The rate of premature birth (infant ‘preparedness’ to be born) has skyrocketed in the U.S. The medical focus is to complete gestation by means of technology (NICU) and to surgically repair damage to the infant, but has this attitude normalized birth of preterm babies, and promoted the concept of impaired fetuses as normal? Has Caesarian surgery become expected, like fast food?
The Role of Fear in the U.S. Birthing Process
by Colleen Bak
© 2003 Midwifery Today, Inc. All rights reserved.
Birth is inherently a female activity. The choice, the ability, the power to give birth is innately female. Historically women were the sole possessors of birthing knowledge and technique, and in certain cultures and time periods men feared them as a result of this (Arms 1996). In some places and times it was thought that women’s control over life also enabled them a certain control over death, and in others, female birth attendants were murdered as witches due to their ability to magically aid in the birthing process. As a result of their pivotal roles in birth and death, female healers “began to be shunned, persecuted, and often even put to death…women healers everywhere were driven underground by those who feared their powers” (Mauger 2000: 126). The social space of birth and how it is collectively understood has changed in many ways since these periods. Today, in the U.S., the hegemonic consensus of birth is currently situated in the masculine realm of science and medicine. The once natural event of female-centered birth has effectively been medicalized. Power and control have been removed from midwives and women and shifted to science and the surgical specialization within medicine, today known as obstetrics. This historical shift resulted in numerous changes in the conceptualization of the birthing process and women’s roles within it. One evident change has been the shift in the experience of fear. Whereas once men were the primary candidates to experience fear of women and birth, today women are the primary candidates to experience fear of and during birth. This shift was caused by numerous changes in the environment of birth as well as in the attitudes and techniques of those attending it, which was largely brought on through the medicalization of childbirth. The fear can partially be attributed to external stressors, such as the unnatural setting in which birth normally takes place in current society, the inadequate level of support women are often provided with and the current lack of understanding and familiarity women have of the process. These causative concepts will be discussed further, but first it is necessary to elaborate upon and explain the negative physiological effect that fear has on the birthing process and thus the importance of the structural changes necessary to alleviate it.
It is a naturally occurring factor of the human psyche to fear the unknown, and through the scientific veiling of the birthing process, birth has been transformed into the unknown for the majority of U.S. primiparas.
The emotional state of fear, on the part of the birthing woman, can have a negative impact on the progress of her labor and her overall experience of birth. The negative response to fear is often manifested through the slowing down or arrest of labor. This physiological phenomenon is observable in animals whose bodies have been shown to instinctively cease labor when a threat is perceived. “Animal studies have shown that when animal mothers are frightened labor stops. This may represent nature’s way to let the laboring female flee a potential danger” (Klaus, Kennel and Klaus 1993: 144). The same occurrence has also often been noted in women upon arrival to the hospital or the appearance of the obstetrician. The hospital, as well as the obstetrician, can elicit nervous reactions that can trigger an instinctive response toward potential danger (Odent 2002). To some women, they may personify their personal lack of power or decision-making and thus evoke fear and subsequently anxiety and stress via feelings of powerlessness.
These situations indicate the power of the mind-body connection, in that emotional changes are shown to affect the physiological state of the birthing woman. In her book The Thinking Woman’s Guide to a Better Birth, Henci Goer (1999) specifically warns women that, in addition to purely physiological occurrences, “fear, anxiety and other psychological issues can also hold up labor” (109). This is a difficult concept to accept and integrate into current U.S. culture, where the separation of mind and body has been universally accepted under the tenets of Cartesian Dualism. “The assumption that mind and body are separate, so can be treated and studied separately—described as dualism—has played an important role in the origins of biomedicine in Euro-American society” (McCourt and Percival 2000). Modern U.S. biomedicine is deeply entrenched in this concept and rarely focuses its care on the mental side of medical situations. On the other hand, holistic models of care focus principally on this connection. In fact “connection” itself is the primary doctrine of holistic care models, which state that “total healing requires attention to the body-mind-spirit-emotions-family-community-environment” (Frye 1998: 3). The examination of the role of fear in the U.S. birthing process involves the integration of aspects that affect both the mind and the body in treating the physical state, and thus is more holistic than the Western philosophical norm.
In the specific case of fear and anxiety, biomedicine is unable to ignore the connection entirely. This is due to the evidence of scientific studies that indicates that certain hormonal changes take place in the presence of the emotions of fear, stress and anxiety. Studies indicate that “these feelings heighten the perception of pain, and they can help elevate stress hormones (adrenaline and noradrenaline), which may slow or stop contractions” (Klaus, Kennel and Klaus 1993: 144). Adrenaline has been referred to as the antithesis of oxytocin, the naturally produced hormone that stimulates uterine contractions (Gaskin 2003). Another category of hormones (catecholamines, which include epinephrine, norepinephrine and dopamine) is indicated in other studies as one of the causative factors in fetal distress, as well as problematic labor. Catecholamines are neurohormones that “pass through the placenta to reach the baby…[they] circulate when the pregnant mother is anxious or afraid, and this affects the baby’s environment” (Wolf 2001: 109–10). Thus, as Naomi Wolf explains, the fetus is subject to the mother’s emotions in a physiological sense. Penny Simkin examined numerous studies concerning stress, pain and catecholamines in labor and found that maternal stress “causes increased maternal catecholamines production which may be related to dysfunctional labor and fetal and neonatal distress and illness” (Goer 1995: 100). This view of fetal danger is substantiated by French obstetrician Michel Odent (2002), who finds that “when a baby is made more fragile before being born through the stress hormones released by its mother, it is possible that the risks of fetal distress during labour are increased” (64). The physiological effects of stress, fear, and anxiety manifest through the maternal production of excessive levels of particular hormones. These hormones can serve as the body’s natural defense mechanisms against imminent danger by slowing down or speeding up bodily functions, but they have not been found to play a helpful role in the modern birthing process. Rather, evidence has shown that the production of these hormones can slow contractions and cause fetal distress. These are serious problems that inhibit the natural birthing process and often result in the need for medical interventions.
…the calm, quiet, darkened room is very different from … the hospital hustle and bustle…
The fact that the fear and anxiety experienced by many birthing women physiologically can result in the need for medical interventions seems to form a sort of self-fulfilling prophecy. It is arguable that the level of fear experienced by women today is in part due to the removal of birth from the natural feminine realm, or in other words its medicalization. Thereby, the medicalization of birth in part causes the fear, which causes the rising hormone levels, which cause the complications, which cause the need for medical intervention, and by way of circular logic make it seem completely sensible that birth is currently normalized as a medical event. It is possible to look at this hegemonic practice critically and see that the way birth is currently conceptualized might be playing a causative role in maintaining the status quo. Simkin also found that “much of the stress of labor is preventable because many of the stressors are not inherent to labor” (Goer 1995: 100). In other words, this is not a static situation; there is hope. The medicalization of birth may have shifted the emotion of fear to women, but that does not mean that women need to allow themselves to be tied to technology while their babies are removed from them rather than birthed. Research has indicated that excessive stressors are not a natural part of the labor process, therefore the fear and stress-inducing agents are outside, unnatural influences, and anything unnatural is subject to change. These unnatural elements simply need to be identified, examined and altered so health care providers can better enable women to give birth.
The unnatural setting in which the majority of births currently take place in the U.S. can be implicated as an external stressor to birthing women. The overwhelming majority of births today take place in hospitals. According to the National Vital Statistics Report of final data for 2000, the percentage of births that take place in U.S. hospitals has remained unchanged since 1989 at 99 percent (Martin et al. 2002). This frequency of usage suggests that the significance of the hospital environment, and its subsequent effect on the fear and anxiety experienced by birthing women, demands investigation. To begin with, hospitals innately embody concepts of sickness, pain and death. Previous visits to the hospital may have been highly emotional or even traumatic experiences for individual birthing women. “Many women associate hospitals with illness and the role of a patient, as well as with a potential for danger, use of unexpected procedures, a lack of privacy, isolation and confusion about high-tech equipment” (Klaus, Kennel and Klaus 1993: 144). Within this setting women often assume Talcott Parsons’ classical “sick role,” which socially requires them to surrender control of their bodies to medical personnel (Conrad 2001). The very environment in which birth is housed is intrinsically evocative of fear, anxiety and powerlessness in many women.
In addition to the problematic associations many women have with hospitals, there are numerous organizational and structural drawbacks to the hospital environment. To their credit, modern hospitals have done some work to adjust their environment to improve the state of birthing. For instance most hospitals allow a woman to labor and birth in the same room; this change alleviates the previous stressor, for the birthing woman, of having to be moved at the peak of transition from a “labor room” to a “delivery room.” Most hospitals also offer private birthing rooms that have been decorated in a modern manner. These are steps in the right direction, but they are largely superficial and do not compensate for the majority of uncomfortable aspects inevitably found in hospitals. One aspect that remains a cause of stress to birthing women is “the noise, bustle and continual interference from the hospital environment [that] often add stress upon stress” (Davis-Floyd 1993: 169). A hospital room is part of the public sphere, even if it is a so-called private room. That is, just because there is only one woman in the role of patient assigned to a room does not indicate that she will have any means of controlling the level of privacy that she experiences. Hospital staff may require that the room door be left ajar and will inevitably come in and out as they please, a condition over which the woman has no control. This is in direct opposition to the importance placed on privacy by Michel Odent (2002), who calls for a birth environment with “complete privacy in semi-darkness” to reduce adrenaline levels in the mother and thereby alleviate fear and anxiety (108).
Birth and sexual intercourse have been linked together due to the release of the female hormone oxytocin during both acts. The physiological reality, during both acts, is that “cervical and vaginal sphincters function best in an atmosphere of intimacy and privacy—for example…a bedroom, where interruption is unlikely or impossible” (Gaskin 2003: 170). This has led some to believe that both acts naturally occur in similar environments; that is birth should take place in a low-light, warm enclosure where women feel secure and safe. This makes logical sense because in the act of birth, just as in sexual intercourse, women are in an introspective physiological state that does not leave them ready to react in peak form to sudden danger. In order for women to allow their bodies to function as nature intended during the birthing process, they should be in an environment that allows them to feel safe while reducing fear and anxiety. Unfortunately, “the idea of the calm, quiet, darkened room is very different from that of the hospital hustle and bustle that is often observed” (Page 2000: 113). A warm, quiet, secure personal bedroom is far from the typical invasive fluorescent lighting and impersonal sterile feel of a modern hospital birthing room.
In addition to the fact that hospitals can cause fear in birthing women, as a result of mental associations and lack of privacy, there are structural aspects of hospital birthing rooms that inhibit natural birth. Due to the design of modern hospital birthing rooms, as well as certain hospital protocol, women are often restricted in their movements. One main problem that architects have located in hospital birthing rooms is the centrality of the bed, which “makes it clear that the woman is supposed to be on it, not moving around, and her posture is restricted and controlled by the professionals managing the labour” (Kitzinger 2000: 175). Hospital protocol often furthers this structural message by requiring a woman to be tethered to the bed via IV tubing and electronic fetal monitoring (EFM). The use of EFM is particularly restrictive to movement as almost any shifting on the part of the woman can cause a misalignment of the sensors (Strong 2000). A 1996 study reported by the Midwives Information Resource Service (MIDIRS) found that “most women being cared for in hospital will stay in bed during labour…this is to a great extent because of frequent use of continuous electronic fetal monitoring, which fundamentally restrains and alters the experience of labour” (Page 2000: 116). The restriction of a woman’s natural movements during labor can inhibit the birthing process in numerous ways including the increase of fear, anxiety and stress. Additionally, studies show that “activity during childbirth not only relieves pain and reduces emotional stress, but also helps the baby to descend and rotate into the best position for birth” (Kitzinger 2000: 185). Movement is intuitive to the birthing woman, thus naturally birthing requires movement, and this is supported by the reduction of negative fearful emotions experienced by women who are free to move about as they please. If women have the freedom to adopt the positions that they personally find the most comfortable they will naturally be less anxious about the physical process they are experiencing. The environment a woman births in plays an instrumental role in either supporting or not supporting this need to move.
Tangential to the environment or atmosphere that a woman labors in is the human support system that occupies it with her. This support group can comprise the birthing woman’s partner, friends and family. It may also include professional labor support from nurses, midwives, obstetricians and doulas. The efficiency of a birthing woman’s support system is one of the factors directly related to the amount of fear and anxiety from influences outside of labor that she experiences. It has been documented that “the most important factor in alleviating the anxiety that most women feel upon arrival at the hospital is the attitude of the people helping her” (Klaus, Kennel and Klaus 1993: 144). The effectiveness of support people in alleviating outside stress, fear and anxiety is reliant on their relationship to the birthing woman, as well as the type and/or quality of support they provide.
The initial qualifier of a support person is that she or he maintains a presence with the birthing woman. This minimal requirement is frequently impossible for busy nurses, midwives and obstetricians practicing in hospitals. However, it becomes more of an option for providers practicing in homes or independent birth centers, where the client-to-provider ratios are significantly reduced. Another 1996 study reported by MIDIRS indicated that “the most beneficial effect was found to be when a woman who had some experience of supporting other women in labour provided the constant support” (Page 2000: 114). According to this study, it did not matter if the support woman had a previously established social bond with the birthing woman or not. This description is unlikely to apply to a female obstetrician as, regardless of gender, obstetricians frequently attend birthing women only during the second stage of labor (Arms 1996; Davis-Floyd 1993). However, this description could apply to a midwife or doula, both of whom are women possessing extensive experience with labor support. Unlike midwives, doulas are not trained in the art of catching babies; rather they are women who have been trained as professional labor support. Having an “outside” trained woman for support during the birthing process has been found to enhance women’s birthing experiences. This is largely due to the fact that when a support person “shares an emotional bond and an ongoing relationship, it is very difficult for that companion to remain continuously objective, calm and removed…from the mother’s discomfort” (Klaus, Kennel and Klaus 1993: 5). This deep connection can result in a subsequent elevation of the support person’s levels of fear. Consequently, when a partner or relative acts as the sole support for a birthing woman, it is found that sometimes their rising level of “anxiety spreads from one person to another” (Page 2000: 112). This contagion can result in the birthing woman’s anxiety levels rising as a direct result of her support system (Arms 1996). However, Klaus and Kennel have found that “the presence of additional support in the form of an experienced woman, far from diminishing the role of the father [or partner], can enhance it by reducing his [or her] anxiety and freeing him [or her] to offer more personal support” (Kitzinger 2000: 123). Thus the presence of professional female labor support can reduce the anxiety experienced by the birthing woman both directly, through trained support methods, and indirectly, by reducing the anxiety of others present.
It is also vital that the support person(s) are knowledgeable concerning the different phases of labor and the various methods of support most beneficial in each. Two particularly helpful methods are touch and vocal encouragement. Although each can be beneficial throughout birth, these methods become increasingly important as women approach and enter transition. The Birthsong Midwifery Workbook defines transition as the time in labor when a woman’s cervix is dilated 7–10 cm. and warns that at this point in particular a woman’s “birth attendant is most helpful…[as] a calm, relaxed and centered environment is essential” (Singingtree 2000: 202). This is often the most intensely scary time for a birthing woman—a time when her body is almost completely open, which can lead to feelings of physical insecurity. Transition is also the “phase of labor that women later relate intimated the experience of dying” (Davis 1997). This is a time of physical detachment during which direct physical contact and clear vocal messages may be the only valid forms of communication with the birthing woman. Without specific people to communicate their support in these particular methods, a birthing woman may feel that she is alone, which would elevate fear and anxiety. Goer (1999) directly recommends both touching and vocal communication as methods for coping with poor labor progress because of the ability of these methods to reduce stress, anxiety and fear. She states “massage can ease pain and induce relaxation” (115) and “talk can provide comfort, reassurance and encouragement; [and] relieve anxiety” (116). Touch can also be utilized to simply convey the important message that the birthing woman is not alone.
The use of touch in birth is altered when birth is located within the social space of the hospital. In modern hospitals the “reliance on technology for enhancing and monitoring labour, may restrict and alter the way in which we use touch to comfort, support and encourage women through labour” (Page 2000: 116). The reliance on technology may also negatively affect the amount of overall interaction busy hospital staff members have with women. Often the vital signs of a birthing woman and her fetus can be monitored from the nursing station, which is advantageous and attractive to staff members as it allows them to watch more clients at a time (Arms 1996). In addition, U.S. research comparing the level and kind of support provided by first-time fathers and that of doulas indicates that “women touch the mother 95 percent of the time, but men only 20 percent of the time that they are present, and also that men choose to be there for shorter periods” (Kitzinger 2000: 123). Each of these findings increases the importance of adequate support provided for the birthing woman by outside trained women. However most women in the U.S. today do not employ doulas, nor do they compensate for this with other sources of adequate labor support. This lack of sufficient support during the birthing process often leads to increased fear and anxiety levels.
The lack of proper preparation, in terms of support, may be reflective of the overall fear-inducing lack of understanding and familiarity many U.S. women have with the birthing process. Knowledge is power after all, and if a woman feels powerful throughout her birthing experience, it is likely that she is embracing rather than fearing it. Unfortunately, the kind of hands-on knowledge about childbirth that is most helpful is something the majority of U.S. women lack. Most women in current U.S. society are not exposed to the birthing process, as was general practice in most traditional cultures (Arms 1996; Gaskin 2003). Rather, in the U.S., birth happens behind closed doors and the majority of women do not witness births before they themselves give birth. Kitzinger (2000) observes that if a woman “is having her first baby she has only the vaguest idea of how birth really feels and how other women cope. Birth is set apart from the rest of women’s lives and accepted as a matter of specialist knowledge” (8). Whereas once women possessed this “specialist knowledge,” the medicalization of childbirth polarized the birthing process, transforming it into a specific medical event and limiting legitimate birthing knowledge to medical professionals. Birth became something that was performed on women, rather than something that women performed, and along with this transformation the knowledge and experience of birthing was relegated to the confines of physicians and hospitals. Birth has been removed from its place in the realm of natural female experiences, and this removal has effectively denied generations of women the right to observe, participate in and fully understand the birthing process before they themselves experience it. It is a naturally occurring factor of the human psyche to fear the unknown, and through the scientific veiling of the birthing process, birth has been transformed into the unknown for the majority of U.S. primiparas.