Sarah Dixon was advised to have an elective Cesarean with her fourth child after a complicated labor with her third had left the baby without oxygen for 22 minutes. The now-49-year-old from Surrey, England, was nervous about raising the idea with the consultant obstetrician who’d delivered her three children, concerned that he might label her “too posh to push.” But her doctor’s reaction was disquieting in a way she hadn’t expected.
“I said: ‘What do you think?’ and he said to me: ‘Well it makes sense, doesn’t it? Because, let's face it, it's like pushing a melon out of a toothpaste tube, who would want to do that?’” she recalls. “He went on to say: 'And you know why women have to do that?…It's god's punishment for Eve eating the apple.’”
This is, without a doubt, an unusual viewpoint for a medical professional to hold. It nonetheless hints at a social and moral currency attached to enduring the pain of birth without painkillers. Women in developed countries who choose to give birth "naturally" are often praised, suggesting this birth experience is somehow more respectable than those who opt for an epidural or other medical intervention. “Our societies have a high degree of importance that we place on maternal sacrifice, and a kind of martyrdom that goes with being a mother,” says Anna Smajdor, associate professor of practical philosophy at the University of Oslo. “It's a badge of honor to show that you’re suffering, that you’re sacrificing yourself as a mother.”
Smajdor studies how artificial womb technology (also known as ectogenesis) could one day change our attitudes toward pregnancy and childbirth. In that context, any birth from a biological womb rather than a synthetic one could be considered natural. But for women living in 2018, wanting to deliver “naturally” usually means having a vaginal birth rather than a C-section, and having no pain-relief drugs during labor whatsoever.
Because Western women have more understanding of and control over their fertility than ever before, we might expect pain relief or interventions that make the experience of childbirth more predictable (like an epidural or the much rarer choice of a planned Cesarean) to be more sought after. However, more and more American women are choosing to have their babies delivered by a midwife instead of an obstetrician (8.8 percent in 2016 versus 3 percent in 1989), a process which tends to lead to a slower labor with fewer interventions. A 2016 literature review by the Cochrane Library, which examined studies involving a total of 17,674 moms, found that women who received midwife-led care in a hospital setting were less likely to have an epidural, episiotomy, induction, or delivery by forceps.
“There’s quite an interesting spectrum of what women will identify as natural,” says Julie Jomeen, professor of midwifery at Hull University, England. “For some women, a natural birth will be absolutely no drug intervention, that they've dealt with all that pain by alternative methods.” This wish, she adds, is often driven by an eagerness to “make sure there's nothing going into the body that is going to potentially have any effect on the baby,” though she emphasizes risk from synthetic pain relief is still “relatively minimal.”
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Other women’s desire to avoid pain relief such as an epidural stems from the belief that it may prolong labor (developing research suggests that this isn't necessarily the case) or from a more philosophical place. “An important driver for some women is the desire to really feel the whole experience, to really be connected to that very primal experience of birth,” Jomeen explains.
However, she is eager to dispel the notion that a birth that involves pain relief and medical or surgical interventions should be seen as an inferior outcome for mother or baby. “What I’d never want to do is to diminish the experience of women who've ended up with some kind of intervention, because actually the important thing here is [natural birthing] doesn't make you a better mother,” she says. “There is something about it being tied up with the sociological discourse of good mothering.”
The movement in favor of natural birthing first emerged in the 1960s and '70s; prior to this, natural versus medicalized birth hadn’t been the all-or-nothing binary we see today. “It was really when second-wave feminists latched on to the idea of birth as a site for feminist empowerment and for liberating women's bodies from the surveillance of male obstetricians that the line between natural and medical birth hardened,” explains Paula Michaels, associate professor of history at Monash University in Melbourne, Australia.
Momentum of this movement slowed towards the end of the 20th century. This was partially a result of third-wave feminism, says Jacqueline Wolf, professor of the history of medicine at Ohio University. “The circumstances of women's lives changed. In the 1970s, women were agitating for their rights and trying to prove their strength and power—and one way they did that was through natural childbirth,” she explains. “Twenty-five years later, women were saying, 'I don't need to prove anything and I want birth to be made as easy as possible.’”
But that didn’t last either. “I think now we are seeing a reversal of that attitude,” Wolf tells me. “There are two medical specialties that are affected by culture and society, and I think very much one is plastic surgery and the other is obstetrics.”
The new natural birthing movement that began in the 1990s and continued into the 2000s was primarily populated by white middle class women, says Alicia Bonaparte, associate professor of sociology at Pitzer College in Claremont, California. “Natural births tend to occur within racialized and class lines, which means that many poor women and women of color do not have the ability to advocate for a natural birth,” she explains. Bonaparte says that marginalized women's pregnancies are "pathologized," meaning that their reactions to the natural processes of birth are often treated as abnormal. This can result in a "push for medical interventions, which can lead to birthing complications."
While the most recently available CDC data in 2016 showed that black women are more likely to have induction of labor or a C-section (even when the pregnancy is low-risk), black moms are also less likely to receive pain relief. Bonaparte, co-editor of Birthing Justice: Black Women, Pregnancy, and Childbirth, says that these differences in care can result from “intended and unintended racial biases” and points out that “inequities in pain-relief solutions for women of color persist beyond just during labor.” A 2016 study published in PLOS One found that black emergency room patients were around half as likely to be offered pain meds as white patients.
The likelihood that a woman will have a "natural" birth—in any of the forms that might take—is also affected by individual healthcare providers, and the care system in which they operate. The American structure of healthcare in particular incentivizes unnecessary C-sections, argues Wolf, who is also the author of Cesarean Section: An American History of Risk, Technology, and Consequence. “Doctors are paid much better for doing the Cesarean section than for attending a natural birth in private health insurance,” she explains. “There's a big financial incentive to do a Cesarean section—hospitals also get paid a lot more.” Wolf says that this, in turn, impacts the training obstetricians receive, biasing them even further towards surgery.
In fact, in 2016, a study by the American Economic Association found that women with medical degrees were 10 percent less likely to undergo a C-section than other mothers, but that this disparity disappeared in HMO-owned hospitals, where financial incentives don’t come into play. Conversely, in the United Kingdom (where the C-section rate is 27.8 percent compared with the US’s 31.9 percent), coroner Andrew Walker accused the National Health Service of deliberately rationing C-section deliveries in 2015, when a baby died after her mother was forced to have a vaginal delivery—which costs the NHS half as much as a Cesarean.
While midwifery is making a comeback in the US, midwife-led deliveries are standard practice in UK hospitals, pushing natural birth to the fore. Last year, however, the UK’s Royal College of Midwives announced its intention to drop its ‘Campaign For Normal Birth’ after the campaign was criticized during an inquiry into the deaths of 16 babies and three mothers at a hospital in Cumbria over a period of nine years.
Jessica Green, 25, gave birth in an NHS hospital in England last year and was discouraged by her midwife from having artificial pain relief, despite asking for an epidural in advance. “When she realized I’d got to seven centimeters [dilated] without anything, she laughed at the idea of an epidural, saying I was far too strong to need one,” she tells me. “It was mentally boosting to hear that, but physically I couldn’t have cared less what they injected into me if it took away the pain, strong or not.”
In Jessica’s case, nitrous oxide (laughing gas, commonly used as mild pain relief for birth in the UK) alone “really didn’t cut it.” She adds: “For me I think the biggest emphasis was placed on natural birthing for the ease of the midwives and doctors being able to follow exactly where you were in your labour, which I understood, but I remain incredibly frustrated that I was made to wait for such an extensive amount of time for pain relief.”
Simply admitting that you don’t want to face the difficulty and pain of pregnancy and childbirth can in itself be taboo. After writing on the artificial womb, Smajdor discovered just how strong a reaction can be provoked by questioning the importance of natural childbirth.
“When I published my papers on ectogenesis, I had large amounts of hate mail from right across the spectrum—hate mail from the outright [misogynist] types, hate mail from feminists, hate mail from almost everyone,” she recalls. “It seems that when you challenge or threaten this very, very deep-seated idea about a woman's role, about the beauty and value of natural childbirth and motherhood, you stir up some extremely passionate and aggressive responses in people.”
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