Choice and the assigning of value in the practices and crafting of life-giving work
In healthy birthing initiatives described by, among others, the World Health Organization, emphasis has been placed on the importance of ‘the golden trio’: vaginal birth, breastfeeding and immediate skin to skin contact after birth. These three experiences are said to seed a baby’s immune system with good bacteria, preventing diseases from allergies through to diabetes and obesity, and facilitating neuroplasticity and brain development. In resource-poor countries, these are cheap and effective public health interventions. Despite these benefits, South Africa’s middle class caesarean section rate is extremely high.
My research is part of the University of Cape Town’s First 1000 days research cohort led by Fiona Ross and focuses on midwife assisted birth. While the WHO recommends that a country should not have a caesarean-section rate higher than 10-15% of all births, South Africa has extremely high rates of c-section birth, largely testament to the highly medicalized private health care system enjoyed by the rich. In some private sector hospitals, particularly in metro centers, the rates vary between 70% and 95%, despite a strong push by the state for so-called ‘natural delivery’ (vaginal birth). Given the prevalence of c-sections in the private sector, and that sector’s broad refusal of midwife attended (rather than obs/gynae attended) birth, middle class women who want a vaginal birth find it difficult to have the ‘natural birth of their dreams’. Private midwife consultation is one of the few options available to them. With a powerful rhetoric encouraging c-sections in the South African context (obstetricians have extremely high medical malpractice insurance fees with increasing legal suits, convenience for doctor and patient in choosing a birth date and the perception that c-sections are safer), women who chose vaginal birth with a midwife are making important medical choices that they understand in political terms.
I’ve spent the last twelve months working with midwives from a private midwifery practice in Cape Town, South Africa. The research has involved hundreds of hours of observations of consultations (800 ‘consults’ in total), training as a doula (birth attendant), attendance at births, interviews, participating in birth preparation classes, visiting women in their homes and attending positive birth movement groups. In the course of this work, I have learned that women seeking midwife-attended births feel pressure to ‘fight’ for their births of choice. These are framed in terms of the benefits of ‘natural’ birth – benefits about which women have educated themselves – and often include not only practical birthing preparations but hypnobirthing, visualization, birth plans, using particular positions to get baby into an optimal birthing position and exercise and yoga for facilitating easier deliveries. A number of women who seek midwife attended births do so with the intention of home-birthing or water-birthing. Among those who seek midwife attended births in hospital, there is a strong desire to be accompanied by a knowing but non-‘invasive’ other. When they succeeded in ‘naturally’ birthing their babies, the women I worked with felt an immense sense of achievement. Marian, an expat living in Cape Town who had researched her options for vaginal birth in South Africa explained:
“I just look at it as, I know what it feels like to have that endorphin kick after you’ve pushed yourself physically and I can only imagine, doing this will be so much more than that – the hormones, physically, mentally knowing I’ve accomplished this and the hormones I know that come with it, I think that’s what I’m excited about.”
Marian had imagined her birth as akin to running a marathon. She believed she would feel a sense of achievement, having pushed her body in an extreme experience. As it turned out, Marian did not get the ‘natural’ homebirth she had wanted. Her baby was breech and after her midwife had managed to turn the baby into birthing position, Marian went past her due date by 10 days and needed to be induced. At this point, hospital birth became her only option, but she still hoped for a ‘natural birth’ in a private hospital. That was not to be. Marian labored for several hours in hospital but after little progress, her midwife suggested a caesarean-section, to which Marian consented. Marian’s midwife explained to me that she had tried to make the decision to have a caesarean as consultative as possible, keeping Marian and her husband informed along the way and discussing the options as the couple’s plans quickly unravelled. The midwife also explained that Marian needed to recognize that her c-section was truly necessary, as the midwives encouraged vaginal birth as far as possible. Six weeks later, I visited her and we discussed the birth. Marian said she was loving motherhood but she had been ‘down’ in the first two weeks after the birth, feeling disappointed at not getting the ‘endorphin rush’ and all the benefits she understood to be part of vaginal birth. Marian explained how she had cried for a few days and experienced some sense of failure, having not ‘accomplished’ a vaginal birth.
For women using private sector healthcare, but wanting a vaginal birth, c-section has become commonplace. Women who chose midwife-led birth felt that their obstetricians lied to them, giving them reasons for c-sections they believed to be invalid. They described women as being ‘cheated’ of their rights as women. They described doctors as ‘robbing’ women of their natural birth and held firm to a binary between ‘natural birth’, midwife attended, and ‘hospital birth’, highly technicized and attended by obstetricians. Whether or not these perceptions were true (often they were not), women placed emphasis on ‘natural’ birth, an experience they saw themselves as ‘designed’ to do.
The separation of intervention-free birth and medicalized, technocratic birth that women set up was not as stark as women imagined. Indeed, their distinction between ‘natural’ and ‘biomedical’ and their equation of midwifery with the former is ironic. In the South African context, midwives offering labour care are biomedically trained, had all worked in large maternity hospitals and all insisted on obstetric back-up. The midwives used ‘intervention’ when necessary and adhered to medicalized notions of pregnancy and labour in time (antenatal checks, safe periods of time to labour), physiological checks and monitoring of baby. Yet women and midwives still understood natural birth as opposed to technocratic birth and because they understood themselves to be fighting against a c-section culture, when they did indeed require a caesarean section, they either imagined themselves being or were enormously disappointed. As women spoke of their feelings on birth, I was bearing witness to the production of a particular set of affects. Some of these affects were feelings, in the form of a rush of relief and elation at giving birth ‘naturally’, others were imagined physiological processes and the associated benefits: a kick of endorphins as women pushed their babies, their bodies flooded with oxytocin, the ‘love hormone’.
A combination of the South African private sector that makes c-section the norm rather than the exception, recent research on the benefits of vaginal birth and a powerful mythology that underpins women’s understandings of natural birth, merged to produce a moment in which women seeking midwives, saw natural birth as the ‘right way’ to birth. They crafted a narrative in which they would feel a sense of achievement, would give their babies a ‘head start’ (an ironic phrase if ever there was one), ‘doing as nature intended’, making them ‘good mothers’. Middle class women read extensively and understood physiology, pregnancy and birth well. Women were knowing mothers, able to talk about birth positions, hormones and the procedures of birth. The knowing mother quickly turned to the good mother, who needed to birth the ‘right’ way for her baby. As Waltz (2014) says, increasingly the good mother is equated with intensive mothering and motherhood becomes a project.
I argue that a strong myth of natural birth exists in South Africa’s private birthing sector. Midwives offered hands-on, continuity of care with a ‘conducive’ birthing environment; yet midwives and their clients did not acknowledge those practices as forms of intervention: the midwife’s support, her creation of a low-lit, quiet and gentle atmosphere for birth and her practical positioning of women, pushing on women’s hips to increase the space in the pelvis. They based their support and desire for a version of vaginal (natural) birth on scientific evidence based practice, including new information about vaginal microbiomes and the effects on infant’s immune systems both in the short and long term. In their model, midwifery was not an ‘intervention’. They argued that they supported a phenomenon that occurred ‘naturally’ with many scientifically proven benefits. They did not support the (similarly) scientifically produced, medicalized versions of birth that were understood by evidence-based studies as unbeneficial when unnecessary. The myth worked to uphold a powerful understanding of the natural. The myth set up a discourse in which choice was the axis upon which birth was approached by South African middle class women: choosing to birth vaginally or surgically. Therefore, when women were unable to have a particular version of birth, because birth was framed within a discourse of choice, women experienced feelings of failure and being a ‘bad’ mother. Fiona Ross, Miriam Waltz, Michelle Pentecost and Min’enhle Ncube’s research have shown the ways that the good mother rhetoric has grown in South Africa for pregnant women and new mothers breastfeeding and bottle feeding. As Waltz (2014) explains, the project of mothering is based in a mode of mothering intensively being equated with good mothering. How women give birth has become part of this project.
The cultural model of the good mother experienced by many South African pregnant women (working class public health users experience the good mother rhetoric too, in different ways), created a scenario where the work of independent midwives was to tailor what and how much women learned in pregnancy, as midwives encouraged women to be selective in who they listened to, and teaching women what they needed to know and what fell under the bracket of unnecessary worry. Midwives also had to tend to women’s expectations of birth, making them realistic to the unpredictability of birth, trying to offset senses of achievement and failure. Working in this context, it is important to think through the role of the midwife as a facilitator of particular versions of birth in a high c-section context, but more so, as a mediator of varying intersections and rhetoric that place women in particular roles and positions in their communities.
Framed as a choice, the binary of the natural/surgical birth is maintained. It produces particular effects, affects and dispositions. For women who do not get their desired (natural) birth, the effects can be devastating: women having caesarean sections are framed as having failed in a critical maternal role. Given the private sector’s institutional push towards c-sections women desiring vaginal birth feel the need to fight for this version of birth. Underlying the harmonious model presented by midwives and their clients is a combative mode.
Thinking about how the cultural modes that frame motherhood, enables a critical conversation that locates the maternal in the midst of institutional, political, economic, social and cultural arrangements and the affects of economies these produce. Birthing emerges as central to ideas about motherhood, and motherhood becomes an experience in which others judge and assign value in the practices and crafting of life-giving work.
Gibbons, L. Belizan, J. Lauer, J. Betran, A. Merialdi, M. Althabe, F. 2010. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: Overuse as a barrier to universal coverage. World Health Report: Background paper (30). World Health Organisation.
Jennifer Rogerson is a PhD student at the University of Cape Town, researching the practices of midwifery in relation to care. She is interested in exploring, alongside the political economy of service distribution, the political economy of affect in South African maternal health care.