What Do We Know? Anthropology And Birth Activism

During a birth advocacy dinner I once attended in Seattle, a doula raised her glass and made the last toast: “For all the women who don’t know.”

My reactions trembled on the existential brink. As both an anthropologist and a birth activist, I am trained to honor and respect women’s choices and the knowledge systems on which they base those choices. I am also trained to deeply question the cultural conditioning underlying all “choice.” I could hear pity in the doula’s toast, mingled with regret and sadness. This was not a celebration made “to” these women, but rather a hope “for” these women. For the women who are statistically unlikely to have a natural childbirth (more than 90 percent of the American childbearing population), a longing that they may come to “know.” That they may come to see the light and truth of what birth activists are sure they are missing: the deeply embodied, tremendously empowering experience of giving birth on one’s own, without the artificial aids of drugs and technologies.

There was a 10-year period in the 1970s during which natural childbirth as a social movement flourished in the U.S. and women welcomed the efforts of birth activists. They succeeded in securing such humanistic rights as the right to the supportive presence of family, friends and doulas; to more comfortable environments for labor and birth; and to breastfeeding support. However, the current generation of U.S. birthing women often takes these rights for granted—right along with the epidural and the fetal monitor, which have served to ensure that American mothers use their choice and agency to reinforce biomedical hegemony and the increasing technologization of birth. A 2002 Harris Poll survey of 1,800 American women, designed by the Maternity Center Association, showed that 63 percent of survey respondents received epidurals, 93 percent received electronic fetal monitoring and many other forms of technological intervention during labor, and more than 90 percent expressed satisfaction with their childbearing experiences.

The endless dialogues birth activists engage in about how to effect changes in childbirth center around the need for education. If women “only understood” the disadvantages—indeed, dangers—drugs and technologies posed to their bodies and their babies, then surely they would be asking for better births. They would seek out midwives who can offer these better births, and who presently attend only 14% of American births because women don’t demand them and doctors don’t want the competition. They would not be (mistakenly) afraid to give birth at home and in birth centers, where a holistic model of birth prevails and the focus is on facilitating women to give birth on their own, avoiding unnecessary interventions. But in spite of the demonstrated safety of out-of-hospital birth, the number of such births long remained at less than 1 percent, although by 2019 it quadrupled to just under 2%.

Birth activists have mountains of scientific data on their side, but this data has made little difference in the practice of birth.

Routine electronic fetal monitoring remains pervasive, even though it does not improve outcomes and raises the incidence of unnecessary cesareans.
Induction of labor increases prematurity rates and labor complications, but its use has skyrocketed to more than 53 percent in the past decade. (I can say with certainty that no woman should allow herself to be induced before 39—ideally 40— weeks for any reason beyond extreme complications. Obstetricians who recommend or perform too-early inductions are acting irresponsibly, and against the scientific evidence that shows that far too many babies end up in the NICU because of early inductions.)
Epidurals can slow labor, generate fevers and necessitate further interventions for both mother and baby (who will end up in the NICU if the mother does develop a fever).
Cesareans generate higher rates of infection and other complications (including death) than vaginal birth, but the cesarean rate in the U.S. is at an all-time high of 32 percent. Doctors “know” that they are giving women “the best care,” and “what they really want.” Birth activists, including myself, know that this “best care” is too often a travesty of what birth can be. And yet on that existential brink, I tremble at the birth activist’s coding of women as “not knowing.” So, here’s to women educating themselves on healthy, safe birth practices—to women knowing what is best for themselves and their babies, and to practitioners learning to listen to what women know.