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Birthing Better

By Wintergreen

Evolving the childbirth conversation for better births.

Here we are in 2021, and there are still many women alive who gave birth in the United States during the 1960s and 1970s. When they listen to the childbirth conversation today, many of them aren’t certain whether birth has improved or gotten worse.

Back then, there was a very high societal expectation that expectant families attend the very first childbirth preparation classes ever taught—Lamaze and the Bradley Method. There were no choices up for discussion. Birth plans didn’t exist. There were no midwives. The overbearing medical practice had lots of assessments, monitoring, and procedures as part of the “guidelines of practice” or “standards of care.”

We had to follow our doctor’s orders. Ninety-five percent of us had a vaginal birth, whether we labored for hours or days; coped well or suffered; had risks or not; had good outcomes or tragedies. Risks, such as a breech baby, were considered normal, natural, and physiological. They were problems that usually got resolved, but, less frequently, became a tragedy…a fact of life that was also accepted. Fathers were just coming into birth. Cesareans were major abdominal surgeries and mostly done to save a woman’s life. These first childbirth education classes were entirely focused on skills. This first childbirth conversation was shared throughout the country: “Learn and use birth and coaching skills.” In other words, we still have a memory of a skills-based childbirth trend.

Back then, we learned breathing and relaxation techniques, which we used the best we could during our births. Lamaze was taught in most hospitals, while the Bradley Method was used more in private classes.

Obstetricians rightly observed at the time that all births were being drawn into the modern maternity systems. They questioned whether this made sense. They believed low-risk pregnant women could use their skills to achieve three goals:

  1. Natural birth

  2. Pain-free labor

  3. No medical interventions

Millions of expectant families in the U.S. from the 1960s to the mid-70s took these skills-based childbirth classes. As a result, OBs and labor-delivery nurses saw millions of birthing families use some level of skills in their labor and delivery, which led to an entirely different achievement than the three above goals. Do you know what was that massive achievement? We hugely reduced suffering.

This broad, skills-based childbirth trend did not occur in all countries. In New Zealand, for example, from 1950 to the 1970s, low-risk pregnant women could be given a “prescription” from their doctor (usually a general practitioner) to attend a Grantly Dick-Read natural childbirth class based on his book Childbirth Without Fear. Birth and coaching skills were not widely learned.

At the same time, aside from in the U.S. and Canada, all modern countries had always had midwives and home birth options. Therefore, this large, societally accepted skills-based childbirth trend was unique to the mid-century United States.

How did we get to today?

As mentioned, the skills-based childbirth trend was based on a philosophy of natural birth for low-risk women. It used words and actions to achieve the three goals stated above.

Unlike in New Zealand, millions of families in the U.S. were learning skills specifically geared for a particular group of women for very specific goals, yet we achieved something else: We reduced suffering.

For birth, we are all faced with a global truth. There’s no way to know what your birth will be like—so, we assume, there’s really nothing we can do to prepare for birth. Suffering and risks have always been part of the fear of birth. Suffering defines a woman’s personal experience while she births her baby. Risks are something that might lead to a problem, or, less frequently, a tragedy.

Who knows why Lamaze, Bradley, and Grantly Dick-Read didn’t see and act on the two obvious and bigger issues: One, that 100% of pregnant women will give birth, so all women can use skills, instead of just “low-risk” women; and two, that suffering, experienced by so many women, can also be reduced by using skills.

The medical profession saw, and birthing families experienced, much less suffering during this skills-based childbirth trend—but this was not the intended outcome, so this huge success was actually overlooked. The medical staff, obstetricians, and newly rising natural birth advocates focused on those three goals (pain-free labor, no medical intervention, “natural” birth) and saw that using skills didn’t achieve them. No one—aside from millions of mothers and fathers—appreciated the obvious success of skills being used broadly to reduce suffering.

The perceived failure of the skills-based childbirth trend led to a new and vibrant natural birth movement and to the modern choice-based childbirth trend to achieve more natural births. At the same time, tensions grew between modern maternity care and birth advocates. The childbirth conversation was focused on natural birth and becoming informed about choices regarding medical intervention. It was less concerned about ways to cope and work through the activity of birth to reduce suffering and stay in control.

Before further discussion, we need to reflect on the fact that there are some periods in history that profoundly change everything. One of those periods was the 1970s and 1980s. Some of these changes had a huge impact on the childbirth conversation. Here’s just a partial list:

  • Women’s liberation: Women wanted choices and more control over their lives.

  • Birth control: Women could now control how many children they had, so each one became more precious.

  • Women started to wear bikinis and didn’t want to be left with an ugly c-section scar; this led to the obstetric “bikini cut” or “low-lying incision.”

  • Society became more risk-averse. People didn’t want to suffer a problem or tragedy and were more comfortable in saying, “If a cesarean is safer for my baby, I’ll do that.”

  • More diagnostic protocols were introduced, leading to more risk-related assessments, monitoring, and procedures.

  • All of modern medicine became more sophisticated in response to the risk-aversion in society.

The rules of this new choice-based childbirth trend were simple. Women knew what kind of birth they wanted; they just needed to learn the pros and cons of interventions (all the medical assessments, monitoring, and procedures), make choices, and write a birth plan. Then the birth provider would endeavor to give them their desired birth.

The tension between natural birth advocates and modern maternity care began to solidify. Natural birth advocates emphasized pregnancy and birth as normal life events, rarely requiring medical care. Women have always given birth and need to trust themselves, and, when possible, choose an out-of-hospital birth with a midwife to avoid unnecessary interventions. The midwife should ideally be able to leave the woman alone to discover birth herself. Fathers shouldn’t coach, but should support their partners in their evidence informed choices. Birth was seen as a very emotional experience, and safe unless proven otherwise.

Modern maternity care, on the other hand, stressed potential risks and approached pregnancy and birth with technological assessments, monitoring, and procedures for everyone. Birth was seen as a physical experience that wouldn’t be safe until after it was over.

We are still in the choice-based childbirth trend, and there is still high tension between providers and families over making evidence-informed choices. The meaning of the word skills has changed since the 70s: Instead of something you use while actively giving birth, skills are now what you use to make the choices that achieve a particular kind of birth.

Let’s just imagine for a moment that reducing suffering for birthing women who use skills is as beneficial as having skills to prepare and cook food to satisfy hunger, or to be a good lover during the natural, normal physiological urge to be intimate. There’s a difference between making choices about what to cook and having the skills to actually cook. The same goes for sex, and being a good lover. Birth is no different. Choices should be involved, and women should be as free as possible to make those choices. And being skilled for birth should be just as relevant a priority, because birth is an infrequent, one-off, can’t-be-replayed event with memories that last the rest of one’s life.

Sensibly, in the 1970s, the success of birth and coaching skills to reduce suffering was observed by everyone and remembered by millions. If skills had been advocated and recognized by the maternity community and natural birth advocates, then skills and choices could easily have been married.

Had that happened, we would now be two or three generations into the skills/choice childbirth trend, with the major premise that it’s normal and natural to learn birth and coaching skills when pregnant and then use those skills to work through the activity of birthing your baby in absolutely any birth, and to make informed choices wherever possible. After all, we get pregnant to have a baby, and each woman has a physiological imperative to do the activity of giving birth to her child.

Unfortunately, the modern maternity system and the natural birth movement left skills behind, and therefore they didn’t evolve with the vigor that could have been expected. Instead, choices became the dominant pathway toward a natural birth without medical interventions.

Where does this leave us? In a place of great opportunity. Neither the narrow three-goal vision of the skills-based childbirth trend nor the “say no to medical intervention” choice-based childbirth trend has increased non-medical births and positive experiences.

Where do we go from here?

For the last 25 years, I’ve been the founder and director of the Common Knowledge Trust, an organization dedicated to sharing birth skills and evolving the conversation in childbirth. Since our trust’s inception as a registered not-for-profit in 1995 in New Zealand, our focus remains on two aspects of pregnancy and birth:

First, to grow the Concept: “It’s normal and natural when pregnant to self-learn birth and coaching skills then use those skills to work through the activity of birthing your baby in all births.” The Concept, of course, includes all skillsbased methods, because individual choices for preferred skills-based methods are equally essential. The goal of this Concept is to reduce suffering and increase conscious capability for both mothers and fathers in pregnancy and birth.

Second, to make available the Birthing Better skills-based method, specifically developed by hundreds of dads and moms in the early 1970s. The goals of Birthing Better are to use skills to prepare our pregnant bodies for birth as well as learn adjustable, adaptable, and sustainable skills to work through the activity of birthing our babies in all births.

Childbirth is so important. In hindsight, we had an opportunity in the 1960s and ’70s to refocus the skills based childbirth trend to include 100% of pregnant women and 100% of births with a simple and achievable goal of reducing suffering. Could we also achieve more natural births? Logic tells us that when women can birth effectively, and therefore cope better, then births are less problematic and birth providers are less anxious.

Looking forward, we have an opportunity for skills and informed choices to progress together. Ultimately, choices aren’t always available, and are subject to circumstance. However, each woman will always have to do the activity of birthing her baby. And we birth better when we are skilled—even with every type of assessment, monitoring, and procedure thrown at us. We cope better, manage well, deal with, work through, stay on top of, and feel more in control during birth, even if we dislike every moment of it for any number of reasons.

We are now 40 years into the choice-based childbirth trend combined with the opposition of medical versus natural; hospital versus out-of-hospital; and doctor versus midwife, which has produced a huge rise in anger, shame, blame, guilt, disappointment, frustration, and trauma. Everything can change easily once we get this new concept spread far and wide.

Expectant families are hungry for change. Change now must come from sensible and pragmatic birth providers and auxiliary birth workers, such as chiropractors and doulas. The message must travel down and across to millions of families, instead of a very few passionate women and men trying to bring the idea “upwards,” against all kinds of institutional pressures and barriers. We must want something that works across the board, and is sustainable into the future.

Common Knowledge Trust will work with any and all, as we have since the 1970s. It’s easy to imagine societies where it’s normal to learn birth and coaching skills and use those skills to work through this one-off, infrequent, can’t-be-replayed, dramatic, dynamic, life-transforming activity. We can also imagine a renewed relationship that will exist between midwives, obstetricians, and families when most birthing mothers and coaching fathers and partners are using skills that fundamentally shift the power back to the birthing family.