Printer Friendly

Ritual in the hospital: giving birth the American way.

Why is childbirth, a unique and individual experience for every woman, treated in such a standardized way in the United States? No matter how long or short, how easy or hard their labors, the vast majority of American women are hooked up to an electronic fetal monitor and an IV (intravenously administered fluids and/or medication), are encouraged to use pain-relieving drugs, receive an episiotomy (a surgical incision in the vagina to widen the birth outlet) at the moment of birth, and are separated from their babies shortly after birth. Most of them also receive the synthetic hormone pitocin to speed up their labor, and give birth flat on their back. Nearly one quarter of them are delivered by cesarean section.

Most Americans view these procedures as medical necessities. But cross-cultural evidence does not confirm that they are. For example, the Mayan Indians of highland Chiapas hold onto a rope while squatting for birth, a position that is far more physiologically efficacious than the flat-on-your-back-with-your-feet-in-stirrups (lithotomy) position. Mothers in many low-technology cultures give birth sitting, squatting, semi-reclining in their hammocks, or on their hands and knees, and are nurtured through the pain of labor by experienced midwives and supportive female relatives. What then might explain the standardization and technological elaboration of the American birthing process?

One answer emerges from the field of symbolic anthropology, which encompasses the study of myth and ritual. As a longtime student of this field, I know that myths express the basic beliefs and values of a culture, and rituals enact and display those beliefs and values. In all societies, major life transitions such as birth, coming of age, marriage and death are times when cultures are particularly careful to display their core values and beliefs. Thus these important transitions are so heavily ritualized that they are called rites of passage. Through these rites of passage, each society makes sure that the important life transitions of individuals can only occur in ways that actively perpetuate the core beliefs and values of their society. Could this explain the standardization of American birth? I believe the answer is yes.

I came to this conclusion as a result of a study I conducted of American birth between 1983 and 1991. I interviewed over 100 mothers, as well as many of the obstetricians, nurses, childbirth educators, and midwives who attended them.(2) While poring over my interviews, I began to understand that the forces shaping American hospital birth are invisible to us because they stem from the conceptual foundations of our society. I realized that American society's deepest beliefs and values center around science, technology, patriarchy, and the institutions that control and disseminate them, and that these core values are very clearly and effectively enacted and perpetuated through the high-tech obstetric procedures that have become standard in hospital birth. In other words, obstetric procedures are far more than medical routines: they are the rituals which initiate American mothers, fathers, and babies into the core value system of the technocracy. The technocracy is what some anthropologists are calling American society in its current form.(3) A technocracy is a hierarchical, bureaucratic society driven by an ideology of technological progress. In the technocracy, we constantly seek to "improve upon" nature by altering and controlling it through technology.

Ritual works by sending messages in the form of symbols. Symbols are received by the right hemisphere of the brain, which means that instead of being analyzed intellectually, a symbol's message will be felt through the body and the emotions. Thus, even though recipients maynot be consciously aware of the symbol's message, its ultimate effect can be extremely powerful. Routine obstetric procedures--the rituals of hospital birthare highly symbolic. For example, to be seated in a wheelchair upon entering the hospital, as many laboring women are, is to receive through their bodies the symbolic message that they are disabled; to be put to bed is to receive the symbolic message that they are sick. Although no one pronounces, "You are disabled; you are sick," such graphic demonstrations of disability and illness can be far more powerful than words. One woman told me:

I can remember just almost being in tears by the way they would wheel you in. I would come into the hospital, on top of this, breathing, you know, all in control. And they slap you in a wheelchair! It made me suddenly feel like maybe I wasn't in control any more.

The intravenous drips commonly attached to the hands or arms of birthing women make a powerful symbolic statement: they are the umbilical cords to the hospital. The cord connecting her body to the fluid-filled bottle places the woman in the same relation to the hospital as the baby in her womb is to her. By making her dependent on the institution for her life, the IV conveys to her one of the most profound messages of her initiation experience: in American society, we are all dependent on institutions for our lives. The message is even more compelling in her case, for she is the real giver of life. Society and its institutions cannot exist unless women give birth, yet the birthing woman in the hospital is shown, not that she gives life, but rather that the institution does.

Why would our society want to send such messages to women as they give birth? Because we have made a heavy investment in the technocratic myth. This myth insists that the more we control nature, the better it gets, and that ultimate control of nature is possible. Believing in this myth, we have focused enormous energy on building machines that we can control, in order to control nature, which we ultimately cannot. But these powerful machines do generate at least the appearance of control. They help us to feel safe, and they extend our human powers enormously. So it's no wonder that we invest so much energy, attention, and faith in them. Back at the beginnings of the Industrial Age, we were so impressed with mechanization that we even began to think of our own bodies as machines that could be taken apart and put back together to ensure proper functioning.

At that time, and for a long time after, it was commonly believed that women were inferior to men--closer to nature and feebler both in body and intellect. Consequently, the men who developed the idea of the body-as-machine also firmly established the male body as the prototype of this machine. Insofar as it deviated from the male standard, the female body was regarded as abnormal, inherently defective, and dangerously under the influence of nature. The metaphor of the body-as-machine and the related image of the female body as a defective machine eventually formed the philosophical foundations of modern obstetrics. Wide cultural acceptance of these metaphors accompanied the demise of the midwife and the rise of the male-attended, mechanically manipulated birth.

In keeping with the industrialization of American society, the rising science of obstetrics adopted the model of the assembly-line production of goods as its template for hospital birth. Accordingly, a woman's reproductive tract came to be treated like a birthing machine by skilled technicians working under semiflexible timetables to meet production and quality control demands. As one fourth-year resident observed:

We shave 'em, we prep 'em, we hook 'em up to the IV and administer sedation. We deliver the baby, it goes to the nursery and the mother goes to her room. There's no room for niceties around here. We just move 'em right on through. It's hard not to see it like an assembly line.

The hospital itself is a highly sophisticated technocratic factory; the more technology the hospital has to offer, the better it is considered to be. Because it is an institution, the hospital constitutes a more significant social unit than an individual or a family. Therefore it can require that the birth process conform more to institutional than personal needs. As one resident explained,

There is a set, established routine for doing things, usually for the convenience of the doctors and the nurses, and the laboring woman is someone you work around, rather than with.

The most desirable end-product of the birth process is the new social member, the baby; the new mother is a secondary by-product. One obstetrician commented.

"It was what we were all trained to always go after--the perfect baby. That's what we were trained to produce. The quality of the mother's experience--we rarely thought about that."

Rituals are often repititious and redundant, conveying the same message over and over again in different forms. The rituals of hospital birth remind women in several ways that their body-machines are potentially defective. These include periodic and sometimes continuous electronic monitoring, frequent examinations to make sure that the cervix is dilating on schedule, and, if it isn't, administration of pitocin to speed up labor so that birth can take place within the required 26 hours.(4) All three of these procedures convey the same messages over and over: time is important, you must produce on time, and you cannot do that without technological assistance because your machine is defective.

When humans are subjected to extremes of stress and pain, they may become unreasonable and out of touch with reality. Ritual assuages this condition by giving people something to hang on to that can keep them from "falling apart" or "losing it." When the airplane starts to falter, even passengers who don't go to church are likely to pray! To perform a ritual in the face of fear is to restore a sense of order and control to the world. Labor subjects most women to extremes of pain, which are often intensified by the alien and often unsupportive hospital environment. American women who believe in the technocratic myth will look to hospital rituals to relieve the distress resulting from their pain and fear. They utilize breathing rituals taught in hospital-sponsored childbirth education classes to restore a sense of order and control. They turn to drugs for pain relief and to the reassuring presence of medical technology for relief from fear. When women who have placed their faith in the technocratic myth are denied its rituals, they often react with intensified fear and a feeling of being neglected:

My husband and I got to the hospital, and we thought they would take care of everything. I kept sending my husband out to ask them to give me something for the pain, to check me, but they were short-staffed and they just ignored me until the shift changed in the morning.

I was terrified when my daughter was born. I just knew I was going to split open and bleed to death right there on the table, but she was coming so fast, they didn't have any time to do anything to me... I like Cesarean sections, because you don't have to be afraid.

When you come from a belief system, its rituals will comfort and calm you. Accordingly, those women in my study who began labor in basic agreement with this technocratic (technological, interventionist) approach to birth expressed general satisfaction with their hospital births. They were the majority--seventy out of one hundred, or seventy percent. Their numbers are not surprising, as their profound distrust of nature and their faith in technology mirror the attitudes of our society as a whole.

In many cultures, to perform a series of rituals in precise order is to feel yourself locking onto a set of "cosmic gears" that will safely crank you though danger to safety. For example, Trobriand sea fisherman regularly perform an elaborate series of rituals on the beach before embarking, believing that these rituals, when properly carried out, will obligate the gods of the sea to bring the fishermen safely home. Likewise, obstetricians and many birthing women believe that correct performance of standardized procedures ought to result in a healthy baby. Such rituals generate in humans a sense of confidence that makes it easier to face the challenge and caprice of nature. However, once those "cosmic gears" have been set into motion, there is often no stopping them. A "cascade of intervention" occurs when one obstetric procedure alters the natural birthing process, causing complications, and so inexorably "necessitates" the next procedure, and the next. Many of the women in my study experienced such a "cascade" when they received some form of pain relief, such as an epidural, which slowed their labor. Then pitocin was administered through the IV to speed up the labor, but pitocin very suddenly induced longer and stronger contractions. Unprepared for the additional pain, the woman asked for more pain relief, which ultimately necessitated more pitocin. Pitocin-induced contractions, together with the fact that the mother must lie flat on her back because of the electronic monitor belts strapped around her stomach, can cause the supply of blood and oxygen to the fetus to drop, affecting the fetal heart rate. In response to the "distress" registered on the fetal monitor, an emergency Cesarean is performed. Elise describes her experience of this "cascade of intervention":

It's funny--it seems so normal to lie down in labor. Just to be in the hospital seems to mean to lie down. But as soon as I did I felt that I had lost something. I felt defeated. And it seems to me now that my lying down tacitly permitted the demerol, or maybe entailed it. And the demerol entailed the pitocin, and the pitocin entailed the Cesarean. It was as if, in laying down my body as I was told to, I also laid down my autonomy and my right to self-direction.

The electronic fetal monitor is a machine that uses ultrasound to measure the rate of the baby's heartbeat through electrodes belted onto the mother's abdomen. This machine has become the symbol of high technology hospital birth. Observers and participants alike report that the monitor, once attached, becomes the focal point of the labor. Nurses, physicians husbands, and even the mother herself become visually and conceptually glued to the machine, which then shapes their perceptions and interpretations of the birth process. One woman described her experience this way:

As soon as I got hooked up to the monitor, all everyone did was stare at it. The nurses didn't even look at me anymore when they came into the room--they went straight to the monitor. I got the weirdest feeling that it was having the baby, not me.

This statement illustrates the woman's internal acceptance of the technocratic myth that she is dependent on the hospital and its technology to give birth. Soon after the monitor was in place, she requested a Cesarean section, declaring that there was "no more point in trying."

Internalizing this technocratic myth, women come to accept the notion that the female body is inherently defective. This notion then shapes their perceptions of the labor experience, as exemplified by one woman's story:

It seemed as though my uterus had suddenly tired! When the nurses in attendance noted a contraction building on the recorder, they instructed me to begin pushing, not waiting for the urge to push, so that by the time the urge pervaded, I invariably had no strength remaining but was left gasping and dizzy... I felt suddenly depressed by the fact that labor, which had progressed so uneventfully up to this point, had now become unproductive.

Note that she does not say, "The nurses had me pushing too soon," but "My uterus had tired," and labor had "become unproductive." These responses reflect her internalization of the technocratic notion that when something goes wrong, it is her body's fault. Such an idea could only arise in a society that values machines more than bodies and institutional routines more than individual needs. Consider the visual and kinesthetic images that the laboring woman experiences--herself in bed, in a hospital gown, staring up at an IV pole, bag, and cord, down at a steel bed and huge belts encircling her waist, and sideways at a moving displays on a large machine. Her entire sensory field conveys one overwhelming message about our culture's deepest values and beliefs: technology is supreme, and you are utterly dependent upon it.

Once the woman's cervix reaches full dilation (ten centimeters), the nursing staff immediately begins to exhort her to push with each contraction, whether or not she actually feels the urge to push. When delivery is imminent, she must be transported, often with a great deal of drama and haste, down the hall to the delivery room. Lest the baby be born en route, the laboring woman is then exhorted, with equal vigor, not to push. Such commands constitute a complete denial of the natural rhythms of her body. They signal that her labor is a mechanical event and that she is subordinate to the institution's expectations and schedule.

Through explicit enactment of a culture's belief system, ritual works both to preserve and to transmit the culture. Preserving the culture includes perpetuating its power structure, so it is usually the case that those in positions of power will have unique control over ritual performance. They will utilize the effectiveness of ritual to reinforce both their own importance and the importance of the belief and value system that legitimizes their positions. In spite of tremendous advances in equality for women, the United States is still a patriarchy. It is no cultural accident that 98% of American women give birth in hospitals, where only physicians, most of whom are male, have final authority over the performance of birth rituals--an authority that reinforces the cultural supervaluation of patriarchy for both mothers and their medical attendants.

Nowhere is this reality more visible than in the lithotomy position. Despite years of effort on the part of childbirth activists, including many obstetricians, the majority of American women still give birth lying flat on their backs. This position is physiologically dysfunctional. It compresses major blood vessels, lowering the mother's circulation and thus the baby's oxygen supply. It increases the need for forceps because it narrows the pelvic outlet and ensures that the baby, who must follow the curve of the birth canal, quite literally will be born heading upward, against gravity. But it is very convenient for the physician, who has a clear view at a height that is comfortable for performing interventions. And it reinforces his status relative to the woman's--she is "down," and he is "up." If she were standing or sitting up to give birth, as many women do in other societies, he would be below her, bending to serve her--a radical departure from the status quo.

The episiotomy performed by the obstetrician just before birth also powerfully enacts the status quo in American society. This procedure, performed on over 90% of first-time mothers as they give birth, expresses the value and importance of one of the technocracy's most fundamental markers--the straight line. Through episiotomies, physicians can deconstruct the vagina (stretchy, flexible, part-circular and part-formless, feminine, creative, sexual, nonlinear), then reconstruct it in accordance with our cultural belief and value system. Doctors are taught (incorrectly) that straight cuts heal faster than the small jagged tears that sometimes occur during birth, and that straight cuts will prevent such tears. But in fact, episiotomies often cause severe tearing that would not otherwise occur. Such teachings dramatize our Western belief in the superiority of culture over nature. Moreover, since surgery constitutes the ultimate form of manipulation of the human body-machine, it is the most highly valued form of medicine. Routinizing the episiotomy, and increasingly, the Cesarean section, has served to raise the status of obstetrics as a profession, by ensuring that childbirth will not be a natural but a surgical procedure.

Paradoxically, ritual, with all of its insistence on continuity and order, can be an important factor in social change. New belief and value systems are most effectively spread through new rituals designed to enact and transmit them; entrenched belief and value systems are most effectively altered through alterations in the rituals that enact them. Nine percent of my interviewees entered the hospital determined to avoid technocratic rituals in order to have "completely natural childbirth," yet ended up with highly technocratic births. These nine women experienced extreme cognitive dissonance between their previously held self-images and those internalized in the hospital. Most of them suffered severe emotional wounding and short-term port-partum depression as a result. But fifteen percent did achieve their goal of natural childbirth, thereby avoiding being influenced by the technocratic myth. These women were personally empowered by their birth experiences. They tended to view technology as a resource that they could choose to utilize or ignore, and often consciously subverted their initiation process by replacing technocratic symbols with self-empowering alternatives. For example, they wore they own clothes and ate their own food, rejecting the hospital gown and the IV. They walked the halls instead of going to bed. They chose perineal massage instead of episiotomy, and gave birth like "primitives," sitting up, squatting, or on their hands and knees. One woman, confronted with the wheelchair, said "I don't need this," and used it for a luggage cart. This rejection of customary ritual elements is an exceptionally powerful way to induce change, and indeed, many hospitals have responded.

During the 1970s and early 1980s, the conceptual dominance of the technocratic myth in the hospital was severely challenged by the natural childbirth movement which these twenty-four women represent. Birth activists succeeded in getting hospitals to allow fathers into labor and delivery rooms, mothers to birth consciously (without being put to sleep), and mothers and babies to room together after birth. They fought for women to have the right to birth without drugs or interventions, to walk around or even be in water during labor (in some hospitals, Jacuzzis were installed). Prospects for reducing the influence of the technocratic myth by the 1990s seemed bright.

Changing a society's belief and value system by changing the rituals that enact it is possible, but not easy. To counter attempts at change, members of a society may intensify the rituals that support the status quo. Thus a response to the threat posed by the natural childbirth movement was to intensify the use of high technology in hospital birth. During the 1980s, periodic electronic monitoring of nearly all women became standard procedure, the epidural rate shot up to 80%, and Cesarean rate rose to nearly 25%. Part of the impetus for this technocratic intensification is the increase in malpractice suits against physicians. The threat of lawsuit forces doctors to practice conservatively--that is, in strict accordance with technocratic standards. As one of them explained:

Certainly I've changed the way I practice since malpractice became an issue. I do more C-sections... And more and more tests to cover myself. More expensive stuff. We don't do risky things that women ask for--we're very conservative in our approach to everything... In 1970 before all this came up, my C-section rate was around 4%. It has gradually climbed every year since then. In 1985 it was 16%, then in 1986 it was 23%.

The money goes where the values lie. From this macro-cultural perspective, the increase in malpractice suits emerges as society's effort to make sure that its representatives, the obstetricians, perpetuate our technocratic core value system by continuing through birth rituals to transmit that system. Its perpetuation seems imperative, for in our technology we see the promise of our eventual transcendence of bodily and earthly limitations--already we replace body parts with computerized devices, grow babies in test tubes, build space stations, and continue to pollute the environment in the expectation that someone will develop the technologies to clean it up!

We are all complicitors in our technocratic system, as we have so very much invested in it. Just as that system has given us increasing control over the natural environment, so it has also given not only doctors but also women increasing control over biology and birth. Contemporary middle-class women do have much greater say over what will be done to them during birth than their mothers, most of whom gave birth during the 1950s and 1960s under general anesthesia. When what today's mothers demand is in accord with technocratic values, they have a much greater chance of getting it than their sisters have of achieving natural childbirth. Even as hospital birth still perpetuates patriarchy by treating women's bodies as defective machines, it now also reflects women's greater autonomy by allowing them to distance their minds from those defective body-machines.

Epidural anesthesia is administered in about eighty percent of American hospital births. So common is its use that many birth practitioners are calling the 1990s the age of the "epidural epidemic." As the epidural numbs the birthing woman, eliminating the pain of childbirth, it also graphically demonstrates to her the truth of the Cartesian maxim that mind and body are separate, that the biological realm can be completely cut off from the realm of the intellect and the emotions. The epidural is thus the perfect technocratic tool, serving the interests of the technocratic myth by enacting it, and of women who find meaning in that myth by enabling them to divorce themselves from their biology:

Ultimately the decision to have the epidural and the Cesarean while I was in labor was mine. I told my doctor I'd had enough of this labor business and I'd like to... get it over with. So he whisked me off to the delivery room and we did it.

For many women, the epidural provides a means by which they can actively witness birth while avoiding "dropping into biology." Explained Joanne, "I'm not real fond of things that remind me I'm a biological creature--I prefer to think and be an intellectual emotional person." Such women tended to define their bodies as tools, vehicles for their minds. They did not enjoy giving in to "biology" to be pregnant, and were happy to be liberated from biology during birth. And they welcomed advances in birth technologies as extensions of their own ability to control nature.

In dramatic contrast, six of my interviewees (six percent) insisted, "I am my body," and chose to give birth at home under an alternative, holistic mythology which tells a very different story. It stresses the organicity and trustworthiness of the female body, the natural rhythmicity of labor, the integrity of the family, and self-responsibility. The holistic story sees the safety of the baby and the emotional needs of the mother as one, and holds that the safest birth for the baby will be the one that proves the most nurturing environment for the mother.(5) Said Ryla,

I got criticized for choosing a home birth, for not considering the safety of the baby. But that's exactly what I was considering! How could it possibly serve my baby for me to give birth in a place that causes my whole body to tense up in anxiety as soon as I walk in the door?

Although homebirthers constitute only one-to-two percent of the American birthing population, their conceptual importance is tremendous. Through the alternative rituals of giving birth at home, they enact--and thus guarantee the existence of--a story about pregnancy and birth based on the value of connection, just as the technocratic myth is based on the principle of separation. The technocratic and holistic myths represent opposite ends of a spectrum of beliefs about birth and about cultural life. Their differences are mirrored on a wider scale by the struggles between techno-medicine and holistic healing, and between industrialists and environmentalists. These groups are engaged in a core value conflict over the future--a struggle clearly visible in the profound differences in the rituals they daily enact.

Obstetric procedures can be understood as rituals. These procedures are profoundly symbolic, communicating messages concerning our culture's deepest beliefs about the necessity for cultural control of natural processes. They provide an ordered structure to the chaotic flow of the natural birth process, appearing to contain and control it. And they strongly affect the birthing woman's perceptions of her experience. As one woman succinctly sums it up:

It's almost like programming you. You get to the hospital. They put you in this wheelchair. They whisk you off from your husband, and I mean just start in on you. Then they put you in another wheelchair, and send you home. And then they say, well, we need to give you something for the depression. [Laughs] Get away from me! That will help my depression!

Through hospital ritual procedures, obstetrics deconstructs birth, then reconstructs it in ways that work to confirm the technocratic myth and to transmit the core values of American society to birthing women. From society's perspective, the birth process will not be successful unless the woman and child are properly socialized during the experience, transformed as much by the rituals as by the physiology of birth.


(1.)This chapter is an abridged version of "The Rituals of Hospital Birth" in Conformity and Conflict: Readings in Cultural Anthropology, 8th edition, edited by James P. Spradley and David McCurdy. New York: HarperCollins, 1994. Robbie Davis-Floyd holds the copyright on this article, and grants permission to the Seattle Midwifery School to reproduce it as needed.

(2.)The full results of this study appear in Robbie Davis-Floyd, Birth as an American Rite of Passage (U. of California Press, 1992).

(3.)See Peter C. Reynolds, Stealing Fire: The Mythology of the Technocracy (Palo Alto, CA: Iconic Press, 1991) and Robbie Davis-Floyd, Birth as an American Rite of Passage.

(4.)In Holland, by way of contrast, most births are attended by midwives who recognize that individual labors have individual rhythms. They can stop and start, can take a few hours or several days. If labor slows, the midwives encourage the woman to eat to keep up her strength, and then to sleep until the contractions pick up again.

(5.)For summaries of studies that demonstrate the safety of planned, midwife-attended home birth relative to hospital birth, see Birth as an American Rite of Passage, Chapter 4.
COPYRIGHT 1995 Association of Labor Assistants & Childbirth Educators
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1995, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
Printer friendly Cite/link Email Feedback
Author:Davis-Floyd, Robbie E.
Publication:Special Delivery
Date:Mar 22, 1995
Previous Article:PMS and diet.
Next Article:Pregnancy tips for sexual abuse survivors.

Related Articles
Fear, surrender and transformation in birth.
95 birth ideas.
The Russian Birth Project: one intern's experience.
The power of being there. (Feature Article)(Cover Story).

Terms of use | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters