It is notable that although childbirth had been socialised for thousands of years, women always tended to protect the birthing place against the presence of men, particularly medical men. There were many strong objections to male attendance; during the sixteenth century in Hamburg, a doctor was condemned and burnt alive after disguising himself as a woman in order to see a birth. At that time, it was said, women were prepared to die rather than admit a man to the lying-in room.1 This is not to suggest that male physicians rarely interested themselves in childbirth, but their influence was discreet and indirect. Their roles concerned two spheres of competence. One was to intervene in desperate situations when the midwives called. Before the invention of forceps, usually all a medical man could do was to remove the infant piece-meal using hooks and perforators, or, if there was still hope of delivering a live child, to perform a caesarean section on the mother after her death.2 The realm of instruments is eminently male. The other sphere of competence of literate male physicians was writing about childbirth, mainly for the purpose of educating midwives and instructing other physicians on the supervision of birthing women. Hippocrates, Aristotle, Celsus, Galen, Soranus of Ephesus and other
writers on medical matters devoted part of their works to this subject. The realm of books is also originally, and eminently, male. Since the medical man was called only for disasters, he had little opportunity to gain a real understanding of the birth process and the basic needs of labouring women. This history helps us interpret the deep-rooted and widespread lack of understanding of birth physiology.
However, despite thousands of years of culturally-controlled childbirth during which the basic mammalian needs of the labouring women and of the newborn babies were ever-more denied and even ignored, and in spite of the indirect influence of male medical men, women were still giving
birth in predominantly female environments—until the middle of the
twentieth century. Around 1950, in the case of home birth, childbirth
was still “women’s business’’. The doctor—usually a general
practitioner—was called at the last minute to use forceps or to witness
a disaster. The husband was either in the pub, or the café, or he was
given a task such as boiling water for hours. At that time, even for a
hospital birth, the environment remained eminently female. The ‘’knitting midwife’’ was the central person in the maternity unit.3
There was a very small number of specialised doctors who were almost
invisible, appearing suddenly if the midwife called them for a forceps delivery, and disappearing as quickly as possible after the birth. In
the maternity unit where I was an ‘externe’ the doctor in charge spent only minutes in his office every morning, listening to a fast report of
what had happened during the previous twenty-four hours and, occasionally, talking with the medical students. As a male medical
student, I did not dare enter a room where there was a
woman in labour.
I could only appear during the second stage, because I was supposed to
learn the use of forceps. Of course, at that time, nobody could even
imagine that the baby’s father might be introduced in the maternity
unit.
After the turning point
It was just after the middle of the twentieth century when the
atmosphere started to be “masculinised”. The number of doctors
specialised in obstetrics increased at lightning speed, and almost all
were men. Later on, during the second half of the century, other
specialised doctors were introduced into the birth environment, such as
neonatologists and anaesthesiologists. Around 1970 an occasional woman
made a new demand (as a way to adapt to the ‘industrialisation of
childbirth’) for the participation of the baby’s father at birth. It
became almost overnight a doctrine supported by theories: the
participation of the baby’s father at birth became within some years an
undisputed “rule”. At the same time, sophisticated electronic machines
invaded the delivery room: high technology is a male symbol. There was
such indifference to the gradual masculinisation of the birth
environment that there were no serious discussions when midwifery
schools started to accept male pupils. Furthermore most schools adopted
such selection criteria that in some countries a young man with a good
scientific background could more easily be selected
than a mother of
three. There are countless stories of women who gave birth (or, rather,
were delivered) under the control of an electronic machine, in the
presence of the baby’s father, a male midwife, and a male doctor. The
almost total masculinisation of birth had been achieved.
One simple question
Is this masculinisation of the birth environment the main factor why
today, at a planetary level, the number of women who deliver babies and
placentas thanks only to the release of natural hormones is approaching
zero?
I am personally convinced that the best possible environment for an
easy birth—even for many modern women—is when there is nobody around
but an experienced and silent midwife or doula, perceived as a mother
figure. I learned this in the time of the ‘knitting midwife —the early
1950s. I became gradually more aware, during my career as a hospital
practitioner, of the turning point in the masculinisation of
childbirth. And I am relearning this today when, occasionally, I attend
a home birth, making the baby’s father busy in the kitchen or elsewhere
around the house, leaving the labouring woman with only one person
around—experienced, motherly and silent. However, in the present age of
evidence-based obstetrical and midwifery practices we cannot rely on
clinical observation to provide an answer. At the same time, the “golden method” cannot evaluate the effects
of different degrees of
masculinisation of the environment on the birth process and on the
first contact between mother and newborn babies. That is, randomised
controlled trials (RCTs) are not feasible. This is why international
comparison is one of the best approaches.
International comparisons are valuable because the alteration of the
birth environment in industrialised countries, although a global
phenomenon, did not occur simultaneously and at the same speed. Number
one among countries where masculinisation started early and developed
at a high speed was the USA. Very early during the second half of the
century, there was such a surplus of American obstetricians that most
of them had the time to be involved in every birth: they became ‘primary care-givers’ instead of being experts only in unusual and
pathological situations. Furthermore, in the USA, the doctrine of the
husband/partner participating in the birth was already well established
in the early 1970s. A similar surplus of (mostly male) obstetricians
had also existed for a long time in most Latin-American cities. In sum,
the turning point started earlier and developed more quickly on both
American continents than anywhere else.
At the other end of the spectrum, the masculinisation process has been
delayed in a certain number of countries. Obstetrics in Ireland is
usually associated with the concept of ‘active management of labour’,
using strict pre-establis
hed criteria to control the speed of labour.
Yet, the routine presence of the father in Irish births was delayed
until the late 1980s. The unique characteristic of the socialised Dutch
system of midwifery and obstetrics is that the midwife is officially
considered the primary care giver. The obstetrician plays the role of
the expert adviser on demand. In Holland about 30% of the births still
occur at home and childbirth in Holland has not been highly influenced
by the theories of most Western natural childbirth movements. The
traditional behaviour of the husband going to the pub or being busy in
the house persisted longer there than elsewhere. The concept of the
couple giving birth appeared much later than in other western European
countries and likewise the masculinisation of childbirth followed a
different and slower route.
Outside Western Europe, Russia is a country where the masculinisation
process has been delayed. During the communist regime most
obstetricians were women and there were many midwives. At that time
fathers were not permitted to enter the maternity units. In 1992, I saw
a mother showing her baby to her husband through the window of a
maternity unit in Moscow, while he had to stay outside, in the street.
As recently as 2006, when visiting maternity unit no.10 in St
Petersburg, all the obstetricians I met looked like nice
grandmothers—even the chief neonatologist looked like a grandmother.
Midwives we
re abundant, and fathers were not yet routinely introduced
to birth units. Now, suddenly all aspects of the Western lifestyles are
becoming widespread in Russia, affecting the birth environment.
Ireland, Holland, and Russia share another common point. The
spectacular ascendance of caesarean sections has been delayed as well.
The incidence today is similar to elsewhere. We can therefore claim
that there is an association between the masculinisation of childbirth
environment and high rates of obstetrical interventions, particularly
caesarean sections. Of course, in order to interpret this association,
we must take into account that in some particular cultural milieus the
inhibitory effect of a male environment might be stronger than
elsewhere. This might be the case, for example, of Southern Italy, a
region influenced by Arabic cultures, where the rates of caesareans are
skyrocketing. Anyway the main question remains: can we claim that there
is a cause and effect relationship explaining this association? Can we
claim that the difficulties in childbirth are related to the degree of
masculinisation of the environment? Can we trust the experienced doula
saying that oxytocin, the ‘shy hormone’, is shyer in a male than in a
female environment?
We can also assume—and this is not contradictory—that the
masculinisation of the birth environment has been originally a
consequence, or a proxy, of a deep-rooted lack of interest in the basic=20
needs of labouring women and newborn babies. If, half a century ago, it
had been easy to explain that all situations associated with the
release of adrenaline and with the stimulation of the neocortex tend to
hinder the birth process, the history of childbirth would have been
pushed in another direction. Simply, if it is had been understood that
a woman in labour needs to feel secure without feeling observed, the
specific role of the midwife as a mother figure would have been more
easily interpreted. If the theoreticians of the 1970s had realized how
contagious the release of adrenaline is, and if they had anticipated
that a man who loves his wife may release stress hormones at the wrong
time, they would have been more cautious before affirming the routine
participation of the father at birth. If obstetricians had anticipated
that the use of continuous electronic fetal monitoring might be
perceived by labouring women as a way to observe their body functions,
and therefore to stimulate their neocortices, they could have predicted
the results of the many RCTs indicating that the only constant and
significant effect of these new inventions was to increase the rates of
caesarean sections. Finally, all aspects of the masculinisation of the
birth environment appear as direct consequences of deep-rooted
ignorance of physiological processes. This can be expected after
thousands of years of culturally controlled childbirth.4
It is no
table that in the scientific context of the twenty first
century, preliminary signs of a ‘de-masculinisation’ of birth
environment are already visible. The doula phenomenon has reached
global dimensions; it might offer an opportunity to rediscover
authentic midwifery. The only fact that today it is becoming
politically correct to discuss the doctrine of the father’s
participation is also highly significant.
Practical conclusion
The priority is to re-discover the basic needs of women in labour and
newborn babies. Since no cultural model exists, we must rely on simple
physiological concepts, in particular the concepts of adrenaline —oxytocin antagonism and neocortical inhibitions. The ‘de-masculinisation’ of childbirth should not be the primary objective,
but rather a consequence of a better understanding of the physiological
processes during the perinatal period. We must phrase appropriate new
questions for absolutely new situations. This is the motive behind ‘The
Midatlantic Conference on Birth and Primal Health Research’ on 26 to 28
February 2010, in Las Palmas, Gran Canaria (details at
www.wombecology.com).
Michel Odent
References:
1-Von Siebold ECJ. Versuch einer Geschichte der Ger
burtshulfe, Berlin 1839
2- Donnison J Midwives and Medical Men. Heinemann, London 1977
3- Odent M. Knitting Midwives for Drugless Childbirth? MidwiferyToday
2004; 71: 21-22
4- Odent M. The functions of the orgasms: the highways to transcendence. Pinter & Martin. London 2009.
