Sentenced to hard labour

Despite advances, women's experience of childbirth is still being dehumanised by medical practice, says Sheila Kitzinger

A psychologist, Marianne Morris, interviews 16 women about childbirth and concludes that women can be classified in three types: Romantic Princess, Romantic Hero and Functional (The Independent, July 5). Why are women always being labelled like this?

Romantics of both kinds are, she claims, at risk of being traumatised by "the most painful experience in a woman's life-time". They look at birth through rose-tinted spectacles or are determined to put on a heroic display, exhibiting a masochism that takes pleasure in excruciating pain. Functionals are level-headed and reasonable. In the paper she presented to the British Psychological Society she quoted Functionals: "As soon as it gets painful they can take over" and "It will only ever be what I want if I'm knocked out cold before anything happens."

There is, in fact, nothing particularly rational about such attitudes and women who plan a completely pain-free birth are often deeply shocked by the reality. The experience of birth is far more complex than this exclusive focus on pain. It depends a vast amount on the quality of the environment in which birth takes place.

That has nothing to do with whether there is a patchwork spread and a rocking chair or a TV set and everything to do with the relationship with those who give care. Many normal labours are made complicated, and apparently easy births made painful and frightening, because a woman's wishes and values are ignored or trivialised and her body is treated like a clapped- out machine that needs constant surveillance and advanced engineering to get it started and keep it running.

To pronounce on women's birth experiences as if they were the consequence of our own deranged psyches is to twist and falsify what women are saying about childbirth. Women are not responsible for bringing on themselves distressing experiences because of unrealistic expectations. Responsibility lies with hospitals in which the requirements of the institution take precedence over the needs of women and where the system of care is hierarchical, rigid and insensitive.

In many hospitals women have labour induced automatically if they go past their due date by 10 days or two weeks. They are harpooned to an electronic foetal monitor in spite of the evidence that electronic monitoring does not save babies' lives or produce them in better condition and that it often leads to emergency Caesarean section for no good reason. Women are subjected to the protocols of Active Management, which impose a time- table that does not permit any labour to continue beyond 12 hours, whatever a woman's wishes.

The whole procedure is clock-watched and the uterus stimulated artificially to force it to conform to the rules. Think of being required to empty your bowels, digest your food, or make love, while an expert stands over you critically observing your performance and with an anxious eye on the clock. Finally the woman's genitals are incised with an episiotomy to get the baby out more quickly.

All three "types" of women whose interviews were printed in the Independent, were distressed by their loss of control. It didn't matter how they were labelled. There is plenty of good research which shows that when women are disempowered in childbirth the experience is traumatic and is often remembered as a kind of rape, with long-term effects on personality and close relationships.

As a social anthropologist of birth, researcher into women's experiences and counsellor with the Birth Crisis Network, I have listened to thousands of women's birth accounts. While most women of all social classes, levels of education and cultural backgrounds are concerned about pain, it is not that they seek a promise of instant anaesthesia. Rather they want ways of handling pain that enable them to remain in control. They require accurate information, choices between alternatives, and to be able to make their own decisions. That may include the decision to hand over to the professionals. Vital is a continuing relationship with a skilled and understanding helper, giving unwavering emotional support.

Through the centuries and all over the world, women have formed a strong network of support for birthing women. Despite a popular Western myth that "primitive" women give birth completely alone, that is rarely the case. The traditional midwife is one of a group of women, family and neighbours, who give practical help and who also often enact powerful rites of birth which have deep religious and spiritual significance. The midwife choreographs a drama that reinforces female friendship and interdependence in the community.

In medieval times, a woman called on her God-Sibs, literally "sisters in God", to support her. The many Siennese paintings of the Virgin mary giving birth depict domestic scenes of women tending mother and baby. Till well into the 20th century this was the typical birth setting throughout Europe. Birth was an affirmation of women's friendship and understanding of each others' needs. Men were turned out of the house and women took over. The word God-Sib gradually changed in male language to "gossip".

In North American pioneer settlements there was a dearth of women to assist at birth, with women often travelling great distances to be with each other. The norm became: "I'll come and sew a quilt, make baby clothes, prepare the borning room, look after you at the time of birth, cook meals and take over the work in the orchard and dairy in the weeks after, and you'll come to me when I have my baby."

This was social childbirth. It is worlds away from the medieval model. Though we should welcome obstetric intervention when it is used appropriately and with discrimination, we should also recognise that we have lost something precious. No woman should have to give birth under the gaze of perfect strangers, feel that she is a product on a conveyer belt, or have her body handled like a carcass in an abattoir.

We can start to reclaim the social model of birth when there is one-to- one midwifery care - when a midwife becomes a friend during a woman's pregnancy and cares for her during birth and post-partum. It is not an impossible dream. In an area of London covered by the Hammersmith and Queen Charlotte's hospitals a one-to-one system of midwife care for 800 women every year has proved safe and is much preferred by women. It leads to fewer birth interventions, and is no more expensive than the standard model.

A research report, The Evaluation of One to One Midwifery Practice, by Dr Christine McCourt and Professor Lesley Page will be published by the Centre for Midwifery Practice at Thames Valley University in September. It reveals that with a midwife whom they already know and who is not flitting from one task to another with different women, women in labour need fewer pain-relieving drugs, and that the drugs work better if they are required.The epidural rate is much reduced, women are less likely to be tethered to a monitor, less at risk of episiotomy and more likely to have an intact perineum. They feel more positive about the birth, their own preparedness and how well they managed. Most women who had personal midwife care found birth "hard work but wonderful".

To give birth is an intimate, sexual and intensely personal act. A good midwife understands this. She provides more than technical expertise, careful observation and manipulative dexterity when it is needed. She gives herself. She is a strong anchor in the stormy sea of labour. She is a skilled companion who can be relied on utterly because she understands what you seek, and is committed to you. The humanisation of birth depends on developing one-to-one mid-wifery care.

The writer's 'Pregnancy and Childbirth' has sold more than 1 million copies.

Andreas Whittam Smith returns next week from holiday.