so I’m very glad dais have to keep updating their knowledge.

    Secondly, is there any scientific research to show the safety of home-births versus hospital births? Surely, you would need medical screening to determine if a home-birth is safe for a particular mother?

    C-sections seem to me to be a totally different matter. We need to know more about the reasons for an increase in these. In some Indian hospitals, C-sections are, deplorably, solutions to administrative problems.

  • I want to bring attention to the other ‘courageous’ thing REba has done. The NewInd Express has also reported that Reba wouldn’t be vaccinating her kid!

    “We have decided not to give any vaccination to our daughter. She is healthy now and we are sure that she will acquire the necessary immunity without vaccination,” said Reba.”

    In my opinion, that is entirely unwise. Hope they haven’t been reading the wrong kind of blogs which link vaccines and autism and such.

  • Thanks for all your comments.

    Space Bar, I have read of several cases where women have delivered breech babies on their own. Laura Shanley, who started the UC site did this (, as did Dr. Sarah Buckley, (

    This indicates that a lot of what the medical community perceives as ‘complications’ can usually be resolved if the mother has full faith in her abilities to give birth.

    There have been studies, especially in the UK, which indicate that homebirth is as safe, even at times MORE safe, than hospital birth. As Reba Daniel’s story shows, many times people pick up infections in hospitals to which they would not be exposed at home. See this page on “Is UC safe?”

    “One of the greatest myths perpetuated by the medical system is that hospitals are the safest place to give birth. Stories abound of women dying in childbirth before the advent of modern hospitals. And yet, few people realize that women were not dying due to the fact that childbirth is inherently dangerous, but rather because of the living conditions at that time.”

    Admittedly, the issues are much bigger than my short post could address. I recommend you to go to the sites I’ve mentioned, where much more information is available. Most women who choose to do UC research extensively before taking this important decision, and to inform themselves on possible risks and complications. Furthermore, they take full responsibility for the outcomes, rather than relying on an outer authority.

    Why is it that when it comes to our bodies, we would rather believe what a doctor is telling us than listen to what our body is telling us?

    Research may not make UCers experts in birth, but it would at least give them the confidence to know that they will do what’s best when the time comes. Much of the decision to UC relies on faith in the higher intelligence/god/spirit: that which knows how to create a human from the union of an egg and sperm knows how to complete the process. Many proponents of natural childbirth believe that our human interventions merely interfere with this process. I find Dr. Buckley’s research on the hormones of birth ( to be especially persuasive in this regard.

    We need to keep in mind that women have been giving birth for millions of years without medical interventions. Indeed, it is only really in the past 100 years that such interventions have become more normalised. We must inquire into why this is the case–and, more importantly, strive to understand how women were, and still are, able to do this on their own.

  • Just some further thoughts after discussing with my partner 🙂

    It turns out he was born unassisted! I had thought there was a dai present, but he just came out too fast. This was in 1981 in the fairly large city of Rajgarh in Rajasthan. Turns out many of his cousins were born this way, as were most of his other relatives.

    He also pointed out how women give birth all the time on trains, as did the now famous woman whose baby fell through the toilet. Also, did you read this week’s story of the teenager who didn’t realise she was pregnant?

    These stories beautifully illustrate how, when birth is unimpeded, it just happens. When there is no fear surrounding it, or no way to opt out, birth simply takes its course.

  • mom

    Scientific research to show the safety of home births versus hospital births:

  • I would strongly recommend reading Henci Goer’s site and book for research based evidence about the safety of homebirth.
    [url] www,[/url]

    Also, there are links to studies on Gentlebirth about the safety of home birthas well:

    Once the safety of home birth is established, we can have a better discussion but it is hard to change a frame of mind, because that is what UC is about. It is not just a choice after evaluating pros and cons, it is also a deep conviction, a view and way of life. That is hard to convey. For most the chances that something goes wrong in a UC in a fatal is so miniscule, it is no warrant to have managed care. Intervention is the number one reason for things going wrong in birth. I would also recommend reading stuff from Michael Odent [url][/url]

    Also, to establish if someone is healthy enough for a home birth is no hocus pocus. People can have an initial blood test if they want, but otherwise urine and blood pressure check is what midwives do. Most women do their own prenatals and keep track of their records. Most women choosing UC are intimately in tune with themselves and will be able to feel/inwardly know when something is wrong too and go from there. UC is not about not seeking help when needed.


  • I am a mother who has given birth 5 times at home and 4 times unassisted. There is too much to say about all the choices in birth to leave such a comment here. That is why women need to study for themselves and then seek God’s direction for their individual needs and birth decisions.

    I will say that in the book, “Three Cups of Tea,” about an American man who primarily builds schools in Pakistan, there is an example that is pertinent to this article.

    I don’t have the book in front of me, so going by memory, this man’s organization assists villages per their needs. In one village they had no running water. There were many deaths, many childbirth related infant and maternal. The assistance they gave this village was running water as well as basic first aid medical supplies which were placed in the care of one woman who was not a doctor nor medically trained. (I believe they may have done other things to help the villagers be able to improve themselves economically.) In the following 5 years there were NO deaths in the village.

    To me this means that birth is safe, and that sanitation, education and basic first aid improves birth outcomes. Medical assistance can be necessary at times, but for the majority of women homebirth is safe and women deserve the right and the information and support to choose for themselves.

  • Interesting thoughts. Three of my cousins were born at home, and they are all thriving. But, like Space Bar, I agree with the I’m-pregnant-not-sick part, but cannot even consider not going to a gynecologist for check-up and delivery.

    Ttraditional knowledge is not always accurate. Just as an example, my grandmothers and their grandmothers absolutely forbid eating gooseberries (amla or nellikaayi as we call them), guavas and sometimes even bananas and tender coconut during pregnancy and for a couple of months after the baby is born. I find this most ridiculous. Of course, there are many sensible practices that ought to be followed, but we really need to be sensible enough to reject the stuff that is absolute hogwash.

    C-sections are – well, different. There are many people who consider it a minor surgery, and that it is safer for both the mother and the baby to be delivered this way! (My MIL is one, she had both her deliveries through C-section). I was initially influenced by her, and actually asked my gynecologist to do a C-section on me without even attempting a normal delivery! After a lot of counselling and reprimanding from my gynecologist, I had a normal delivery and am darned happy about it.

    The solution, IMO, is to find a middle-ground. As long as there are no complications and a trained person available to intervene in case there is one, home-births should be fine.

  • Some other information on the safety of homebirth:

    Henci Goer’s site and book has research based evidence about the safety of homebirth:

    Also, there are links to studies on Homebirth Safety/Advocacy here:

  • Let’s put this in perspective. All this stuff about “faith in the higher intelligence / god / spirit” is so much superstition, as are opinions based on anecdotal evidence from news stories and personal accounts that are fraught with retrospective bias. Talking about individual cases where women gave birth at home unassisted is silly because we’re talking about risks that are low probability but high impact (overall mortality rates in the UK population are around 0.7 in a 1000). So saying women don’t need hospitals because look, so-and-so had a baby at home and nothing happened to her is a bit like saying you don’t need to wear a seatbelt because I’ve driven without one sometimes and nothing happened to me.

    Personally, I think the best summary comes from the editorial of a 1996 special issue of the BMJ on home births:

    “General practitioners and midwives have responsibility for creating the right circumstances for safe and satisfying home births. This means, firstly, selecting women who are not at high risk of complications; secondly, establishing an infrastructure for safe obstetric interventions–such as providing elevated beds and ensuring adequate hygiene; thirdly, providing support during labour and in the days after delivery, for which maternity home care assistants are important; and, finally, allowing access to hospital facilities–this is vital, as serious complications during labour can never be excluded. Transfer during labour can be safe,6 7 but safety must not be assumed, and the availability of obstetric care must be established beforehand. Coordinated planning between primary care practitioners and obstetricians is crucial, and much will depend on local conditions: hospital facilities are usually available within 15 minutes in densely populated Holland, but transfer will take much longer in remote areas of North America and Australia. Such variation underlines the importance of comprehensive care for pregnant women. This should focus on patients’ individual needs, based on a proper assessment of risk and local circumstances, rather than simply accommodating patients’ demands.”

    So: home birth may be an equivalent (not necessarily better) option for low-risk women (assuming low-risk is competently assessed) with adequate home conditions and rapid access to hospitals, who are attended by trained professionals (a category in which, I, for one, would not include dais).

    I’m not aware of any research that scientifically examines the health outcomes of planned home births in the Indian context, and I’m not sure such a study would be feasible given the selection effects involved (though it would be worth trying, certainly). Extrapolating from studies in developed nations context is problematic, given that they’re really talking about a very different paradigm of ‘home birth’, but even if we are generalizing from such studies it’s clear that an unbiased look at the research suggests that home birth is only a safe alternative in selected cases and assuming appropriate safety conditions are met – advocating home birth without consideration of those contingencies is just plain irresponsible.

  • Hi Falstaff-
    Thanks for your comments. I note that the study you refer to is from 1996–surely things have changed a bit since then! Did you see the link in the comments to the BMJ article from 2005 on ‘Outcomes of planned home births with certified professional midwives: large prospective study in North America’? I also suggest you read the link to Dr. Sarah Buckley’s research on the hormones of birth.

    Whether or not you think I am irresponsible for my views, I also think it is irresponsible for people to wholly rely on doctors, who are as fallible as we are. Admittedly, the question I posed of why we are more willing to give doctors authority rather than our own instincts is too big to broach here. But the unquestioned assumption that birth must neccessarily be safer just because trained professionals are present really needs to be examined in my view.

    It’s funny to me that you mention ‘opinions based on anecdotal evidence from news stories and personal accounts’. What about the countless women whose unassisted birth stories have gone untold, because there was nothing remarkable about them? If you call faith superstition, then perhaps you believe in science, which in any case is largely behind the theory of evolution. Women’s bodies are designed to give birth, and certainly have done so for millions of years before current obstetric practices were invented to ‘facilitate’ this process.

    It is with sadness that I am bringing up a recent death in my extended family here due to repeat c-section, and I link this to the following study:

    Rixa ( ) also directs us to a study showing that repeated Vaginal Birth After Cesarean (VBACs) become safer and more successful, though this is is not the current medical norm. The link is:

    I digress away from the discussion on the safety of homebirth/unassisted birth because I think it is crucial that we evaluate our deep-held beliefs that 1) birth is always a dangerous process, and 2) hospitals and doctors automatically make birth safer.

    Lastly, I want to direct you to a long passage from a book called “The Power of Pleasurable Childbirth” by Laurie Morgan posted here:

    “Life itself is dangerous it’s true, and sometimes unfortunate things happen to perfectly good people. But just as healthy people would not take up residence in a hospital for fear of dying, it is insane to approach childbirth – a normal, healthy function of the female anatomy – with the focus on pre-empting disaster.

    Our normal bodily functions are absolutely not made safer by monitoring and interference. Even the mere observation, or subtlest alterations, of childbirth processes have the potential to adversely affect the intricate organic symphony that plays out best in privacy and security. But childbirth itself – when it is naturally free from obstruction — is as trustworthy as breathing. Eventually we all must come to terms with our human frailty, but the fact that tragedies exist must not be accepted as an excuse for the blind application of unnecessary “safety measures” that actually cause harm. Giving birth unassisted is a responsible, safe thing to do for all but the microscopic percentage of women that have such serious medical conditions as to make even everyday activities a challenge…

    We “mere mothers” are smart. Not only that, but by sheer virtue of our anatomies, women are the preeminent experts of our own bodily functions. Having previously been discouraged from taking up that role does not change the facts: women are created able to give birth without any assistance at all. We mustn’t be afraid to shout this truth from the mountain tops. If women can be trusted to care for their bodies during pregnancy and then to nurture their offspring until maturity, women can surely be trusted to make the right choices in childbirth, even if that means choosing to give birth unsupervised.”

  • Becky:

    a) No, things haven’t changed in the last 12 years. Or if they have they’ve only got worse. An April 2008 study of booked home births in England and Wales in the BJOG finds some evidence of an increase in IPPM rates over the 1993-2004 period – this while the overall IPPM rates for the population were improving. Commentators have linked this increase to a paucity of trained midwives.

    b) Yes, I’ve read the 2005 study. Did you notice that it’s a study only of ‘low-risk’ women, and systematically excludes high risk mothers from its sample? Did you also notice that 12.1% of the women in their sample who planned to give birth at home eventually had to be transferred to hospital? And did you notice that their sample consisted of home births attended by “certified professional midwives”? What the study says therefore, is that home births have comparable outcomes to hospital births for low-risk women who can be safely and quickly transfered to hospital in case things go wrong and where the home births are attended by trained professionals. Which is what I was saying in my comment. Any other conclusion from that study is your own, and potentially false.

    c) As I’ve already said, the “thousands of women who’ve given birth unassisted” point is irrelevant. If the probability of complications is a fraction of 1% then obviously thousands of women will and could give birth unassisted – no one is disputing that. The question is whether giving birth at home increases the probability of an adverse health outcome significantly. In the BJOG study, IPPM rates for women who planned home births and needed to be transferred are 5 to 9 times as high as those for the overall population. They’re still under 1%, so the vast majority of women who had to be transferred to hospital during home birth came through safely, but they were at 5 to 9 times higher risk of losing their children as the general population (admittedly there are some selection issues that the study doesn’t control for, which is why I didn’t link to it the first time around, but still, it’s something to think about).

    d) You say “the unquestioned assumption that birth must neccessarily be safer just because trained professionals are present really needs to be examined in my view.” Okay. How do you propose we do that? Nothing in your post suggests to me that that is not true (I’m still trying to figure out the point of the Laurie Morgan post – so someone wrote a nicely worded blog post. Big deal. As for the c-section article, it’s not comparing morbidity rates for home births at all, is it, so how does that help?). The only way to test that assumption would be to randomly assign women to condition where they gave birth without trained professionals and compare their health outcomes to a control group who were attended by trained professionals. I can’t imagine any ethics committee in the world okaying a study like that.

    As I’ve said before, I’d love to see a scientific study comparing health outcomes of planned home births in India to hospital births. I’d also love to see a study that compared the health outcomes of high-risk women who chose to have home births without a professional present to those who had their children in hospital. Until we have such studies (and I doubt we ever will, because of the ethics issues involved) let’s be clear that the only scientifically valid conclusion we have is that home births are no riskier for low-risk women when attended by trained professionals and where transfers to a hospital are possible.

    If you’re claiming more than that – and you are – you need to provide evidence that the risks to mother and child – however miniscule – are not going to go up. Or you need to argue that even if the risks do go up the additional risk is worth it. In either case you need to stop pretending that the research supports any conclusion more than the one outlined above. You want to make a sentimental case for unassisted home births, fine. Let’s be clear that there is no research to support the view that unassisted home births are, in all cases, as safe as hospital births. Nor is there any research to suggest that hospital births have worse outcomes than unassisted home births.

  • Indhu Subramaniam

    advocating home births in the Indian context with a maternal mortality rate of 540 and around 619 in rural areas per 100,000 deliveries is a rather difficult one. the reasons for hight maternal mortality has been attributed to excessive bleeding and other causes which are preventable if there had been timely and adequate access to health services. my paternal grandmother went through 11 pregnancies and 8 children survived. My maternal grandmother went through 12 pregnancies and 9 children survived. all were home deliveries. which is roughly a success rate of around 72-75% now with the two child and one child norm, am not sure how this will extrapolate. I have also heard enough stories of their contemporaries having died in childbirth. it was touch and go and fate for many of them and it is so even today for so many others. even in the middle class today, albeit being fit, there are hardly any safe ways of unassisted birth.

  • Sowmya

    A nice line of thought, agreed.

    But I am not gutsy enough to explore an unassisted birth. While I agree that I dont want to be treated ‘sick’, nor do I want to get periodic checks done, I still feel that I am safe when I have a doctor (with all scary gadgets, of course) attending on me when I am ‘pushing’.

    And about the supine position during labour, never knew all these things! I felt comfortable as they propped a couple of pillows beneath my back on the labour table.

    But I will have to thank you for one thing – I had after my daughter (normal delivery), decided to avoid a normal delivery and have a planned c-section. I have doubts about it now. I am not pregnant yet, but I think when I have my next one, I would brave myself up for a normal delivery again, unless complications arise!

  • “This indicates that a lot of what the medical community perceives as ‘complications’ can usually be resolved if the mother has full faith in her abilities to give birth.”

    Erm. I find myself rather disturbed by the way you’ve framed this statement. If a breach birth does turn out to be a serious complication for a woman giving birth at home, are we to assume that it was her fault for having insufficient belief in her ability to give bith perfectly?

    I realise this probably sounds rather petty and nitpicky. But words matter, and while I’m in favour of people choosing natural childbirth (as I’m in favour of people choosing anything related to their bodies) I feel that a tone of judgement has come into this debate (wherever I’ve encountered it) that implies that “natural” childbirth is somehow morally superior to medically assisted childbirth. That women should be/are just inherently able to give birth and if things go wrong they’re just not trying hard enough. Which is precisely the sort of thing feminism tries to avoid.

  • Just wanted to share this awesome video of a breech birth:

    Aishwarya, I appreciate your comment. Of course I don’t mean to blame women in any way. So I’ll just say that, especially in reference to this video/post on breech birth, that a lot of what the medical community perceives as ‘complications’ are not necessarily so.

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