By Shirley Vanderbilt
Originally published in Massage & Bodywork magazine, December/January 2001.
“It’s a tragedy what has happened here in the United States.” So says Sandy Ventura Gordon, director and president of Bodyworkers Association for the Birthing Year, Inc. (B.A.B.Y.). In a recent interview, Gordon spoke of the 20th century trend toward the medicalization of childbirth, and the consequent relinquishment of women’s power in the process. “Delivery has been turned into a medical situation and instills in a woman not to trust herself. She thinks her body can’t do it right. Women who trusted in their bodies and their ability to give birth now fear birth. I want to change that paradigm,” she said.
Gordon’s own experiences with childbirth and as a midwife inspired her to establish B.A.B.Y., a training program for LMTs, nurses and LPNs to become certified Massage Birth Assistants (MBA). The MBA’s primary job is to empower the mother to understand she has the inner knowledge and strength to give birth. This is accomplished through emotional and physical support, by staying at the mother’s side throughout the delivery, explaining to her at each step of the way what is happening and cheering her on. “The MBA provides massage, encouragement and information to help the mother work through her fears before going into labor,” said Gordon. The program involves doula (a “woman caregiver”1) training, but incorporates the skills of the bodyworker to expand the reach of service. “A therapist doing prenatal massage during pregnancy can help the mother trust her body, then carry on to the next step of labor. Women’s bodies were made to give birth. If the mother removes her fear and works with the process rather than against it, she can relax and her body will open up.”
The MBA does not take the place of the birth partner, nor does she deliver babies. Rather, she establishes a relationship with the mother and her partner, and provides factual information, enabling the couple to make sound choices about the delivery. She also is a mediator with the caregiver staff to make sure the mother’s decisions are honored. This is an important component of the MBA’s job. For decades, birth has been orchestrated by medical staffs according to hospital schedules, not necessarily the mother or child’s needs. “Being forced to try to give birth is hostile – not in the sense that there is hostility, but in that it creates a situation that makes it difficult for a woman to give birth,” said Gordon. “It has become a medical event, something to fix...rather than normal and natural.”
Consider an all-too-frequent scenario: A laboring woman goes into the hospital and immediately she is asked to remove her clothes, put on a hospital gown and get into a hospital bed. She begins to feel helpless, viewing her situation as an illness rather than a normal physiological and psychological process. She’s given an IV and she’s now confined. The electronic fetal monitor placed around her belly restricts her to her bed, which is the worst position for labor and can prolong the event. She is given drugs that slow delivery, then other drugs to speed up delivery, then a routine episiotomy, or even worse, a cesarean section. What if she were left to trust and listen to her body, to walk when she needs to, to forego drugs and to assume positions that allow the baby to slowly and perfectly maneuver into position?
The Medicalization of Childbirth
From ancient time, women have been gathering together to support each other through labor and delivery. In many indigenous cultures, this practice continues, creating a community bond in celebration of woman’s power to bring life into the world. The transfer of power from women to physicians in industrialized societies took place gradually, being greatly influenced by the Catholic church which banned the use of “surgical” instruments by women as early as the 13th century. Although the practice of midwifery flourished during early years of immigration to this country, it was the American Medical Association that dealt a major blow to this practice in the early 1900s through lobbying efforts to ban its use. As doctors took over labor and delivery, the field of obstetrics was established and childbirth was transformed from a natural event to a potential medical emergency. Interestingly, obstetrics comes from the Latin word obstetrix, which translates as midwife.2
In 1900, 95 percent of births took place in the home. By the close of the century, 95 percent of deliveries took place in hospitals.3 Through this evolution, women came to view medical birth as safer and less painful by virtue of the drugs and techniques available, and in so doing gave up control. They also gave up natural birthing positions and the continuous female support that once been an essential part of their journey into motherhood. In her book, Gentle Birth Choices, Barbara Harper writes, “The emotional richness, the transformational power, and the amazing energy of birth have been ignored. The centuries of feminine wisdom about the birth process have been lost in the creation of this new medical mythology.” Women no longer trust their own ability to give birth without the assistance of a physician and modern technology.4 That trust has been replaced by fear. A recent British survey of 2,000 women found that eight out of 10 feared going into labor. This response is attributed to the fact that very few mothers have a completely natural delivery. According to the study, most of the respondents were afraid throughout the entire birth of their child.5 While some women are once again turning to the use of midwives and doulas, and taking advantage of holistic birthing centers, the vast majority are still delivering under the tight control of the medical system.
What Medicalization Hath Wrought
Many routine procedures used in obstetrics have been developed to enhance the physician’s control over birth, but in turn have complicated the event. To make it easier for the doctor to examine progress and execute the delivery, women have been required to remain on their back and in bed. This supine position prolongs labor, restricts proper fetal positioning and can increase pain.6 “It puts the baby on the sacrum, causes compression, puts pressure on the perineum and narrows the birth canal,” said Gordon. In contrast, the most natural position for childbirth is squatting, which opens up the pelvis, enhances blood flow and allows the baby’s head to come down properly.7
It has been proven fetal monitoring does not lead to improved outcome, but does increase the odds for use of forceps or cesarean section, as well as increasing the stress to the mother and subsequently the baby.8 Whether for convenience or prediction of a large or “overdue” baby, the rate of induced labor is high. The rationale is to produce a controlled, safe delivery. But in fact, induction can cause overly long contractions and force labor before the baby is properly positioned. Breaking the bag of waters, which often accompanies induction, forces the head down into the pelvis without the cushioning of amniotic fluid and allows contractions to squeeze the umbilical cord.9 Once these membranes have been stripped, frequent pelvic exams can interrupt labor, increase pain and introduce bacteria, increasing the risk of infection.
Episiotomy, the surgical cutting of the perineal area to provide a wider opening, has come under mounting criticism as the result of recent studies. The procedure frequently causes severe tearing and can lead to long-term complications, yet it remains a standard procedure in many hospitals. Natural tearing, without intervention, tends to be minor and less painful.10
The most common surgery in the country today is cesarean section, with some institutions reporting rates of 50 percent.11 “Many women don’t realize it’s major surgery,” said Gordon “They welcome it over going through labor, not realizing that it increases sustained pain for weeks – months, if there are complications such as a perforated bladder or infection.” Complications from other technologic interventions frequently lead to a cesarean, and in some cases the decision is simply based on the mother’s fear of vaginal delivery.
Epidurals, which are used to relieve pain, interfere with ability to move the legs, slow labor and lead to the use of oxytocins to speed up labor. In turn, this can result in a higher rate of use of episiotomy, forceps, vacuum extraction or cesarean section, which in turn increase the rate of complications.12
Armstrong and Feldman, in their book, A Wise Birth, noted, “For decades, indeed, up to the present, neither doctors nor women have been able to distinguish between the complications that medicine was causing (iatrogenic) and those that erupted naturally from women’s bodies. In an era in which science was more credited than women, the benefit of the doubt went to science.”13 That attitude is slowly changing as more and more studies reveal that nature, and women, know best.
Ancient Wisdom/New Science
In 1999, Scott and Klaus published a review of three meta-analyses of 12 randomized, controlled trials comparing obstetrical and postpartum outcomes for women with and without doula support during childbirth. The meta-analyses were each different in their approach, but produced the same general findings of shortened labor and a decrease in need for cesarean sections, forceps and vacuum extractions, and oxytocin and analgesia use in doula groups. Mothers supported by a doula also rated childbirth as less difficult and painful. The review noted that father support did not appear to produce the same results. In eight of the 12 studies, early psychological benefits of labor support included “reduction in state anxiety scores, positive feelings about the birth experience, and increased rates of breastfeeding initiation. Later postpartum benefits included decreased symptoms of depression, improved self-esteem, exclusive breastfeeding, and increased sensitivity of the mother to her child’s needs.”14
Two meta-analyses conducted by Klaus and Kennell — of five randomized controlled trials in 1995 and six in 1993 — found reductions of 50 percent in overall cesarean rate, 25 percent in length of labor, 40 percent in oxytocin use, 30 percent in pain reduction use, 40 percent in forceps use and 60 percent in requests for epidural anesthesia, all with doula support.15
The birth assistant, or doula, creates a holding environment for the mother in which she can rely on her body to tell her what to do and when to do it, rather than relying on the stringent demands of a medically orchestrated birth. According to Kennell, labor support could save the health care system as much as $2 billion yearly in unnecessary costs. He stated, “If a drug were to have this same effect, it would be unethical not to use it.”16
Attending the Birth
The MBA wears many hats, but her primary role is one of constant, unwavering support. “They are there to ‘mother the mother’ and facilitate a bond between the mother and her partner,” said Gordon, reflecting on the fact that family members may be overwhelmed by the event. When her own daughter was giving birth, Gordon had to leave the room a few times. “It was very stressful despite that fact that I was trained in midwifery and had assisted others. When it’s a loved one, you can’t separate as easily,” said Gordon. Fathers, or others chosen as birth partners, have to handle their own emotional reaction in addition to providing care for the mother. The MBA relieves them of the pressure of performing this dual role. She provides expertise and performs skills that likely are not in the partner’s repertoire. Her support is more of a practical nature, while the father’s is more emotional.
When Gordon arrives at the hospital, one of her first priorities is to create a rapport with the staff. “I make friends with them rather than assert my authority,” said Gordon. Offering friendly conversation, she talks to nurses about how difficult their job is, offers empathy and compassion, and then she offers a massage. “But when it’s necessary to be assertive, I will do that, like if mom wants to walk and the staff says no without a valid medical reason,” she said. In order to establish herself as a professional hired by the parent, Gordon also recommends an MBA wear a nametag citing her credentials.
During the mother’s ebb and flow of labor pains, Gordon provides massage, breathing techniques and encouragement. She helps with position changes, applies wet compresses and when the mother is wavering because the pain is too intense, Gordon suggests a shower to soothe and relax her. The mother is encouraged to eat or drink, if she wishes, and to continue to move about. Gordon shows the father how to massage, but then may give the father a break and do the massage herself. She is constantly working with the mother and father, providing suggestions and guiding them toward creating birthing positions that will enhance their experience. In one position, the father is in a chair, with the mom on a birthing ball, facing him. Gordon stands behind her providing counter pressure for the low back pain, while the mother has her arms around her partner. “I instruct her on how to push, and as the baby is coming out, I encourage her to look, to touch the baby,” said Gordon. “In a squatting position, you can do this.”
Gordon also encourages the mom to talk to the baby during delivery. “If mom and dad have been talking to the baby during the pregnancy, even with a lot of people and noise, the baby will turn to the sound of their voice and make eye contact,” continued Gordon. Rather than cutting the cord right away and having the baby whisked out of sight, the mother can hold the baby against her body, leaving the cord intact until it stops pulsating. “The staff can do procedures with the baby on the mother’s belly, unless the baby is in serious distress,” said Gordon.
It depends on the individual MBA as to how long she stays once the baby has been delivered. Retiring to the background and giving mom and dad the space to share their experience is most important. But at this point, Gordon also grabs her camera and starts capturing memories for the family. After leaving, the MBA may call the family later to check in, or send a card with a photo or gift. Gordon emphasizes that it’s important to create an ending, similar to cutting the cord. But again, the individual MBA determines the timeline.
Summarizing the birthing experience, Gordon said, “I want to provide women with accurate knowledge so they will once again embrace the thought process to trust their bodies. It’s like with athletes. When they have to go through pain, injuries and working hard, when they reach the finish it empowers them to go through the struggle. Labor does the same thing for a mother. Giving birth prepares them for the rigors of raising a child.”
MBAs in Training
Gordon’s MBA students reflect a wide range of the birth-experience spectrum. For older students, delivery may have been a traumatic event, while younger ones accept as fact the need for medical interventions such as epidurals. Gordon observed there is a definite shift in their thinking by the end of the program. In addition to learning the basics of labor and delivery, students are provided with an opportunity to examine their beliefs and expectations regarding childbirth. “There is a huge generation of women who have their own emotional scars from birthing,” said Gordon. They experience guilt about their role in the trauma and defend their doctors. “Healing begins once they hear the facts and understand they were put in an environment that was against them from beginning,” she said. They can then resolve their emotional trauma and change the paradigm to empower themselves as a support system.
To accomplish that shift, Gordon probes into the students’ thoughts and assumptions: Where is the safest place to give birth? Describe the pain of birth. How do you feel about home birth or giving birth in water? Is it better to have an episiotomy than risk tearing? How do you feel about continually monitoring the baby? “We ask questions about what they truly feel,” said Gordon. “It gives them an opportunity to explore where their belief system is influenced by their own experience or where it has been imposed by the medical system.” Gordon then goes through actual facts, such as the proven risks of episiotomy and the dangers of routine technological intervention. “We use an analogy (referring to epidurals) in class,” said Gordon. “Imagine that you can’t feel from the waist down and people tell you when to push. Do you think you’d be very successful? When a woman is able to listen to her body and feel, she will push when she’s supposed to and will get the baby out.”
By examining her beliefs and learning the facts, the MBA won’t take some of her own baggage of expectations into the birth. Students learn to identify the signs of labor, both physical and emotional components, as well as alternatives to traditional hospital techniques. Gordon recommends that the MBA carry a birthing bag with supplies – massage tools, a birthing ball, hot/cold compresses and oils, a change of clothes, and a journal or tape recorder. Before going home, they can stop and document the birth experience – their impressions and feelings about what occurred. “There’s a concentrated effort to labor. It can be draining, emotionally and physically,” said Gordon.
That can be most true when tragedy strikes. “In training, we go over death; how to help the couple and yourself,” said Gordon. Students are taught skills for establishing an environment in which the parents can create memories by holding the baby, taking photographs and saying their goodbyes. In these situations, MBAs are encouraged to continue to be a resource for the parents, staying in contact and referring them to a support group. Gordon emphasizes the importance of honoring the anniversary of the death by sending a card or making a phone call. She also stresses that the therapist needs time to process her own grief over the loss.
Gordon noted labor is basically the result of a large muscle tightening up intermittently. Massage, relaxation and hypnosis techniques can help reduce the pain and allow for a more normal labor. “It provides a perfect scenario for a therapist working with the pregnant mother as a client,” said Gordon. “She helps the mother to prepare for the upcoming birth, gives her things to do – breathing, awareness of her body – so she can trust her body and see this as a normal healthy experience. The mother has the inner knowledge and wisdom and is supported in that once again.”
The Mother/Birth Assistant Match
In first establishing a business, the MBA sets up protocols, deciding what services she will or won’t provide. Included may be home visits and caretaking after the birth, support with nursing, or simply a conclusion of services upon leaving the hospital. Developing a statement of disclosure to present to the client, describing range of services and a back-up plan, is another vital step. Setting fees is an individual thing, but the cost usually ranges from $200 to $700 or more, depending on variables such as the location and services offered. Some MBAs offer a sliding scale or barter for their services.
When interviewing the family, the MBA provides a questionnaire to the parents, not only for basic information but to give them an opportunity to explore their beliefs surrounding labor and delivery. From this questionnaire, the MBA can determine what information is needed to prepare them for making decisions. A major benefit of this process is education. “There may be several meetings to talk about expectations,” said Gordon. “I give them the resources — books, videos — to investigate, to empower them, and then the responsibility is theirs. I’ve seen a total belief system just make a huge shift. It’s an opportunity to educate and change the paradigm in addition to supporting the birth.”
The final agreement is a matter of matching comfort level between the mother and her birth assistant and establishing fees and frequency of contact. From the client’s perspective, it may be beneficial to ask about the doula’s belief system and fees before making an appointment for an interview. Prior to the birth, the MBA may meet with the parents to review breathing techniques and provide childbirth classes or instruction, if she is trained to do so. Prenatal massage may be included, as well as information on birthing positions and their benefits. In the end, it’s up to the MBA and the mother to determine the boundaries of their relationship.
Gordon recommends parents thoroughly investigate their physician and choice of birthplace in regard to policy and procedures. Do they have a shower or birthing tub? Are there protocols that interfere with the mother’s plan, like breaking her water and preventing her from using the tub? What about episiotomy? If the physician says it’s only used when necessary, what is the definition of necessary? What are the hospital’s and doctor’s rates of cesarean section? “It will give the mother a true gauge of her caregiver’s belief system,” said Gordon. The purpose is to find a birth place that will support the mother’s decisions. With experience, the MBA becomes more aware of the practices of local hospitals and physicians and can determine when one is not a good match for her client, then steer the parents to resources more conducive to their plan. “If the mother feels uneasy about her caregiver, she is encouraged to interview others,” said Gordon. The parents are also asked to discuss use of a birth assistant with their chosen caregiver. If the idea is not acceptable, the mother is encouraged to find another caregiver who will cooperate.
Gordon’s goal is to inspire women to talk about the wonders of massage and empowerment and to rely on the intuition within to make this a true communal rite of passage. Reflecting on her efforts, she said, “It’s going to happen.” The process is not just about bringing a baby into the world. It’s also about bringing forth a mother who rejoices in her strength and ability to nurture, and creating positive memories that forge a solid bond within the family. In childbirth, as in other transitions through life, the journey holds as much significance and sacredness as the destination.