In pain and sorrow: childbirth, incarnation, and the suffering of women.

About ten years ago, I gave birth to a ten-pound, two-ounce baby boy after a long day and an even longer night of labor. The labor was obstructed: not only was he huge, he was turned sideways, and had absolutely no intention of entering the world in the way of most babies. The midwife spent hours instructing me in various techniques and positions that were supposed to help shift the baby's position and get him moving, but nothing worked. In the end, the obstetrician was called and Thomas was safely delivered via C-section. Aside from a relatively small scar, I emerged from the experience physically unscathed.

Yet it was weeks--perhaps months--before I could talk about Thomas's birth without sobbing uncontrollably: the experience of being in such pain for so long, and the lingering terror that it would have gone on and on and on--perhaps until my death--if I did not live in a time and a place where surgical intervention was possible, had left a part of me completely undone. But as it happened, of course, I was fine, and Thomas was fine, and that was the end of it.

Until, that is, I read about what really happens in obstructed labor when surgery is unavailable. I had always assumed, of course, that the mother dies--that I would have died. In fact, the reality of obstructed labor and its aftermath is far worse than that. Such labors can go on for days, even up to week (which is, to put it mildly, an absolutely terrifying amount of time). The baby usually dies after the first few days, but is only born much later, when the mother's body has been so injured by the unrelenting pressure of the child's body pushing against hers--resulting in a good bit of her living skin and muscle and tissue dying from lack of blood flow--that her body rips apart and frees the dead child at long last. In the best case scenario, the tear opens her bladder and she is left incontinent, unable to contain a constant flow of urine. In the worst case, the tear opens not only her bladder but her rectum, and both feces and urine spill forth from her body in a relentless, unstoppable flow that--without surgical repair--will last for the rest of her life. Some women also have nerve damage and find themselves unable to move their legs properly, or at all. So: a child born dead, grievous untended internal injuries, filth, stench, perhaps even paralysis. Of course, this is only the beginning: who would live with such a creature? She smells, she cannot keep herself clean or dry, she is not fit for society and barely fit for work. Her husband leaves her. The other women of the village shun her. Her child is dead. She is in the words of Dr. Catherine Hamlin, a surgeon who has dedicated her life to the repair of obstetric fistulae in Ethiopia, "abandoned to her shame ... [and] spends the rest of her life in misery." (1)

This is the fate of some 100,000 women a year--or girls, really, since it is usually young mothers, perhaps fourteen or fifteen years old, bearing their first child, who suffer fistula. The United Nations estimates that up to two million women in the developing world are living with fistula--a nearly unimaginable living death. Clearly this is a public health disaster of the highest order: it is a medical problem, a problem of poverty and access to health care. It is also a political problem, having to do with government priorities, distribution of scarce resources, and unintended consequences of supposedly unrelated policies, like agricultural subsidies in the First World that destroy the farming economies of the Third World. Surely it is also a problem rooted in sexism, in the patriarchy that marks so many societies and makes women and women's health of such small value.

But it is also a theological problem, one with roots deep within our understanding of both incarnation and salvation--indeed, deep within the fundamental story Christians tell about the history of God's relationship to humanity. The destruction of women's bodies and their lives through obstetric fistula and its social consequences is deeply colored by our Christian assessment of the value of women's bodies and the importance (even, perhaps, the necessity) of women's suffering. The Christian understanding of human bodies is of course deeply linked to our understanding of the Incarnation, the event in which God took on a human body in Jesus; it is also true that how Christians understand physical suffering is driven by our understanding of sin and redemption, especially with respect to the suffering of Christ during his Passion. Finally, how we think about women and suffering (especially in childbirth) carries us straight back to Eve, and the idea that the Incarnation was necessary only because of her sin--and that she and all her descendents will be punished for her crime by bearing children in great pain.

Is fistula, then, simply an extreme version of the punishment of Eve? Do we see in the faces of these suffering girls and women the face of evil, of pride, of the destruction of Paradise? "Because of you, even the son of God had to die," Tertullian once said of women. In such a world-view, fistula is simply part of the just punishment handed out by God to sinful women. Surely not many would dare say that today to a young girl whose life has been devastated by fistula ... but our current theology of incarnation does in fact still point us in that direction--and in the twenty-first century we can no longer claim ignorance or innocence if we choose to continue to live within a destructive and sexist formulation of a central doctrine of Christian faith. Fortunately, our tradition contains within it an alternative understanding of incarnation that emphasizes not women's sin but God's original and ongoing love for humanity. Accordingly, I believe that we are called today to jettison our long-standing but destructive understanding of incarnation as a response to sin, especially women's sin, and return to the other ancient tradition of seeing incarnation as part of God's ongoing plan of revelation. It is only by making this choice--and it is a dramatic one, one that fundamentally reshapes our understanding of the relationship between humanity and God--that our theology will be able to respond in justice and with the Good News of Christ for the women whose lives have been devastated by fistula.

Childbirth in Christian tradition 

Before specifically addressing incarnation, I want to discuss the traditional Christian understanding of the pains of childbirth. These two things are linked of course by the story of Eve: both pain in childbirth and the Incarnation are said to be a direct result of her sin, the first as punishment and the second as the first step in God's forgiveness and redemption of the whole human race.

The pain of childbirth has been seen to require some sort of explanation since ancient times. It is a puzzle, of course--why should the necessary human activity of giving birth be such a painful and harmful and sometimes even deadly experience? Eating does not hurt; breathing does not hurt; most human activities necessary to life only hurt if something is terribly wrong. Animals give birth far more easily than human beings, and that fact would surely have been noted as soon as domesticated animals became a part of human communities. Why do women suffer so? Clearly the pain of childbirth is a mystery--and like all mysteries, especially those having to do with life and death, the best explanation available to our earliest thinkers was that this must have something to do with God. Given the ancient assumptions that God actively controls our fate and that good things happen to good people and bad things only happen to those who invite punishment by some sort of crime against God, it makes a sad sort of sense that our earliest understanding of the pain of childbirth is that women must have somehow deserved it. A just God could not possibly inflict such suffering on the innocent--and so women's guilt, as a class, as an entire sex, is proven by their suffering.

Theodicies of this type, which defend God's justice by blaming victims for their fate, are remarkably persistent even today (there are those who, for example, think that New Orleans was destroyed by Hurricane Katrina because of its sinfulness). However, the theological struggle against this type of thinking goes back at least to the book of Job. Christian theology has long recognized that the suffering of the innocent does in fact exist, and must be accounted for, or at least given meaning (hence the idea that our suffering participates in Christ's, or that it can be "offered up" on behalf of others). Yet in the case of childbirth, the possibility of innocent suffering was never seriously considered. Scripture was absolutely clear on this point: the pains of childbirth are punishment for sin, period. Moreover, since Scripture so explicitly connects the pains of childbirth to the crime of Eve--which allowed sin to enter the world, destroyed the perfection of humanity, and forced God to allow the brutal murder of his only Son in order to offer us forgiveness--given all this, it is not surprising that there was not much room theologically for sympathy for a woman in labor.

Further, the deep theological connection between women's pain in childbirth and the whole narrative of Christian salvation meant that there was a sacred dimension to this pain: it was decreed by God from the beginning of time, and marked out women forever as the guilty ones, the broken ones, the ones who caused the whole mess in which we live. It is no wonder that many Christian clergy in the 19th century opposed the newfound medical ability to offer women pain relief during childbirth; it is no wonder that in 17th-century France, women were taught prayers like this:

  In my confinement, strengthen my heart to endure the pains that come
  therewith, and let me accept them as the consequence of your judgment
  upon our sex, for the sin of the first woman, In view of that curse,
  and of my own offenses in marriage, may I suffer the cruelest pangs
  with joy, and may I join them with the sufferings of your Son upon
  the cross, in the midst of which He engendered me into eternal life.
  Never can they be as harsh as I deserve, for although holy matrimony
  has made my conception legitimate, I confess that concupiscence
  mingled its venom therewith and that it has urged me to commit faults
  which displease you. If it be your will that I die in my confinement,
  may I adore it, bless it, and submit to it. (2)

Such prayers have no place in the delivery rooms of Christian mothers today; indeed, the sentiments expressed in the prayer would shock most Western Christian women. In childbirth classes today, women are often taught that the pain of labor is "good pain": it is an indication of how hard their bodies are working to do something incredibly difficult. On the other hand, evolutionary biologists tell us that most mammals give birth without nearly as much difficulty and pain as human beings, who suffer as a result of the mismatch between our large brains and the pelvic design required to enable us to walk upright. The pain is merely the consequence of an evolutionary compromise, and carries with it no inherent valuation, neither good nor bad. Both of these explanations stand in stark contrast to traditional Christian teaching: it would appear that acceptance of either would mean, in the end, rejection of the entire Christian narrative of salvation.

Yet clearly that is not what is going on: it is not only secular mothers who ask for epidurals during labor, but pious Christian women as well. Christian women as a class do not refuse pain relief in labor on religious grounds (3) (although some refuse out of concern about the effects of the drugs on the child)--and this is not a sign of their ignorance of tradition not of their sinful rejection of the just teachings of the Church. Instead, I will argue that it is perfectly possible to reject the mythological understanding of the origins of painful childbirth and its accompanying understanding of sin as the reason for the Incarnation and still celebrate the Good News of the Incarnation, life, death, and resurrection of Christ Jesus.

Incarnation

The traditional Western narrative of God's relationship to humanity goes something like this: out of nothing, God created a perfect world, a world in which humanity was deeply connected to God and did not suffer the separation and alienation from God or from each other that we do today. Then, tragically, this perfection was broken: the first woman committed the first sin, and urged her husband to follow her. In punishment for their crime, creation itself changed dramatically: the Earth was no longer a garden, but yielded food only with sweat and labor; God no longer walked in the midst of creation; and women were condemned to pain in childbirth and to subjection to their husbands. Pain, hierarchy, difficult physical labor, and the loss of God's felt presence among us were all results of sin. The worst punishment, in the end, was the loss of God--the banishment from Eden--and the knowledge that nothing we ever did could bring us back into God's presence, or bring God back to walk among us again. We were banished; we were lost, In the early Church's understanding, the coming of Jesus was a direct response to this terrible situation: in the Christus Victor understanding of atonement, which dominated the church for centuries, Jesus came to free us from our bondage to sin and the Devil; the death of Jesus was both payment of the debt of sin and a ruse that forced the Devil to free humanity forever. A thousand years ago, Anselm proposed a different understanding of "Cur Deus Homo," or why God became human: he argued that Jesus' death did not pay off the Devil, but was instead payment, or satisfaction, owed to God from sinful humanity. That understanding, with some modifications, still undergirds most thought on redemption today, especially popular thought.

There is, of course, another long-standing Christian understanding of why the Incarnation happened--and how to describe the fundamental relationship between God and humanity. In the early church, the Greek Fathers "dared to speak of humanity's 'deification' ... [the idea that humanity is] called to become by grace what God is by nature." In order for human beings to share in God's glory, the Eastern Fathers argued, a bridge must exist between the divine and the human, and that bridge is Jesus Christ, fully human and fully divine. (5) The Incarnation was not merely a response to sin--although certainly it did respond to humanity's sin--but instead had been decreed from the beginning of creation, as it was necessary to fully bind human creatures to their divine Maker. St. Athanasius boldly claimed that "God became human that we might be made God;" (6) here the Incarnation is rooted in God's eternal love for humanity, not in a complex scheme concocted only in response to humanity's failings. Indeed, medieval Franciscan scholar John Duns Scotus argued that it is flatly inconceivable that "God's supreme work"--the Incarnation--was an afterthought in creation, or that it might never have happened at all if we had behaved ourselves. Instead, arguing from Scripture (especially the Prologue to John's Gospel) as well as drawing on the work of the Eastern Fathers, Duns Scotus claimed boldly that "the Incarnate Word is the foundation of the creative plan of God, the very reason for the existence of all creation." (7) The reason for the incarnation then, has nothing to do with Eve: human sin is not the beginning of the story of Jesus. Instead, human sin is always embraced by and subject to the grace and love of God which preceded it. The Christian narrative of God's engagement with humanity has thus been profoundly reconfigured: sin is no longer the pivot around which the entire story turns; rather, the centerpiece of the story is (as it should be) the love and self-communication of God.

In our own time, Karl Rahner's Christology forwarded this understanding of the incarnation as rooted primarily in God's original and ongoing love for humanity, and God's original and ongoing plan for human transformation and divinization. In addition, Rahner made the intriguing (and appropriate) move of setting this understanding of incarnation within the context of an evolving universe and evolving humanity, both of which are realities completely unknown to all but the most recent of Christian theologians. (8) Up until now, the alternative understanding of incarnation presented here merely sidestepped the importance of Eve to the Christian story--but the acceptance of evolution as part of the Christian story means that the entire framework of an original perfection destroyed by sin falls away. There was no original perfection: trace humanity back far enough and you do not find Adam and Eve, fully and consciously human but innocent; instead, you find a continuum of creatures developing toward consciousness and modern human intellectual ability--creatures who most likely (as our closest relatives, the apes, do) lived in hierarchical social arrangements, struggled to find food, and in their pre-rational innocence already suffered all the "punishments" human beings supposedly earned only through Eve's sin.

Evolution, then, requires us to rethink the Christian story and the traditional understanding of why Incarnation happened. Interestingly, the minority tradition of incarnation as the route to divinization gives us the theological tools we need to incorporate the new science into our religious understanding of the history of the world and of humanity. Incarnation as divinization always implied some sort of evolution of humanity: to find the details of this evolution not only in human beings but in the very structure of the universe is a powerful confirmation of the theological suspicion that Incarnation was meant to call us forward to something new, not repair an unexpected flaw in what should have been a static perfection.

There is still, however, the matter of suffering (and not just suffering in childbirth). The amount of suffering, over billions of years, required in the scientific story of the evolution of the universe is a profound challenge to those who would believe in a loving God. Darwin and many other scientists were driven to atheism when they began to grasp that evolution functions in large part through destruction, and that the lion and lamb are not predator and prey because of sin (and so without sin they could lie down together), but they are who they are because the mechanism of God's creation led them to be that way. In other words, violence, death, and suffering are an inescapable part of our world. How can this be? Is it even possible that a good and loving God--a God who Christians name as the incarnation of Love and Compassion--would create such a universe, and design it so that life must feed on suffering and death? Why wouldn't a good and loving God create a perfect universe, one in which life did not depend on death, or at least in which suffering was not so staggeringly prominent? Theologian John Haught offers an explanation that challenges our basic conception of God: he argues that only when we understand God not as Coercive, Kingly Power, or as Infinitely Powerful Clockmaker, but instead as suffering, humble love will we understand why the universe has unfolded in such a slow and stumbling manner:

  If ultimate reality is conceived of ....as self-emptying, suffering
  love, we should already anticipate that nature will give every
  appearance of being in some sense autonomously creative ... Since it
  is the nature of love, even at the human level, to refrain from
  coercive manipulation of others, we should not expect the world that
  a generous God calls into being to be instantaneously ordered to
  perfection. Instead, in the presence of the self-restraint befitting
  an absolutely self-giving love, the world would unfold by responding
  to the divine allurement at its own pace and in its own particular
  way. The universe then would be spontaneously self-creative and
  self-ordering (9) (italics added).

Indeed, Haught goes on to claim that the suffering, humble love revealed in the processes that brought the universe into being are definitively on display in the incarnation, life, death, and resurrection of Jesus: the suffering, self-giving love embodied here is the truth of the universe, the ultimate truth of our lives: self-giving love will always entail suffering, but it also births new life.

And here we come to a startling consequence of our investigation: we began with the ancient idea that the suffering of women proved their sinfulness. In this new configuration of how suffering, incarnation, and the love of God come together, the idea that women suffer in giving birth can in fact be understood through the lens of God's suffering to give birth to humanity through the Incarnation. In other words, the image of a woman in labor, struggling to give birth to a child, can be placed alongside the image of Jesus on the cross, suffering to give birth to graced, divinized humanity. Intriguingly, this connection was made long ago, centuries before evolution reconfigured the Christian story, and is perhaps best expressed in the words of a woman, Julian of Norwich:

  But our true Mother--Jesus, All love--alone bears us for joy and for
  endless living ... he sustains us within himself in love and hard
  labor, until the fulness of time. Then he willed to suffer the
  sharpest thorns and most grievous pains that ever were or ever will
  be, and at the last he died. And when he had finished, and had borne
  us so for bliss, still all this could not satisfy his wonderful
love. (10)

And even more dramatic are the words of Margaret Hammer, a contemporary pastoral theologian, who offers this prayer to be said by a laboring woman: "Lord Jesus Christ, who gave birth on the cross, bless us as we labor." (11)

Women with fistula in an evolutionary Christianity

When the incarnation is not a response to sin but a gift of love given from eternity; when Eve is not a focal point of the relationship between human and divine; when suffering exists in God's evolving creation but is not a judgment upon its creatures: when all this is true, how do we as Christians understand and respond to women suffering in child birth--and in the extreme case, a woman injured by fistula?

First, I would suggest, we should respond to women injured in childbirth in the same way Jesus' tender women friends responded to his body after it had been taken down from the cross. As soon as their Sabbath rest had ended, they made haste to care for him tenderly, bringing spices and ointments and clean linen cloths. His body mattered to them. Even so, the bodies of women in labor should matter to us, and we should rush to attend to them with honor, ceremony, and dignity. Further, moving from the realm of story and image to the more strict demands of theological reflection, we know that as human beings called to self-transcendence towards God, we act in discipleship to the One who was entirely open to the radical presence of God in the world. And that openness, that "yes," had a lot to do with healing, with priorities that put the poor and the suffering first, with a critique of social and religious structures that burdened and oppressed the people of God, and with joy. Christians, then, would do well to respond to women with fistula with Drs. Catherine and Reg Hamlin as their models. The Hamlins moved to Ethiopia in 1959, and have since performed over 25,000 successful fistula surgeries. They founded a hospital completely dedicated to the care of women with fistula, and have trained surgeons from all over the developing world in the repair of fistulae. Obviously the vast majority of us are not surgeons and cannot join the work of physically curing women with fistula. But most of us could support the work of fistula repair: the UN has begun raising money for fistula repair and preventive obstetric care, and the Hamlin's hospital, the Addis Abbaba Fistula Hospital, has a foundation which is continually in need of funding. Perhaps even more important than supporting the work of fistula repair is supporting the eradication of the problem: it does not, after all, exist in the West. It would be possible to live in a world without fistula. According to Dr. Catherine Hamlin, however, this would require far more than the extension of good obstetric care and adequate transportation services to the remotest of poor villages around the world: it would also--and more importantly, require:

  a whole new attitude to marriage and childbirth ... Parents have to
  change their minds about the worth of their daughters. Teachers and
  religious heads have to show a lead, and the girls themselves must
  somehow learn that they do not have to marry when they are still
  children ... Grass-roots community education programs are [beginning]
  ... The [educators] know that they need to involve the men of the
  village, as unless they co-operate and are convinced that women often
  need help during labor, there is nothing the women can do on their
  own. All the decisions in the family are made by men. (12)

Parents must change their minds about the worth of their daughters; the daughters themselves must learn their own worth; the husbands must learn the value of their wives. Fistula will exist, in other words, until the fundamental, God-given dignity of women is recognized and respected. Fistula will exist until people look at--and smell--a woman with fistula and do not see "damaged goods" or a burden for the community or a punished sinner ... but a neighbor in need of compassion and care, and a human being who was injured in the service of self-giving love. Theology has a role here, as Dr. Hamlin speaks of "teachers and religious heads" who can and should be teaching Christian theology, especially incarnational theology, in a way that does not devalue women. Certainly not all of these leaders are Christian (though many are): some are Muslim, some are traditional tribal religious leaders. This means that our work is not limited to educating Christian pastors and teachers in a contemporary understanding of incarnation and women's dignity before God, but should also extend to interfaith dialogue about the value of all people, the structures of marriage, and the relationship between a community and its sick or injured.

We have, in the end, much theological work to do; we have even more practical work to do in teaching and preaching what we have studied and researched. God was enfleshed in the human being Jesus of Nazareth, and because of that we recognize God's presence in all human flesh--even or perhaps especially in flesh that is broken and bleeding, even or perhaps especially in the bodies of women broken by fistula.

Notes

(1.) Hamlin, Catherine, with John Little, 2001, The Hospital By the River: A Story of Hope, Oxford, UK and Grand Rapids, MI: Monarch Books, p. x.

(2.) Frymer-Kensky, Tikva, 1995, Motherprayer: The Pregnant Woman's Spiritual Companion, New York: Riverhead Books, p. 183.

(3.) In fact, however, some Christian women today do refuse pain relief because they believe that their suffering is mandated by God. A friend recently asked me if it was true that she couldn't accept any drugs during childbirth because it would be sinful. The idea that women "must" suffer, not because of their own faults or sins, but simply because they are women, is still very much alive.

(4.) Ware, Timothy (Bishop Kallistos), 1997 (originally published 1963), The Orthodox Church, New Edition, New York: Penguin, 1997, p. 21.

(5.) Ibid.

(6.) Athanasius, On the Incarnation, section 54, http://www.newadvent.org/fathers/2802.htm, accessed on January 29, 2008.

(7.) Overberg, Kenneth R., S.J., 2002, "The Incarnation: Why God Wanted to Become Human," Catholic Update C1202, December, St. Anthony Messenger Press, p. 3.

(8.) Rahner, Karl, 1987, Foundations of Christian Faith: An Introduction to the Idea of Christianity, New York: Crossroad. See especially chapter VI: 1, "Christology within an Evolutionary View of the World," pp. 178-203.

(9.) Haught, John, 2000, God After Darwin: A Theology of Evolution, Boulder, CO: Westview Press, p. 53.

(10.) Julian of Norwich, 1977, Revelations of Divine Love, translated and with an introduction by M. L. del Mastro, New York: Image Books, ch. 60.

(11.) Frymer-Kensky, p. 187.

(12.) Hamlin, pp. 259-60, 300.