According to her midwife Jana, Mira’s was a textbook birth: it was quite fast, even for a second birth, and proceeded without any complications. In reflecting on her attendance at Mira’s birth, which I had witnessed the day before, Jana emphasised that her task during birth is only to observe: “Observing, keeping an objective view, and recognising what the situation requires, is what I do. Not intervening if it is not necessary. Actually, women can find their way with birth”.
For the midwife to position herself as an observer who does not intervene “if it is not necessary”, the woman in labour needs to take part in the events in particular ways. Mira gave birth well according to midwife Jana because she followed the midwife’s and the environment’s invitations to take part in what was happening to her, which was giving birth. What is often framed as an ‘innate talent for giving birth’ by midwives is, on closer inspection, the result of quite some effort. Already in prenatal care, both the pregnant woman and the midwife learn to correspond successfully to one another and to the environment in which they work together.
But how exactly is the woman’s participation in giving birth enacted in a midwife-led birth attendance situation? In order to find answers to this question, I introduce the story of Mira giving birth in a birthing centre run by midwife Jana and her colleagues.
On Mira’s due date, Jana calls me at seven in the morning: “I am in the birthing centre with Mira now. Do you want to join?” When I arrive half an hour later, Mira is lying on the large double bed, and she greets me tiredly. Her partner sits behind her, massaging her lower back. Mira breathes intensely during her contractions – they seem to be strong. Jana is occupied with preparing the bathroom that is connected to the delivery room: she fills the big red tub, positioned in the centre of the small bathroom, with water, lights the candles on the walls, and spreads out towels.
Mira steps into the tub and glides slowly into the warm water. Her partner takes a place on a chair to her left while Jana and I sit down on the floor at her feet. During the contractions Mira bends forward, clasping the edge of the bathtub, breathing deeply. Then she leans back slowly: “I am feeling the contractions very far down by now”. Midwife Jana nods: “Yes, that is where they are supposed to go. You are doing so well”. Mira smiles: “Oh, I should have slept a bit”. “You can still close your eyes during the pauses.”
Half an hour later, Mira’s sister arrives. She sinks into the chair placed to Mira’s right, and asks Jana excitedly how much the cervix is dilated. “We don’t know”, Jana responds, slightly annoyed. Unimpressed, Mira’s sister continues: “And have her waters broken?” “No.” Mira’s sister seems disappointed. “Oh, no…” she utters. Jana, obviously bothered, emphasises: “But it is going well!” And turning to Mira adds: “Or do you doubt it, Mira?” “No, I don’t”, Mira responds.
Midwife Jana’s reaction to the intervention of Mira’s sister, who insists on the significance of obstetrical markers for evaluating birth, makes clear that Jana expects Mira to take part in some activities and to share certain goals, while neglecting – or at least not centring – others. Obstetric evaluations are supposed to stay out of the situation, as they interrupt the birthing process by (re-) defining what is going on in more objectifying terms: knowledge about Mira’s birthing body would be separated from Mira’s body and would become explicitly articulated with obstetrics. In order to avoid this, midwife Jana renders implicit her activities and work that do indeed take into account the medical viewpoint, such as when she is “observing, keeping an objective view, and recognising what the situation requires”. Births can go wrong, and only in such an obstetrically critical situation would the medical markers that co-determine ‘giving birth successfully’, and that would have been, up till then, backgrounded, become prominent.
Instead of allowing obstetrical markers to define the progress of giving birth and to direct Mira’s birthing body towards ‘fitting’ these markers, midwife Jana and Mira together concentrate on creating a birthing trajectory within which Mira’s birthing body corresponds to the offers made by the surroundings, the midwife and her partner. Mira is invited to lie down on the bed, to be massaged, to take a bath, to express how she perceives her birthing body and to be convinced that “it is going well”. These offers are supposed to help Mira to ‘give birth well’. In accepting them, Mira co-crafts an effective set of birth practices that fit both the environment as well as midwife Jana’s – and probably Mira’s own – expectations.
However, what seems nicely equilibrated in Mira’s birth story – namely a helpful midwife, a supportive partner, as well as a pain relieving bath, all of which make Mira ‘give birth well’, and are simultaneously made to be effective by Mira ‘giving birth well’ – should not camouflage the fact that taking part in giving birth is also a necessity. Such an active taking part is not only indispensable for making the birth work within this environment. Taking part is also unavoidable, as giving birth is an event that Mira necessarily is also part of, an event which ‘overcomes her’. This is what midwife Jana explains when she emphasizes that her task consists of “[n]ot intervening if it is not necessary”: she allows Mira, who cannot escape her birthing body, to “find [her] way with birth”. By adapting a reactive and waiting approach, midwife Jana gives space and time to birthing as an event that Mira both “is part of” and also needs to “take part in”.
So what can we learn about participation when thinking with “taking part in” and “being part of” giving birth, as I have described for Mira giving birth?
The event of Mira giving birth is created through different participants taking part in different ways. I have explained that the socio-material environment in which Mira gives birth shapes the event by allowing certain ways of dealing with Mira’s birthing body and inhibiting others. While bathing and breathing are enacted as helpful birthing techniques, examining and defining the body in obstetric terms are strategies that are backgrounded and rendered implicit because they risk drawing the attention away from Mira’s birthing body. In order to give birth successfully, Mira’s body needs to correspond to the invitations and offers that the environment presents. So for Mira, taking part in giving birth is also an obligation in order to make the event work. Not accepting the offers made within this environment is not an option, and might easily result in the need to transfer Mira to the hospital, where other interventions could be made.
But Mira giving birth is not only something that is created and shaped by her and the other participants, who all take part. It is also an event that is happening to Mira, whose birthing body is also part of the event. Taking part in giving birth is thus not only a strategy that is used to achieve certain goals such as giving birth successfully, but is also a way of crafting the inescapable involvement of Mira’s birthing body. What is at stake is not if Mira participates (she cannot not take part), but how she is facilitated to take part, and in which ways participation is distributed. This approach to participation allows us to understand the importance of qualities of participation: it seems important to focus on the different ways in which people might participate in what happens to them within particular socio-material environments.
My story continues: Midwife Jana asks Mira’s sister to hold a cooling cloth on Mira’s forehead. Mira closes her eyes in between the contractions: “Oh, this is hurting so much! Maybe I need to sit differently?” Jana prepares the gloves she will put on in order to help the baby out. “Mira, relax your legs and let the baby out. It is the end now. A few more contractions and the baby will be here.” Mira spreads her legs and leans back. She rants and raves after every contraction. “Great, Mira, perfect!” Jana puts on the gloves: “The baby is coming now!” Mira’s partner and sister sit up on their chairs. Sitting next to Jana, I can see the scantily haired head of the baby appear between Mira’s labia. Jana gets up and bends over the bath tub: “Ok, try once again, Mira! Do you want to feel the baby’s head? One more contraction and it is going to be born”. Jana takes the baby’s head in her hands. Mira, leaning forward to take a look, pushes once more and the baby glides slowly into the water, guided by midwife Jana.
Annekatrin Skeide is a PhD candidate within the Programme Group Health, Care and the Body at the University of Amsterdam in the Netherlands. Building on insights from ‘actor-network-theory’ (ANT) and material semiotics, she studies midwifery practices in Germany through ethnographic research. In her thesis, she explores how and with which effects midwives and women shape different techniques and ideals in practice. The concept of multiplying, that she develops, allows for analyzing how those different approaches are entangled in midwifery practices and in which ways they are productive and/or create tensions.
This post is a contribution to ‘Daily life’ in the Somatosphere series ‘Thinking with dementia.’
Read the next story in the series here.
Read the refraction of the theme here.