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The Ritual of Hospital Birth: Birth as an American Rite of Passage.

Birth as An American Rite of Passage

In an age when American women are seeking empowerment in many spheres, it is surprising that we still flock to hospitals to have babies. Reliable studies say that hospital birth in America today is no safer than planned home birth, yet many mothers find that hospital birth can be degrading and disempowering and riddled with unnecessary interventions. Why, then, are women so willing to place themselves in an environment where a profound expression of their feminine power is upstaged by men and machines? Why are women so slow to realize the implications of a 90% episiotomy rate for vaginal birth, and a one-in-four rate of cesarean birth?

Cultural anthropologist Robbie Davis-Floyd studied a hundred middle-class mothers. She found that the desires and beliefs of most of her subjects were strongly aligned with the dominant "technocratic model" of hospital birth. It is to her credit that she listened carefully to her subjects and confronted the disparity between their beliefs and her own; she believes that mothers and babies are better served by the minority "wholistic model" that respects women's rhythms and abilities.

Trying to understand this pattern, she interpreted the routines of hospital birth as elaborate rituals that reflect and reinforce our deeply held American "core values," including patriarchy, cultural control over nature, and the supremacy of technology and institutions. From pregnancy test to cesarean section, she analyzed each procedure as though she were visiting an exotic tribe.

We tend to think of hospital birth as deritualized and free from superstition and taboo; Davis-Floyd argues that it is highly stylized and symbolic. She is not judgmental about women's choices, as it is human nature for most of us to want to be part of the dominant culture. But it is to our advantage to recognize the forces that shape our beliefs.

Birth as an American Rite of Passage is fascinating and indispensable for childbirth professionals. It offers a framework with which to understand women's conscious and unconscious decision-making, and a vocabulary with which to explain the choices parents have. It will help us to see, with more compassion, how culture influences a woman's interpretation of her birth experiences.

The Technocratic and Wholistic Paradigms

The wholistic model, based in systems theory, holds that the mind and body are one, the mother and baby are one, nature is trustworthy, and women are active, healthy "doers of birth." However, the percentage of women in Davis-Floyd's study who actually experienced drug-free natural childbirth is smaller than the percentage of American women who have cesareans.

The technocratic model both demonstrates and transmits some of American society's basic values: faith in technology. control over nature, and patriarchy. Birth is an opportunity to instruct at least three people about the validity of these values: the mother, the father, and the baby.

Under the technocratic model, the mind is separate from the body (dating back to Descartes, in the 17th century). Thus the body may be anesthetized and repaired. Since the Scientific Revolution in Europe, bodies have been regarded as machines. (Heart specialist: "He's in the shop now, and we'll have him just as good as new in no time.") The male body, with its straight lines, is the prototype, and the female is a defective machine. (This dates back to Aristotle: "The female is, as it were, a mutilated male, and the [female secretions] are semen, only not pure; for there is only one thing they have not in them, the principle of soul.") Institutions are superior to individuals, and science is superior to nature. The baby is society's product, and the mother's needs can sometimes conflict with the baby's.

This model both "proves" and reinforces the supremacy of patriarchy, technology, and institutional control. The trick, says Davis-Floyd, is getting women "to accept a belief system that inherently denigrates them."

She postulates that the rituals of hospital birth capitalize on women's desire to be free of their biological destiny in a culture that values neither pain nor procreative power. But this "freedom," masquerading as increased "equality," entails buying the notion that women's bodies are inherently defective.

What is a Rite of Passage?

The initiate is separated from her former life. She is under stress, and her belief system is breaking down, but she does not yet have a new framework to replace it. She is betwixt-and-between, but she is not alone. Her fellow initiates share this dangerous and sacred passage, guided by ritual elders. The initiates are vulnerable, yet this is a powerful moment in their lives.

She is bombarded with experiences that break down her ability to discriminate. She is challenged with great difficulties Everything seems strange and upside-down. Her thoughts become simpler, either/or. She is open to new information that will define her reality in the new state she is about to enter. When the elders provide that information, she accepts it hungrily. She needs to know where she stands in the world. The new information sinks in, imprinted deeply by the emotional power of the moment. It will shape her future, her relationships, her new role.

Whether she has joined the Army, undergone a tribal puberty ritual, or had a baby in an American hospital, the steps are the same. First, there is separation from the familiar. Then comes a transitional period marked by hazing, "strange-making," and symbolic inversion, all combining to open her up to a new understanding of herself. Finally, she is reintegrated with a transformed identity.

Hospital Birth Rituals

Davis-Floyd analyzes "standard hospital procedures" in terms of their textbook rationale, their physiological effects, and their ritual purposes as elements of an elaborate rite of passage that lasts a year. Here are some examples of ways these procedures meet the criteria for a rite of passage:

The hospital gown marks the mother as institutional property. It is not hers; indeed, she seems to possess nothing. It denotes her lack of autonomy -- she wouldn't dream of walking out the door in that outfit! It is homely, marking her status, and uniform, showing her affinity with other laboring mothers sharing her liminal (in-between) state of being. It is upside-down: the most private parts of her are public and available for "institutional handling and control." This symbolic inversion helps to break down her belief systems in preparation for her to be "fashioned anew."

The wheelchair and bed mark the mother as "sick," and place her physically below the attendants who are standing up Her sedentary position and ritual fasting might well slow her labor, necessitating intervention later on. If her pubic hair is shaved or clipped (a practice that is mercifully disappearing as it becomes evident that it increases infection and offers no medical benefits whatsoever), she appears more childish and less sexual, further removing her from her former conceptions of herself. The intravenous line deepens the symbolic concept that the mother is dependent and childlike. Davis-Floyd interprets the IV as a symbolic umbilical cord, tying the mother to the hospital as if it, not she, is the giver of life.

Hospital birth resembles factory production, concerned as it is with "delivery" of the "uterine products." Pitocin, amniotomy (breaking the waters), fundal pressure, forced pushing, and forceps speed up labor so the factory stays on schedule. Medication controls screaming and deadens pain, making women more like machines. The anesthetic separation of mind from body is part of the "strange-making" process. Without sensory feedback to guide her, the mother is dependent on machines and experts to tell her what to do.

The mother's connection to the world of machinery is made explicit by hooking her up to the electronic fetal monitor, a form of "ritual adornment." It is the authority on when the mother is having contractions, and the father/partner is often coopted out of his role as a lover and into a new role as monitor-watcher. The EFM has not decreased mortality rates, but it is linked with a steep rise in cesarean birth. While its medical value is not borne out by statistics, its symbolic value at center stage is enormous. Even its inventor, Dr. Edward Hon, believes that it is misused: "When you mess around with a process that works well 98% of the time, there is much potential for harm. . . [most women in labor may be] much better off at home [than in the hospital with the EFM]." Because using the EFM requires immobilization of the mother in bed, it can interfere with blood flow to the baby and thereby cause the very problems it is supposed to measure.

The baby, represented by the EFM as a beeping numeral, becomes even more of a "technocratic artifact" with the attachment of an internal monitor to its scalp. The baby is society's product, and must be protected from the mother's potential for malfunction. And it must be easier "to stick an electrode into an infant's scalp i one holds the belief that, being an object, the not-yet-born does not feel any pain."

Cervical exams are much more frequent in American hospitals than anywhere else. They can be invasive, disruptive and painful, and therefore form pan of the hazing part of the rite. Though they can interfere with the progress of labor, they are important as "production control checks." They also intensify the process of symbolic inversion, as having strangers reach deep inside one's vagina is about as far as a woman can get from her everyday social interactions.

Once the cervix has dilated to the arbitrary 10 cm (though babies, heads come in many sizes). the woman is exhorted to push her baby out as quickly as possible. Her rhythms and urges are often subordinate to the hospital's expectations. The factory model dictates that the baby should not spend too long inside a machine that could malfunction at any time.

The move to the delivery room may disrupt the mother's rhythms, but it is an essential symbolic trip into the most sacred shrine. Since birth is an inherently healthy process, the profession of obstetrics is "constrained to justify itself as of equal medical value to other branches of medicine." The delivery room is the symbolic obstetric equivalent of the surgeon's operating room.

When the paradigm of birth as a dangerous medical event is challenged, the response is to step up the performance of rituals, not to decrease them. One of the most dramatic and most-hated interventions is the episiotomy, which anthropologist Sheila Kitzinger calls "ritual genital mutilation." The straight line of the incision marks our separation from nature. The vagina, symbolic of female power, sexuality, and creativity, is deconstructed and then reconstructed ("repaired"). In the Netherlands, this procedure is deemed necessary in 8% of births. In America, it is performed on over 90% of first-time mothers.

The ultimate symbol of technology's superiority over nature is, of course, the cesarean section. Someday, Davis-Floyd hopes, our culture will realize how futile it is to assume such superiority. Then we will respect nature's infinite complexity and wisdom, and the cesarean rate will stabilize around 4%. In the meantime, the national rate of delivery "from above" is around 25%.

Doctors as Ritual Elders

In order for doctors to fulfill their role as elders transmitting important cultural messages, they themselves must submit to a strenuous rite of passage that lasts a full eight years. Medical school starts with two years of scientific study that objectifies the human body and has little relevance to clinical practice. It is so intense, competitive, and time-consuming that the initiate is cut off from previous roles, relationships, and self-concepts (strange-making). The irrelevance is irritating (hazing). Having once been at the top of the class, the initiate is reduced to lowly status (symbolic inversion).

In this isolation, with a narrow focus, the initiate loses sight of his/her initial idealism and develops goals "in accordance with the technocratic and scientific values of the dominant medical system." Once this has been accomplished, the initiate begins to see actual patients, also known as CPCs: clinical-pathological correlations.

Faced with real people in life-or-death situations, deprived of sleep, rewarded for sticking to protocols, residents learn to perform rote procedures. This is an emotional hedge against the unpredictability of birth. Residents who witness things going wrong will step up the performance of these rituals. They offer a sense of security, of control over the uncontrollable. This is what people in all cultures do under stress, says Davis-Floyd. It is "an adaptive evolutionary development for finding the courage to carry on."

Residents are taught that modern obstetric procedures are the main reason birth is safer now than in the past. While procedures can and do save lives, critics note that there are other factors which are at least as important: "a decrease in the number of unwanted pregnancies, improved prenatal care and maternal nutrition, and increased intervals between births."

Poor outcomes are blamed on the "inherent defectiveness of nature and the female body," not on flaws in the rituals. How many times have we heard women themselves say, "I wasn't dilating fast enough," or "I broke my waters too soon" or "I started breathing too fast"?

Women trained in obstetrics are subject to the same socialization as the men. As a minority, they sometimes feel the need to overcompensate for being female, and many have tended to align themselves more with male doctors than with female midwives. The percentage of female medical students is on the rise, and it will be interesting to see whether obstetrics changes as more women become doctors.

Just as some birthing women "fail" to accept the messages conveyed by hospital birth, some doctors manage to maintain "conceptual distance" from their socialization into the medical world. These "humanistic" doctors find themselves between the poles of the spectrum of beliefs, respecting the natural process while remaining in the hospital environment. They are likely to employ nurse-midwives and/or doulas for labor support, allow limited monitoring and choices of position and nourishment, and avoid episiotomy through perineal massage and support.

Obstetrics is uniquely vulnerable from two standpoints. It is conceptually vulnerable because, unlike other branches of medicine, it treats mostly healthy people. It is economically vulnerable because the cost of malpractice insurance is becoming so prohibitive that many obstetricians and family doctors are no longer delivering babies. Many feel they must intensify intervention to protect themselves from litigation -- so-called "defensive medicine." Davis-Floyd points out that this is society's way of making sure that doctors can,t escape from the technocratic model, even if they want to.

The Mother's Experience

Davis-Floyd does not suggest that natural childbirth always means birth satisfaction. Rather, it's the match between expectations and outcome that makes the difference. She notes that women who expect an epidural feel cheated and neglected if they don't get one. while women who plan natural childbirth and instead receive overwhelming medical intervention feel violated. This is complicated by the fact that sometimes the mother's conscious ideas about how birth should be are in conflict with her deeper unconscious beliefs.

She found that the women in her study had a wide range of childbirth experiences. Some of the women in her study transformed the hospital experience into an expression of their personal power: "I want my cesarean now!" Some expected the doctor to take care of everything, and some insisted on giving birth their own way. Some used the pregnancy and birth as an opportunity for spiritual growth, while others rejected biology in favor of technology.

A full 42% entered the hospital believing in natural childbirth but were satisfied that the interventions they received were necessary. These women aligned themselves with the technocratic model during childbirth, yet did not perceive the experience as traumatic, as it confirmed the messages of female inadequacy they had received and internalized all their lives. 9% also entered the hospital believing in natural childbirth, but came out feeling like failures. These women suffered postpartum depression which later turned to rage at the way intervention had violated them.

Davis-Floyd notes that one avenue for healing from such an experience is having a subsequent birth wherein the mother's expectations closely match her practitioner's philosophy. The mother may shift from one birth paradigm to another if she is dissatisfied with her birth experiences. Other avenues for healing include sharing with other women and becoming involved with childbirth in the community.

What's Next?

Davis-Floyd envisions "a world in which those who wish to take responsibility for their own health and births are empowered to do so, and those who wish others to take that responsibility are cared for by a compassionate and humanized medical system...physicians will redefine their roles from managers to facilitators...midwives will become the primary birth attendants and they will be able to move between paradigms, providing the technology when the woman desires it and supporting her with hands-on skills when she doesn't."

I would recommend that pregnant parents take the time to discover where their beliefs and expectations lie on the spectrum, both at the conscious and unconscious levels. Then their task is to find a practitioner and a birth setting to match their concept. If they are unable to find such a practitioner, they can buffer themselves against trauma through education, labor support, careful prenatal communication and negotiation, and cultivating an attitude of self-acceptance and flexibility. They can also place technology at their service rather than the other way around.

In all cultures, birth rituals reflect the values of the whole society and of the individual mother. Birth is an opportunity for transformation, a time when we are especially open to new ideas about ourselves. It's up to us to decide whether that leads us into deeper technocratic socialization or a fresh perspective on the interrelatedness of all life. Robbie Davis-Floyd's work will enable us to be more conscious of that choice.

Vicki Elson holds a degree in "Childbirth Education in Anthropological and Historical Perspectives." She teaches IH/IBP classes in Massachusetts, where she is president of the Birthing Network, Inc. and teaches our Empowering Women through Childbirth Education workshops. She lives in Conway, MA with her husband Barry and three children.
COPYRIGHT 1993 Association of Labor Assistants & Childbirth Educators
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1993, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:Elson, Vicki
Publication:Special Delivery
Article Type:Book Review
Date:Mar 22, 1993
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