Birth, pain, and why we still need feminist obstetrics

Today the Observer published an extremely alarming report that Dr Denis Walsh, “one of the countries most influential midwives,” has argued that women should be receiving less pain relief in child-birth, in favour of “yoga, hypnosis, massage, support from their partners, hydrotherapy and birthing pools as natural ways of alleviating their pain.” Walsh mixes up a few different arguments for this, some of which are medical (the risks of pain relief, particularly epidural) and some of which quite clearly are not. He writes that that “over recent decades there has been a loss of ‘rites of passage’ meaning to childbirth, so that pain and stress are viewed negatively”, and that “pain prepares women for the demands of motherhood.” I am not a medical professional, so I will abstain from commenting on the truth or falsity of his medical claims, but I would like to call into question what Walsh has to say about the socio-cultural aspects of birth. That being said, in phrasing this attack in these terms, I am already doing damage to the project of feminist obstetrics insofar as a battle that has been strongly fought is for the integration of socio-cultural aspects of medicine into the discipline as a whole. Nonetheless, I think in this case the separation is justified if only for the sake of clarity.

I have to admit that I am no expert on medical ethics, but I do take an interest. I’ve been working for an organisation that is important in the practice of obstetrics and gynaecology as a temp for a few months now, and whilst my work has nothing to do with the medical or ethical side of obstetrics and gynaecology, I have taken the opportunity to spend a little time doing some reading around the profession. So, upon seeing this article this morning, I dug out my mother’s old copy of Wendy Savage’s A Savage Enquiry, so as to get into the mindset of some good old feminist obstetrics in an attempt to form a critique of Walsh’s comments. Wendy Savage was a significant obstetrician and gynaecologist working at The Royal London Hospital, when she was suspended from practice in 1985 over alleged incompetence. Her practice focussed on the empowerment of women in giving birth, and challenged the dominance of the consultants in the process of a woman giving birth. She was exonerated during an enquiry in 1986, and went on to write A Savage Enquiry as a personal account of the suspension and the campaign against it. Whilst her book focuses particularly on Caesareans and breech presentation, some of the politics is important for formulating a feminist response to the comments made regarding pain management in birth in the Observer today.

A large part of Savage’s argument in the book is about the dangers of surgical intervention, and her preference for natural means of birth. She writes, “Women throughout the country have realised that they have the right and the power to see that the health services they get are the ones they want (pp. 73 – page references refer to the old Virago edition), and goes on to say that “[a]lthough obstetricians justify their takover of birth by reference to the improved outlook for mother and baby, and although there have been many advances for which women are grateful, there are still a large number of situations about which doctors lack adequate information to say which is the best course of action. My philosophy, in which I am not alone, of involving the woman in the decisions about her care, means that the obstetrician must relinquish some power.” (pp. 176)

Whilst Savage is a staunch defender of “natural”, or vaginal birth where possible, what is clear is that her reasons for this are medical. She believes that the best care for mothers and babies is this sort of birth (better survival rates, less risks of complications, and less trauma for the woman,) and it is on this point that Walsh comes somewhat unstuck. In the quotations from his recent article in the Journal of Evidenced Based Midwifery, he too is arguing for natural births when possible, but alongside the aims of survival, safety, and recovery he introduces a number of more dubious political objectives: natural childbirth for the sake of being natural; a return to birth as a rite of passage; and pain as a means of preparing a woman for motherhood. In fact, he is completely explicit that pain-relief may be desirable but advocates “natural” methods over conventional pain-relief, seemingly giving no other reason than the fact that they’re natural.

Outside of the context of birth, some of these objectives can be examined in greater depth as a means of exploring their underlying conservatism, and ultimately their challenge to feminism. The demand for rites of passage is a very strange one to hear from a medical professional today. Historically rites of passage have been brutal, and one would wonder whether Walsh would equally justify circumcision (both male and female), in order to preserve cultures in which these practices are dominant. Furthermore, rites of passage have for so long been a key means by which women have been (and are) disempowered: Through marriage women have become subservient to men; and through childbirth women have become subservient to the structure of the family.

Walsh writes that “Celebrity births, television portrayals of labour as a highly medicalised process and films such as Knocked Up have added to a culture where pain relief seems normal, even though labour pain is natural, healthy and temporary.” He fails to mention that in many case the avoidance of pain regardless of the fact that it is natural, healthy and temporary may actually be desirable, not least for the woman involved. Furthermore, the argument that pain is a good preparation for motherhood is at the very least problematic; there is an implication that those women who choose to have an epidural are for that reason worse mothers. As an aside, I am also reminded of a line from an aria in Humperdinck’s opera Hänsel und Gretel, in which the father sings “Hunger ist der beste Koch!” [Hunger is the best cook!] Well of course, those who are hungry enjoy their food more, but I am yet to be convinced by an argument that we should starve ourselves so as to create a healthy relationship with food.

It would be unfair, though, for me to suggest that Savage and Walsh are diametrically opposed. Whilst Savage doesn’t talk much about pain-relief in A Savage Enquiry, she does say that “men […] have the feeling that they have got to do something about the pain, about the way the labour is progressing, whereas women, who know that they will probably go through this experience, even if they have not already been through it, understand that it is a very important part if how a woman functions in life, and that there are worse things in life than pain, and that to go through the process of pregnancy and labour and be in control of it is a very important part of a woman’s self-esteem.” (pp. 137) She also writes that one of the key points of her obstetric philosophy is that “Midwives and doctors must have clear reasons for procedures and birth management options” (pp. 88) It is really only with reference to Walsh that we are able to come to a resolution of this seemingly intractable contradiction within the feminist viewpoint of a woman’s wish for pain-relief and the demand for a medical procedure that is in itself not medically necessary.

Walsh writes that, “many women avoid experiencing the discomfort of childbirth because hospital maternity staff are too quick to offer an epidural or agree to a woman in labour’s request for a pain-killing injection in her back to ease her suffering.” (italics mine) What has happened in the 23 years since the publication of A Savage Enquiry is the normalisation and democratisation of epidural as a medical procedure. Whilst previously medical intervention was used as a means of subordinating the woman, what Walsh unintentionally shows with absolute clarity is that the refusal of the procedure is now the means by which women can be subordinated and controlled, most worryingly to fit in with his conservative views of womanhood and motherhood.

It may be the case that we need further discussion regarding the dangers of medical intervention, but this discussion should take the form of education, in which women (and people in general) are empowered, rather than simply refusing the treatment, and with that disenfranchising women from the control of their bodies and their experiences.

Wendy Savage published Birth and Power: A Savage Enquiry Revisited in 2007, which contains essays on a number of related issues alongside the full text of her original book on the enquiry.