The American way of Birth 
by Jessica Mitford.
Gollancz, 237 pp., £16.99, October 1992, 0 575 05430 1
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Suffering pain, writer’s block, and the rage of critics, Philip Roth’s hero Zuckerman resolves to quit writing fiction and go to medical school. ‘Who quarrels with an obstetrician?’ he reasons:

He catches what comes out and everybody loves him. When the baby appears they don’t start shouting: ‘You call that a baby!’ No, whatever he hands them, they take it home. They’re grateful for his just having been there ... Conception? Gestation? Gruesome laborious labour? The mother’s business. You just wash your hands and hold out the net.

Poor Zuckerman. What an ill-informed – and male – view of the matter! Clearly he has never dipped into the vast popular literature on childbirth, which blames the obstetrician for everything – from the quality of the baby that appears to the quality of the experience of that ‘gruesome laborious labour’. Most American obstetricians, terrified of malpractice suits and broken by astronomical insurance premiums, would give their eye-teeth for nothing more hostile to contend with than bad reviews.

In 1963, when Jessica Mitford’s American Way of Death was published, America was in the middle of a full-scale critique of its mores and institutions. This was the golden age of the exposé. Vance Packard’s Status Seekers, Alvin Toffler’s Future Shock and Galbraith’s Affluent Society all performed the rhetorical feat of revealing what was beneath our very noses – of digging deep to uncover the sordid surface of American life. Back then, Mitford still placed terms like ‘status symbol’ in quotation marks, and caused genuine surprise and outrage by describing the American funeral industry as ‘a huge, macabre and expensive practical joke on the American public’. An ethnographer of consumer life, she discovered a ‘new mythology’ among funeral directors selling their ‘grief therapy’ both to the public and to themselves. She found that crematoria required coffins for corpses because they were in the business of selling coffins, and that embalmers sacrificed the preservative powers of their art in the interest of high production values at the funeral. Equally scandalous were the industry’s sins against language. Grotesque advertisements made coffins such as the Colonial Classic Beauty sound like the latest model of racing-car with their ‘18-gauge lead-coated steel, seamless top, lap-jointed welded-body construction’. Professional delicacy dictated that a burial plot purchased before one’s death be termed a ‘pre-need memorial estate’. The industry justified its lies and euphemisms on the grounds that it was giving the public what it wanted, the same dispiriting argument that continues to justify the abysmal mediocrity of American television (and much else).

The shock value of Mitford’s exposé depended on the novelty of the idea that something as painful, personal and natural as death could be accommodated to the sales strategies of business. But in the 29 years between Mitford’s Death and Birth we have experienced Woodward and Bernstein on Watergate, documentary photos from Vietnam, the Iran-Contra hearings, Foucault’s deconstructions of the ideology of institutions, the reports of Ralph Nader and his consumer watchdogs, feminist critiques of the crimes of an all-pervasive patriarchy, revelations of widespread child abuse and incest, new-journalistic explorations of the criminal mind, and endless press leaks about the secret love-lives of notables. It sometimes seems as if ‘routine news reporting’ is an empty category, that the only news (and scholarship) that counts is an exposé, and that anything looked at through the searching gaze of the consumerist, the feminist, the cultural critic will turn out to be a scandal.

After endless reports about the sins of the medical establishment, The American Way of Birth seems both tame and self-serving: ‘tame’ because the scandal is by now familiar, and ‘self-serving’ because it is used to validate one particular narrative of childbirth – that of Mitford herself. Her book begins with an account of the births of her four children, the first in England at home with a midwife and an ether-wand which Mitford held to her face to calm the pain. Each of the three successive births was more alienating than the last, as modern obstetrics and American exile moved her from home to hospital, female to male attendant, and numbed consciousness to full anaesthesia. The joyful first birth makes a wonderful story which is presented as an ideal that Mitford wishes all women could share.

Some women hate their obstetricians because they ruin what might otherwise have been a profoundly self-validating story. For Mitford, a good childbirth story requires the birth of a healthy baby by a mother in control of the situation. There are probably few women who would disagree. Mitford had such an experience with the birth of her first child, and her investigations have led her to believe that this was no accident, since midwives are non-interventionist, empathetic to women, and inexpensive – everything that male obstetricians, she claims, are not. A raft of distinctly bad stories follows: stories of births marred by the erroneous reports of intrusive machines such as sonograms and electronic foetal monitors; by unnecessary and debilitating Caesarean sections, episiotomies and induced labours; by total anaesthesia and the strapping of women to delivery beds in positions that force them to work against gravity. All these horrors Mitford blames on men. And she is not alone. An anonymous hand, she reports, has added to the index of Williams Obstetrics (1980) the following entry: ‘Chauvinism, male, voluminous amounts, pages 1-1102.’

If gravid women have suffered at the hands of medical science, midwives have fared even worse. ‘All wickedness is but little to the wickedness of a woman,’says the Malleus Maleficarum, which goes on to claim that the wickedest women of all are midwives. ‘Are medieval witch-hunts a parallel to the persecution of midwives by today’s medical establishment?’ Mitford asks. ‘Not exactly a parallel ... It’s more a continuum.’ The suppression of midwives – to the point of police raids on their houses – is today an especially American phenomenon. Midwives are the principal birth attendants in Europe: they have been virtually eliminated, according to Mitford, in the United States.

Peter Chamberlen, a Huguenot barber-surgeon whose family settled in London, invented the forceps in 1588. The family kept it a secret for over a hundred years, travelling about to attend the births of those wealthy enough to pay for their ministrations. Not only does Mitford present this as a typical case of men getting rich at women’s expense: she always seems to imply that forceps were another of those interventionist devices that did more harm than good. At the same time she notes that ‘until the advent of forceps, there had been no live deliveries of births which presented unusual difficulties. Instead, to save the mother’s life, various hooks and a nightmarish instrument called a cranioclast were used to break open the child’s skull, dismember it, and drag it out bit by bit.’ In the circumstances, it’s rather hard to share Mitford’s disdain for the instrument.

Mitford is nothing if not consistent: every advance in childbirth technology is shown to be an advance in the power of the male medical establishment at the expense of the humane midwife. When Dr Ignaz Semmelweis discovered in the mid-19th century that physicians could eliminate puerperal fever by disinfecting their hands on their way from the morgue to the maternity ward, he was driven out of the profession. Doctors were apparently unwilling to believe that they could be a danger to their patients. Needless to say, puerperal fever was unknown in home births using midwives. A young Victorian noblewoman who developed a bulge in her abdomen was declared pregnant by physicians who did not feel free to examine her beyond the point of ascertaining that she was a virgin. Virginity was apparently no proof against pregnancy, and good manners stood in the way of men looking more closely at pregnant bodies – at any rate if they had upper-class owners. The lady soon died of what turned out to be a tumour. Midwives would not have been so shy.

Another harrowing story concerns a 19th-century American doctor, James Marion Sims, who was dubbed the ‘Architect of the Vagina’. Because only the poorest women gave birth in hospitals before the 20th century, physicians found in the wards a ready supply of powerless subjects for experimentation. Sims used black slaves and Irish immigrant girls to discover which vaginal sutures would not become infected. Some patients reportedly underwent over forty surgeries without anaesthesia until Sims hit upon the silver sutures that made him rich.

When chloroform was introduced into the delivery room in 1847, the Anglican Church disapproved. Chloroform, they said, was ‘a decoy of Satan, apparently offering itself to bless woman, but in the end it will harden society, and rob God of the deep earnest cries which arise in time of trouble for help.’ In this case, the interests of women and the medical profession coincided. Dr James Young Simpson defended the drug by noting that God himself favoured anaesthesia as when he ‘caused a deep sleep to fall upon Adam’. Born of a sleeping man, why should women not sleep as they gave birth? Queen Victoria herself was an enthusiast, and chloroform came to be known as anesthésie à la Reine.

The first Caesarean section in which both mother and child survived, Mitford reports, was not performed until 1500 when Jacob Nufer, a Swiss pig-gelder, saved his wife by delivering her baby this way. We are apparently supposed to see poetic justice here, as if a woman-friendly Caesarean has some direct connection to gelding. In any case, the medical profession quickly turned the operation to its typically selfish purposes, so that nowadays it is used to ensure that births do not interrupt the doctor’s dinner hour. The fact that, in Brazil, 90 per cent of private-clinic births are elective Caesarean sections performed on women anxious to keep their vaginas ‘honeymoon fresh’ does not stop Mitford from blaming men for the prevalence of the operation.

Current childbirth practice in America is, she claims, the culmination of this whole sad story. In 1900, fewer than 5 per cent of American births took place in hospital. By 1970, the rate was virtually 100 per cent. Between 1970 and 1988, Caesarean sections rose from one in 20 to one in four births. At the same time, the United States is 24th among Western industrial nations in rates of infant mortality because of the health system’s neglect of the poor, the uninsured, teenage mothers, and alcoholics and drug addicts. Again Mitford blames ‘the passing of power over the birth process from traditional female to professional male’ for creating this state of affairs.

None of the statistics will come as a surprise to any middle-class woman who has borne a child in the United States in the past twenty years. The Natural Childbirth movement has done its job; feminist historians have presented a much fuller account of medical misogyny than Mitford attempts; and the callousness of the private health insurance system is apparent to anyone who walks through American cities. As an exposé, a consumer manual, or an incitement to social reform, The American Way of Birth is a distinct anti-climax. Far worse than this, it fails to inquire into the reasons why women, however much they resent the obstetric establishment, are at the same time so willing to co-operate with it. The trouble cannot simply be men. In an aside, Mitford reports the wretched treatment of Russian women in maternity wards which are wholly run by female doctors. In a parenthesis she admits that ‘it does cause one to reflect on the generally accepted view that male domination is responsible for the many indignities visited upon women in childbirth. Could there also be another component – that regardless of gender, absolute power wielded over the powerless in enclosed institutions such as prisons, insane asylums and hospitals creates the potential for abuse?’ This interesting hypothesis does not survive its parentheses.

Surely one of the reasons women are so critical of their obstetric arrangements is that the experience of pregnancy and parturition is marked by powerlessness. Though men are allegedly cowed and resentful at woman’s pro-creative capacities, any mother will remember a sense of bewilderment surrounding the event, the feeling of it all happening without her control. Despite the most elaborate training in childbirth techniques, the event has a pace and a character that knowledge cannot tame. One goes through it – suffering it, co-operating in it, waiting for it to be over – but despite all the informed decisions, despite consciousness and skilled breathing and superhuman pushing, one is at the will of one’s body, a body grown unfamiliar and astonishingly violent.

Mitford is disdainful of physicians like Joseph De Lee who consider all births inherently pathogenic. ‘It always strikes physicians as well as laymen as bizarre,’ he wrote, ‘to call labour an abnormal function, a disease, and yet it is a decidedly pathological process.’ Though we have been trained to believe that labour is normal, healthy, and in 90 per cent of cases without complication, it creates in a woman all the subject-object, mind-body disjunction of disease. One can never know, moreover, that one’s labour will not fall within that 10 per cent that is pathogenic. A ‘natural’ process that feels abnormal and may turn out to be so, labour provokes the unease and resentment of a story whose protagonist may turn out to be a victim.

Our consumerist, scandal-sensitised, anti-institutional sensibility fights powerlessness with information. And it does not take much acuity to detect the strong propagandistic bent of much childbirth training. Mitford likes a birth in which the mother participates fully, painlessly, and with no nonsense, and her book validates such a preference. Thus, she describes husbands’ participation in childbirth classes with a certain disdain, and thinks devices like the Empathy Belly (a heavy vest that fathers wear to experience the swollen flesh and backache of pregnancy) are downright laughable. Though I would hope empathy might arise more spontaneously, I find nothing silly about wanting an understanding ally in the delivery room, and I was very glad to have had one.

My two children were born after totally uneventful and mercifully short labours – four hours for the first, three for the second. I used no anaesthetics. My obstetricians were women who had had babies of their own and who had looked after me before the births. By the time my second child appeared, the hospital had acquired a reasonably pleasant delivery room complete with armchairs and a television. I was alert throughout and ostensibly in control of myself. ‘Mrs Steiner, stop screaming and push,’ the doctor instructed me at one point, and without hesitation I did just that.

The event had rather gratifying drama as well, for after I had dutifully walked about the hospital corridors, halting to pant when a pain came on, suddenly I felt that the time had come to stop walking. I climbed onto the bed and said to my husband: ‘I think the baby’s coming.’ He remembered the intercom and reported what I had said, and in case there was any doubt I thought it wise to yell out. In seconds, a crowd of white-coated attendants rushed in, reading charts, washing hands and tying gowns. One thrust her gloved hand into me and exclaimed, ‘Complete. Complete,’ meaning that both full dilation and effacement of the cervix had occurred, and that the second phase of labour was beginning. A part of me fell very proud at having achieved so much in such a short time and at having remembered about dilation and effacement on top of it all, and it is that part of me that has constructed this story so far.

Mitford gives a helpful explanation of what was happening:

the first phase of labour begins when contractions are occurring regularly every five minutes or so, and there is progressive opening and thinning of the cervix, which is at the lower end of the uterus. It ends when the cervix is fully dilated, meaning approximately ten centimetres, and when one can no longer feel the cervix as a separate entity on vaginal examination ... And the second stage? ... from complete surgical dilation ... until delivery of the baby. Third stage is from delivery of the baby to delivery of the placenta.

How many times had I gone over these stages in classes, along with all the dangers and complications each stage could present? How little relevance this information actually had to my experience! The last phase of the first stage was called transition, and I remember wondering in a panic whether I was in transition yet or whether I had somehow missed it. I had heard that births which were too quick often left women with a sense of incompletion. Would that happen to me? What a confusion it was to have a schema of organs and stages and actions that had to be thought about – one kind of breathing for early first stage, another for transition, huge gulps of air for the second stage. I focused on a spot on the wall and panted. After all, that is what I was supposed to do and I was going to do it right. I was not going to be the irrational ‘cow’ that all the books said chauvinistic males thought labouring women were. Yet nothing I felt had anything remotely to do with the cervix and dilation and thinning and the euphoria of control. It hurt terribly and all the breathing and focusing did not change that. I felt exhausted, moreover, keeping up this double consciousness. I was split in two. I obviously had a clever body that was proceeding quite efficiently without me, as my eyes rolled back in pain. Where had the scream come from that made the doctor say: ‘Mrs Steiner, stop screaming and push? Was I screaming? How extraordinary’.

And then there was a baby’s head I was supposed to look at in a mirror because that would be encouraging and fun, but it was hard to get the angle right in the mirror, and besides, I am myopic. I stared up and found the mirror and nodded as the doctor said, ‘See the baby?’ though I was not sure I had seen anything at all. But it was time to push again to the count of ten, and who could worry about mirrors? I pushed the baby out. I could actually feel it as it left me. And then my body stopped doing all the things it had been doing for the past few hours. The baby was being tended to somewhere else, and everybody was busy with it – the ‘he’ and ‘she’ blend into one generic baby in my memory – and I was content to lie there doing nothing until the nurse said ‘push’. I thought she had missed something – it was all over, wasn’t it? – but then I remembered phase three and desultorily pushed out something I paid no attention to. And then the nurse was pressing hard on my abdomen, and I looked at her resentfully. This was not kind, I thought, but she said it was important and I grumpily and without proper breathing or focusing or control got through it. And then they brought the baby to me and everyone was pleased.

Sally Mann, whose photographs of her children are causing a stir in the United States, has an extraordinary image of a birth. She herself is on a delivery table. At her shoulder stands an enormous camera, and she is reaching for a cord attached to the shutter to catch on film the moment when her baby will emerge from her. Her husband, invisible in the scene, is the one taking this picture. All these elaborate preparations have been made to record the baby at the instant of its appearance. But all we see of it is a blur. This photographing of the photographing of birth, this picture of foiled female control, holds a pathos that we might well ponder.

Mitford quotes a woman who underwent an apparently unnecessary Caesarean as saying she was cheated of the birth experience: ‘I felt the whole process of birth had been orchestrated by the medical staff instead of by my body.’ I had had no Caesarean, and yet I, too, feel cheated. My body and the medical profession had conspired to take control of the process of birth – the one by flaunting before me the absolute power of the involuntary, the other by filling my mind with anatomical diagrams and physiological schedules and strategies of control that had seemed foolishly irrelevant and distracting at the time of labour.

Should you think me impossible to satisfy, you are absolutely right. There is no way for consumerism and medicine to write me a perfect birth story because to some degree – to put it abstractly – labour deprives one of agency. Of course, I am grateful to be able to tell a story that has no disaster in its script or that does not read as an allegory of female degradation at the hands of insensitive men. But I cannot say that I triumphed or prevailed or even persevered, as proper heroines or even protagonists are supposed to do. The birth took place, I played my voluntary and involuntary parts, and luckily there were no complications. The best thing to be said about the whole business was that it produced two very nice babies and a wry story.

Jessica Mitford is surely right that we should give all women and children an equal chance for a healthy delivery, and she is probably right that obstetricians have not covered themselves in glory in the past. Maybe midwives are the answer, though I cannot imagine less interventionist deliveries than the two I experienced with doctors in a hospital. But Mitford is surely wrong if she thinks the problem is as simple as kicking men out of obstetrics. Even if we could create a world in which there was no one to blame for our childbirth stories but ourselves, they would still be oddly unsettling stories.

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