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XTHE RITUALS 
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OF AMERICAN HOSPITAL BIRTH..
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by Robbie E. Davis-Floyd, Ph.D.
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Thanks to the author for allowing us to share this paper with you!
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This article appears in Conformity and Conflict: Readings in Cultural Anthropology, 8th ed.,David McCurdy, ed., HarperCollins, New York, 1994, pp. 323-340.
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Abstract
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Why is childbirth, which should be such a unique and individual experience for the woman, treated in such a highly standardized way in the United States? No matter how long or short, how easy or hard their labors, the vast majority of American women are hooked up to an electronic fetal monitor and an IV (intravenously administered fluids and/or medication), are encouraged to use pain-relieving drugs, receive an episiotomy (a surgical incision in the vagina to widen the birth outlet in order to prevent tearing) at the moment of birth, and are separated from their babies shortly after birth. Most of them also receive doses of the synthetic hormone pitocin to speed their labors, and give birth flat on their backs. Nearly one quarter of them are delivered by Cesarean section.
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Many Americans, including most of the doctors and nurses who attend birth, view these procedures as medical necessities. Yet anthropologists regularly describe other, less technological ways to give birth. For example, the Mayan Indians of Highland Chiapas hold onto a rope while squatting for birth, a position that is far more physiologically efficacious than the flat-on-your-back-with-your-feet-in-stirrups (lithotomy) position. Mothers in many low-technology cultures give birth sitting, squatting, semi-reclining in their hammocks, or on their hands and knees, and are nurtured through the pain of labor by experienced midwives and supportive female relatives. What then might explain the standardization and technical elaboration of the American birthing process?
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One answer emerges from the field of symbolic anthropology. Early in this century, Arnold van Gennep noticed that in many societies around the world, major life transitions are ritualized. These cultural rites of passage make it appear that society itself effects the transformation of the individual. Could this explain the standardization of American birth? I believe the answer is yes.
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I came to this conclusion as a result of a study I conducted of American birth between 1983 and 1991. I interviewed over 100 mothers, as well as many of the obstetricians, nurses, childbirth educators, and midwives who attended them. (1) While poring over my interviews, I began to understand that the forces shaping American hospital birth are invisible to us because they stem from the conceptual foundations of our society. I realized that American society's deepest beliefs center around science, technology, patriarchy, and the institutions that control and disseminate them, and that there could be no better transmitter of these core values and beliefs than the hospital procedures so salient in American birth.
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Rites of Passage
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A ritual is a patterned, repetitive, and symbolic enactment of a cultural belief or value; its primary purpose is alignment of the belief system of the individual with that of society. A rite of passage is a series of rituals that move individuals from one social state or status to another as, for example, from girlhood to womanhood, boyhood to manhood, or from the womb to the world of culture. Rites of passage transform both society's perception of individuals and individuals's perceptions of themselves.
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Rites of passage generally consist of three stages, originally outlined by van Gennep: (1) separation of the individuals from their preceding social state; (2) a period of transition in which they are neither one thing nor the other; and (3) an integration phase, in which, through various rites of incorporation, they are absorbed into their new social state. In the year-long pregnancy/childbirth rite of passage in American society, the separation phase begins with the woman's first awareness of pregnancy; the transition stage lasts until several days after the birth; and the integration phase ends gradually in the newborn's first few months of life, when the new mother begins to feel that, as one woman put it, she is "mainstreaming it again."
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Victor Turner, an anthropologist famous for his writings on ritual, pointed out that the most important feature of all rites of passage is that they place their participants in a transitional realm that has few of the attributes of the past or coming state. Existing in such a non-ordinary realm, he argues, facilitates the gradual psychological opening of the initiates to profound interior change. In many initiation rites involving major transitions into new social roles (such as military basic training), ritualized physical and mental hardships serve to break down initiates' belief systems, leaving them open to new learning and the construction of new cognitive categories.
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Birth is an ideal candidate for ritualization of this sort, and is, in fact, used in many societies as a model for structuring other rites of passage. By making the naturally transformative process of birth into a cultural rite of passage, a society can ensure that its basic values will be transmitted to the three new members born out of the birth process: the new baby, the woman reborn into the new social role of mother, and the man reborn as father. The new mother especially must be very clear about these values, as she is generally the one primarily responsible for teaching them to her children, who will be society's new members and the guarantors of its future.
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The Characteristics of Ritual
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Some primary characteristics of ritual are particularly relevant to understanding how the initiatory process of cognitive restructuring is accomplished in hospital birth. We will examine each of these characteristics in order to understand (1) how ritual works; and (2) how the natural process of childbirth is transformed in the United States into a cultural rite of passage.
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Symbolism
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Above all else, ritual is symbolic. Ritual works by sending messages in the form of symbols to those who perform and those who observe it. A symbol is an object, idea, or action that is loaded with cultural meaning. The left hemisphere of the human brain decodes and analyzes straightforward verbal messages, enabling the recipient to either accept or reject their content. Complex ritual symbols, on the other hand, are received by the right hemisphere of the brain, where they are interpreted holistically. Instead of being analyzed intellectually, a symbol's message will be felt through the body and the emotions. Thus, even though recipients may be unaware of incorporating the symbol's message, its ultimate effect may be extremely powerful.
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Routine obstetric procedures are highly symbolic. For example, to be seated in a wheelchair upon entering the hospital, as many laboring women are, is to receive through their bodies the symbolic message that they are disabled; to then be put to bed is to receive the symbolic message that they are sick. Although no one pronounces, "You are disabled; you are sick," such graphic demonstrations of disability and illness can be far more powerful than words. One woman told me:
I can remember just almost being in tears by the way they would wheel you in. I would come into the hospital, on top of this, breathing, you know, all in control. And they slap you in a wheelchair! It made me suddenly feel like maybe I wasn't in control any more.
The intravenous drips commonly attached to the hands or arms of birthing women make a powerful symbolic statement: they are umbilical cords to the hospital. The cord connecting her body to the fluid-filled bottle places the woman in the same relation to the hospital as the baby in her womb is to her. By making her dependent on the institution for her life, the IV conveys to her one of the most profound messages of her initiation experience: in American society, we are all dependent on institutions for our lives. The message is even more compelling in her case, for she is the real giver of life. Society and its institutions cannot exist unless women give birth, yet the birthing woman in the hospital is shown, not that she gives life, but rather that the institution does.
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A Cognitive Matrix
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A matrix (from the Latin mater, mother), like a womb, is something from within which something else comes. Rituals are not arbitrary; they come from within the belief system of a group. Their primary purpose is to enact, and thereby, to transmit that belief system into the emotions, minds, and bodies of their participants. Thus, analysis of a culture's rituals can lead to a profound understanding of its belief system.
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Analysis of the rituals of hospital birth reveals their cognitive matrix to be the technocratic model of reality which forms the philosophical basis of both Western biomedicine and American society.
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All cultures develop technologies. But most do not supervalue their technologies in the particular way that we do. This point is argued clearly by Peter C. Reynolds in his book, Stealing Fire: The Mythology of the Technocracy (a technocracy is a hierarchical, bureaucratic society driven by an ideology of technological progress). There he discusses how we "improve upon" nature by controlling it through culture.
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The technocratic model is the paradigm that charters such behavior. Its early forms were originally developed in the 1600s by Descartes, Bacon, and Hobbes, among others. This model assumes that the universe is mechanistic, following predictable laws that the enlightened can discover through science and manipulate through technology, in order to decrease their dependence on nature. In this model, the human body is viewed as a machine that can be taken apart and put back together to ensure proper functioning. In the 17th century, the practical utility of this body-as-machine metaphor lay in its separation of body, mind, and soul. The soul could be left to religion, the mind to the philosophers, and the body could be opened up to scientific investigation.
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The dominant religious belief systems of Western Europe at that time held that women were inferior to men--closer to nature and feebler both in body and intellect. Consequently, the men who developed the idea of the body-as-machine also firmly established the male body as the prototype of this machine. Insofar as it deviated from the male standard, the female body was regarded as abnormal, inherently defective, and dangerously under the influence of nature.
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The metaphor of the body-as-machine and the related image of the female body as a defective machine eventually formed the philosophical foundations of modern obstetrics. Wide cultural acceptance of these metaphors accompanied the demise of the midwife and the rise of the male-attended, mechanically manipulated birth. Obstetrics was thus enjoined by its own conceptual origins to develop tools and technologies for the manipulation and improvement of the inherently defective, and therefore anomalous and dangerous, process of birth.
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The rising science of obstetrics ultimately accomplished this goal by adopting the model of the assembly-line production of goods as its template for hospital birth. Accordingly, a woman's reproductive tract came to be treated like a birthing machine by skilled technicians working under semiflexible timetables to meet production and quality control demands. As one fourth-year resident observed:
We shave 'em, we prep 'em, we hook 'em up to the IV and administer sedation. We deliver the baby, it goes to the nursery and the mother goes to her room. There's no room for niceties around here. We just move 'em right on through. It's hard not to see it like an assembly line.
The hospital itself is a highly sophisticated technocratic factory; the more technology the hospital has to offer, the better it is considered to be. Because it is an institution, the hospital constitutes a more significant social unit than an individual or a family. Therefore it can require that the birth process conform more to institutional than personal needs. As one resident explained,
There is a set, established routine for doing things, usually for the convenience of the doctors and the nurses, and the laboring woman is someone you work around, rather than with.
The most desirable end-product of the birth process is the new social member, the baby; the new mother is a secondary by-product. One obstetrician commented,
It was what we were all trained to always go after--the perfect baby. That's what we were trained to produce. The quality of the mother's experience--we rarely thought about that.
Repetition and Redundancy
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Ritual is marked by repetition and redundancy. For maximum effectiveness, a ritual concentrates on sending one basic set of messages, repeating it over and over again in different forms. Hospital birth takes places in a series of ritual procedures, many of which convey the same message in different forms. The open and exposing hospital gown, the ID bracelet, the intravenous fluid, the bed in which she is placed--all these convey to the laboring woman that she is dependent on the institution.
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She is also reminded in myriad ways of the potential defectiveness of her birthing machine. These include periodic and sometimes continuous electronic monitoring of that machine, frequent manual examinations of her cervix to make sure that it is dilating on schedule, and, if it isn't, administration of the synthetic hormone pitocin to speed up labor so that birth can take place within the required 26 hours.(2) All three of these procedures convey the same messages over and over: time is important, you must produce on time, and you cannot do that without technological assistance because your machine is defective. In the technocracy, we supervalue time. It is only fitting that messages about time's importance should be repeatedly conveyed during the births of new social members.
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Cognitive Reduction
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In any culture, the intellectual abilities of ritual participants are likely to differ, often markedly. It is not practical for society to design different rituals for persons of different levels of intellectual ability. So ritual utilizes specific techniques, such as rhythmic repetition, to reduce all participants to the same narrower level of cognitive functioning. This low level involves thinking in either/or patterns that do not allow for consideration of options or alternative views.
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Four techniques are often employed by ritual to accomplish this end. One is the repetition already discussed above. A second is hazing, which is familiar to undergraduates who undergo fraternity initiation rites but is also part of rites of passage all over the world. A third is strange-making--making the commonplace appear strange by juxtaposing it with the unfamiliar. Fourth is symbolic inversion--metaphorically turning things upside-down and inside-out to generate, in a phrase coined by Roger Abrahams, "the power attendant upon confusion."
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For example, in the rite of passage of military basic training, the initiate's normal patterns of action and thought are turned topsy-turvy. He is made strange to himself: his head is shaved, so that he does not even recognize himself in the mirror. He must give up his clothes, those expressions of his past individual identity and personality, and put on a uniform identical to that of the other initiates. Constant and apparently meaningless hazing, such as orders to dig six ditches and then fill them in, further breaks down his cognitive structure. Then through repetitive and highly symbolic rituals, such as sleeping with his rifle, the basic values, beliefs, and practices of the Marines are incorporated into his body and his mind.
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In medical school and again in residency, the same ritual techniques that transform a youth into a Marine are employed to transform college students into physicians. Reduced from the high status of graduate to the lowly status of first-year medical student, initiates are subjected to hazing techniques of rote memorization of endless facts and formulas, absurdly long hours of work, and intellectual and sensory overload. As one physician explained:
You go through, in a six-week course, a thousand-page book. You have pop quizzes in two or three courses every day the first year. We'd get up around 6, attend classes till 5, go home and eat, then head back to school and be in anatomy lab working with a cadaver, or something, until 1 or 2 in the morning, and then go home and get a couple of hours sleep and then go out again.
Subjected to such a process, medical students often gradually lose any broadminded goals of "helping humanity" they had upon entering medical school. A successful rite of passage produces new professional values structured in accordance with the technocratic and scientific values of the dominant medical system. The emotional impact of this cognitive narrowing is aptly summarized by a former resident:
Most of us went into medical school with pretty humanitarian ideals. I know I did. But the whole process of medical education makes you inhuman....you forget about the rest of life. By the time you get to residency, you end up not caring about anything beyond the latest techniques and most sophisticated tests.
Likewise, the birthing woman is socialized by ritual techniques of cognitive reduction. She is made strange to herself by being dressed in a hospital gown, tagged with an ID bracelet, and by the shaving or clipping of her pubic hair, which symbolically de-sexualizes the lower portion of her body, returning it to a conceptual state of childishness. (In many cultures, sexuality and hair are symbolically linked.) Labor itself is painful, and is often rendered more so by the hazing technique of frequent and very painful insertion of someone's fingers into her vagina to see how far her cervix has dilated. This technique also functions as a strange-making device. Since almost any nurse or resident in need of practice may check her cervix, the birthing women's most private parts are symbolically inverted into institutional property. One respondent's obstetrician observed, "It's a wonder you didn't get an infection, with so many people sticking their hands inside of you."
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Cognitive Stabilization
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When humans are subjected to extremes of stress and pain, they may become unreasonable and out of touch with reality. Ritual assuages this condition by giving people a conceptual handle-hold to keep them from "falling apart" or "losing it." When the airplane starts to falter, even passengers who don't go to church are likely to pray! Ritual mediates between cognition and chaos by making reality appear to conform to accepted cognitive categories. In other words, to perform a ritual in the face of chaos is to restore order to the world.(3)
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Labor subjects most women to extremes of pain, which are often intensified by the alien and often unsupportive hospital environment. They look to hospital rituals to relieve the distress resulting from their pain and fear. They utilize breathing rituals taught in hospital-sponsored childbirth education classes for cognitive stabilization. They turn to drugs for pain relief, and to the reassuring presence of medical technology for relief from fear. One woman expressed it this way:
I was terrified when my daughter was born. I just knew I was going to split open and bleed to death right there on the table, but she was coming so fast, they didn't have any time to do anything to me...I like Caesarean sections, because you don't have to be afraid.
When you come from within a belief system, its rituals will comfort and calm you. Accordingly, those women in my study who were in basic agreement with the technocratic model of birth before going into the hospital (70%) expressed general satisfaction with their hospital births.
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Order, Formality, and a Sense of Inevitability
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Its exaggerated and precise order and formality set ritual apart from other modes of social interaction, enabling it to establish an atmosphere that feels both inevitable and inviolate. To perform a series of rituals is to feel oneself locking onto a set of "cosmic gears" that will safely crank the individual through danger to safety. For example, Trobriand sea fishermen described by anthropologist Bronislaw Malinowski regularly performed an elaborate series of rituals on the beach before embarking. The fishermen believed that these rituals, when carried out with precision, would obligate the gods of the sea to do their part to bring the fishermen safely home. Likewise, obstetricians, and many birthing women, feel that correct performance of standardized procedures ought to result in a healthy baby. Such rituals generate in humans a sense of confidence that makes it easier to face the challenge and caprice of nature.
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When women who have placed their faith in the technocratic model are denied its rituals, they often react with fear and a feeling of being neglected:
My husband and I got to the hospital, and we thought they would take care of everything. I kept sending my husband out to ask them to give me something for the pain, to check me, but they were short-staffed and they just ignored me until the shift changed in the morning.
Hospital rituals such as electronic monitoring work to give the laboring woman a sense that society is using the best it has to offer--the full force of its technology--to inevitably ensure that she will have a safe birth.
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However, once those "cosmic gears" have been set into motion, there is often no stopping them. The very inevitability of hospital procedures makes them almost antithetical to the possibility of normal, natural birth. A "cascade of intervention" occurs when one obstetric procedure alters the natural birthing process, causing complications, and so inexorably "necessitates" the next procedure, and the next. Many of the women in my study experienced such a "cascade" when they received some form of pain relief, such as an epidural, which slowed their labor. Then pitocin was administered through the IV to speed up the labor, but pitocin very suddenly induced longer and stronger contractions. Unprepared for the additional pain, the woman asked for more pain relief, which ultimately necessitated more pitocin. Pitocin-induced contractions, together with the fact that the mother must lie flat on her back because of the electronic monitor belts strapped around her stomach, can cause the supply of blood and oxygen to the fetus to drop, affecting the fetal heart rate. In response to the "distress" registered on the fetal monitor, an emergency Caesarean is performed.
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Acting, Stylization, Staging
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Ritual's set-apartness is enhanced by the fact that it is usually highly stylized and self-consciously acted, like a part in a play. Most of us can easily accept this view of the careful performances of TV evangelists, but it may come as a surprise that those who perform the rituals of hospital birth are often aware of their dramatic elements. The physician becomes the protagonist. The woman's body is the stage upon which he performs, often for an appreciative audience of medical students, residents, and nurses. Here is how one obstetrician played to a student audience observing the delivery he was performing:
In honest-to-God natural conditions babies were sometimes born without tearing the perineum and without an episiotomy, but without artificial things like anesthesia and episiotomy, the muscle is torn apart and if it is not cut, it is usually not repaired. Even today, if there is no episiotomy and repair, those women quite often develop a rectocoele and a relaxed vaginal floor. This is what I call the saggy, baggy bottom.
Laughter by the students. A student nurse asks if exercise doesn't help strengthen the perineum....
No, exercises may be for the birds, but they're not for bottoms....When the woman is bearing down, the leveator muscles of the perineum contract too. This means the baby is caught between the diaphragm and the perineum. Consequently, anesthesia and episiotomy will reduce the pressure on the head, and hopefully, produce more Republicans.
More laughter from the students. (3)
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Cognitive Transformation
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The goal of most initiatory rites of passage is cognitive transformation. It occurs when the symbolic messages of ritual fuse with individual emotion and belief, and the individual's entire cognitive structure reorganizes around the newly internalized symbolic complex. The following quote from a practicing obstetrician presents the outcome for him of such transformative learning:
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I think my training was valuable. The philosophy was one of teaching one way to do it, and that was the right way....I like the set hard way. I like the riverbanks that confine you in a direction....You learn one thing real well, and that's the way.
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For both nascent physicians and nascent mothers, cognitive transformation of the initiate occurs when reality as presented by the technocratic model, and reality as the initiate perceives it, become one and the same. This process is gradual. Routine obstetric procedures cumulatively map the technocratic model of birth onto the birthing woman's perceptions of her labor experience. They align her belief system with that of society.
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Take the way many mothers come to think about the electronic fetal monitor, for example. The monitor is a machine that uses ultrasound to measure the rate of the baby's heartbeat through electrodes belted onto the mother's abdomen. This machine has become the symbol of high technology hospital birth. Observers and participants alike report that the monitor, once attached, becomes the focal point of the labor. Nurses, physicians, husbands, and even the mother herself become visually and conceptually glued to the machine, which then shapes their perceptions and interpretations of the birth process. One woman described her experience this way:
As soon as I got hooked up to the monitor, all everyone did was stare at it. The nurses didn't even look at me anymore when they came into the room--they went straight to the monitor. I got the weirdest feeling that it was having the baby, not me.
This statement illustrates the successful conceptual fusion between the woman's perceptions of her birth experience and the technocratic model. So thoroughly was this model mapped on to her psyche that she began to feel that the machine was having the baby, that she was a mere onlooker. Soon after the monitor was in place, she requested a Caesarean section, declaring that there was "no more point in trying."
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Consider the visual and kinesthetic images that the laboring woman experiences--herself in bed, in a hospital gown, staring up at an IV pole, bag, and cord, and down at a steel bed and a huge belt encircling her waist. Her entire sensory field conveys one overwhelm-ing message about our culture's deepest values and beliefs: technology is supreme, and the individual is utterly dependent upon it.
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Internalizing the technocratic model, women come to accept the notion that the female body is inherently defective. This notion then shapes their perceptions of the labor experience, as exemplified by one woman's story:
It seemed as though my uterus had suddenly tired! When the nurses in attendance noted a contraction building on the recorder, they instructed me to begin pushing, not waiting for the urge to push, so that by the time the urge pervaded, I invariably had no strength remaining but was left gasping and dizzy....I felt suddenly depressed by the fact that labor, which had progressed so uneventfully up to this point, had now become unproductive.
Note that she does not say "The nurses had me pushing too soon," but "My uterus had tired," and labor had "become unproductive." These responses reflect her internalization of the technocratic tenet that when something goes wrong, it is her body's fault.
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Affectivity and Intensification
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Rituals tend to intensify toward a climax. Behavioral psychologists have long understood that people are far more likely to remember, and to absorb lessons from, those events that carry an emotional charge. The order and stylization of ritual, combined with its rhythmic repetitiveness and the intensification of its messages, methodically create just the sort of highly charged emotional atmosphere that works to ensure long-term learning.
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As the moment of birth approaches, the number of ritual procedures performed upon the woman will intensify toward the climax of birth, whether or not her condition warrants such intervention. For example, once the woman's cervix reaches full dilation (10 cm), the nursing staff immediately begins to exhort the woman to push with each contraction, whether or not she actually feels the urge to push. When delivery is imminent, the woman must be transported, often with a great deal of drama and haste, down the hall to the delivery room. Lest the baby be born en route, the laboring woman is then exhorted, with equal vigor, not to push. Such commands constitute a complete denial of the natural rhythms of the woman's body. They signal that her labor is a mechanical event and that she is subordinate to the institution's expectations and schedule. Similar high drama will pervade the rest of her birthing experience.
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Preservation of the Status Quo
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A major function of ritual is cultural preservation. Through explicit enactment of a culture's belief system, ritual works both to preserve and to transmit the culture. Preserving the culture includes perpetuating its power structure, so it is usually the case that those in positions of power will have unique control over ritual performance. They will utilize the effectiveness of ritual to reinforce both their own importance and the importance of the belief and value system that legitimizes their positions.
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In spite of tremendous advances in equality for women, the United States is still a patriarchy. It is no cultural accident that 99% of American women give birth in hospitals, where only physicians, most of whom are male, have final authority over the performance of birth rituals--an authority that reinforces the cultural supervaluation of patriarchy for both mothers and their medical attendants.
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Nowhere is this reality more visible than in the lithotomy position. Despite years of effort on the part of childbirth activists, including many obstetricians, the majority of American women still give birth lying flat on their backs. This position is physiologically dysfunctional. It compresses major blood vessels, lowering the mother's circulation and thus the baby's oxygen supply. It increases the need for forceps because it both narrows the pelvic outlet and ensures that the baby, who must follow the curve of the birth canal, quite literally will be born heading upward, against gravity.
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This lithotomy position completes the process of symbolic inversion that has been in motion ever since the woman was put into that "upside-down" hospital gown. Her normal bodily patterns are turned, quite literally, upside-down--her legs are in the air, her vagina totally exposed. As the ultimate symbolic inversion, it is ritually appropriate that this position be reserved for the peak transformational moments of the initiation experience--the birth itself. The doctor--society's official representative--stands in control not at the mother's head nor at her side, but at her bottom, where the baby's head is beginning to emerge.
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Structurally speaking, this puts the woman's vagina where her head should be. Such total inversion is perfectly appropriate from a social perspective, as the technocratic model promises us that eventually we will be able to grow babies in machines--that is, have them with our cultural heads instead of our natural bottoms. In our culture, "up" is good and "down" is bad, so the babes born of science and technology must be delivered "up" toward the positively valued cultural world, instead of down toward the negatively valued natural world. Interactionally, the obstetrician is "up" and the birthing woman is "down," an inversion that speaks eloquently to her of her powerlessness and of the power of society at the supreme moment of her own individual transformation.
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The episiotomy performed by the obstetrician just before birth also powerfully enacts the status quo in American society. This procedure, performed on over 90% of first-time mothers as they give birth, expresses the value and importance of one of our technocratic society's most fundamental markers--the straight line. Through episiotomies, physicians can deconstruct the vagina (stretchy, flexible, part-circular and part-formless, feminine, creative, sexual, non-linear), then reconstruct it in accordance with our cultural belief and value system. Doctors are taught (incorrectly) that straight cuts heal faster than the small jagged tears that sometimes occur during birth. They learn that straight cuts will prevent such tears, but in fact, episiotomies often cause severe tearing that would not otherwise occur. These teachings dramatize our Western belief in the superiority of culture over nature. Because it virtually does not exist in nature, the line is most useful in aiding us in our constant conceptual efforts to separate ourselves from nature.
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Moreover, since surgery constitutes the ultimate form of manipulation of the human body-machine, it is the most highly valued form of medicine. Routinizing the episiotomy, and increasingly, the Caesarean section, has served both to legitimize and to raise the status of obstetrics as a profession, by ensuring that childbirth will be not a natural but a surgical procedure.
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Effecting Social Change
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Paradoxically, ritual, with all of its insistence on continuity and order, can be an important factor not only in individual transformation but also in social change. New belief and value systems are most effectively spread through new rituals designed to enact and transmit them; entrenched belief and value systems are most effectively altered through alterations in the rituals that enact them.
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Nine percent of my interviewees entered the hospital determined to avoid technocratic rituals in order to have "completely natural childbirth," yet ended up with highly technocratic births. These nine women experienced extreme cognitive dissonance between their previously held self-images and those internalized in the hospital. Most of them suffered severe emotional wounding and short-term post-partum depression as a result. But fifteen percent did achieve their goal of natural childbirth, thereby avoiding conceptual fusion with the technocratic model. These women were personally empowered by their birth experiences. They tended to view technology as a resource that they could choose to utilize or ignore, and often consciously subverted their socialization process by replacing technocratic symbols with self-empowering alternatives. For example, they wore their own clothes and ate their own food, rejecting the hospital gown and the IV. They walked the halls instead of going to bed. They chose perineal massage instead of episiotomy, and gave birth like "primitives," sitting up, squatting, or on their hands and knees. One woman, confronted with the wheelchair, said "I don't need this," and used it for a luggage cart. This rejection of customary ritual elements is an exceptionally powerful way to induce change, as it takes advantage of an already charged and dramatic situation.
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During the 1970s and early 1980s, the conceptual hegemony of the technocratic model in the hospital was severely challenged by the natural childbirth movement which these twenty-four women represent. Birth activists succeeded in getting hospitals to allow fathers into labor and delivery rooms, mothers to birth consciously (without being put to sleep), and mothers and babies to room together after birth. They fought for women to have the right to birth without drugs or interventions, to walk around or even be in water during labor (in some hospitals, Jacuzzis were installed). Prospects for change away from the technocratic model of birth by the 1990s seemed bright.
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Changing a society's belief and value system by changing the rituals that enact it is possible, but not easy. To counter attempts at change, members of a society may intensify the rituals that support the status quo. Thus a response to the threat posed by the natural childbirth movement was to intensify the use of high technology in hospital birth. During the 1980s, periodic electronic monitoring of nearly all women became standard procedure, the epidural rate shot up to 80%, and the Caesarean rate rose to nearly 25%. Part of the impetus for this technocratic intensification is the increase in malpractice suits against physicians. The threat of lawsuit forces doctors to practice conservatively--that is, in strict accordance with technocratic standards. As one of them explained:
Certainly I've changed the way I practice since malpractice became an issue. I do more C-sections...And more and more tests to cover myself. More expensive stuff. We don't do risky things that women ask for--we're very conservative in our approach to everything....In 1970 before all this came up, my C-section rate was around 4%. It has gradually climbed every year since then. In 1985 it was 16%, then in 1986 it was 23%.
The money goes where the values lie. From this macro-cultural perspective, the increase in malpractice suits emerges as society's effort to make sure that its representatives, the obstetricians, perpetuate our technocratic core value system by continuing through birth rituals to transmit that system. Its perpetuation seems imperative, for in our technology we see the promise of our eventual transcendence of bodily and earthly limitations--already we replace body parts with computerized devices, grow babies in test tubes, build space stations, and continue to pollute the environment in the expectation that someone will develop the technologies to clean it up!
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We are all complicitors in our technocratic system, as we have so very much invested in it. Just as that system has given us increasing control over the natural environment, so it has also given not only doctors but also women increasing control over biology and birth. Contemporary middle-class women do have much greater say over what will be done to them during birth than their mothers, most of whom gave birth during the 1950s and 1960s under general anesthesia. When what they demand is in accord with technocratic values, they have a much greater chance of getting it than their sisters have of achieving natural childbirth. Even as hospital birth still perpetuates patriarchy by treating women's bodies as defective machines, it now also reflects women's greater autonomy by allowing them conceptual separation from those defective machines.
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Epidural anesthesia is administered in about 80% of American hospital births. So common is its use that many childbirth educators are calling the 1990s the age of the "epidural epidemic." As the epidural numbs the birthing woman, eliminating the pain of childbirth, it also graphically demonstrates to her through lived experience the truth of the Cartesian maxim that mind and body are separate, that the biological realm can be completely cut off from the realm of the intellect and the emotions. The epidural is thus the perfect technocratic tool, serving the interests of the technocratic model by transmitting it, and of women choosing to give birth under that model, by enabling them to use it to divorce themselves from their biology:
Ultimately the decision to have the epidural and the Caesarean while I was in labor was mine. I told my doctor I'd had enough of this labor business and I'd like to...get it over with. So he whisked me off to the delivery room and we did it. (Elaine)
For many women, the epidural provides a means by which they can actively witness birth while avoiding "dropping into biology." Explained Joanne, "I'm not real fond of things that remind me I'm a biological creature--I prefer to think and be an intellectual emotional person." Such women tended to define their bodies as tools, vehicles for their minds. They did not enjoy "giving in to biology" to be pregnant, and were happy to be liberated from biology during birth. And they welcomed advances in birth technologies as extensions of their own ability to control nature.
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In dramatic contrast, six of my interviewees (6%), insisting that "I am my body," rejected the technocratic model altogether. They chose to give birth at home under an alternative paradigm, the holistic model. This model stresses the organicity and trustworthiness of the female body, the natural rhythmicity of labor, the integrity of the family, and self-responsibility. These homebirthers see the safety of the baby and the emotional needs of the mother as one. The safest birth for the baby will be the one that provides the most nurturing environment for the mother.(4) Said Ryla,
I got criticized for choosing a home birth, for not considering the safety of the baby. But that's exactly what I was considering! How could it possibly serve my baby for me to give birth in a place that causes my whole body to tense up in anxiety as soon as I walk in the door?
Although homebirthers constitute only about 1% of the American birthing population, their conceptual importance is tremendous, as through the alternative rituals of giving birth at home, they enact--and thus guarantee the existence of--a paradigm of pregnancy and birth based on the value of connection, just as the technocratic model is based on the principle of separation.
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The technocratic and holistic models represent opposite ends of a spectrum of beliefs about birth and about cultural life. Their differences are mirrored on a wider scale by the ideological conflicts between biomedicine and holistic healing, and between industrialists and ecological activists. These groups are engaged in a core value struggle over the future--a struggle clearly visible in the profound differences in the rituals they daily enact.
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Conclusion
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Every society in the world has felt the need to thoroughly socialize its citizens into conformity with its norms, and citizens derive many benefits from such socialization. If a culture had to rely on policemen to make sure that everyone would obey its laws, it would disintegrate into chaos, as there would not be enough policement to go around. It is much more pratical for cultures to find ways to socialize their members from the inside, by making them want to conform to society's norms. Ritual is one major way through which such socialization can be achieved.
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American obstetrical procedures can be understood as rituals that facilitate the internalization of cultural values. These procedures are patterned, repetitive, and profoundly symbolic, communicating messages concerning our culture's deepest beliefs about the necessity for cultural control of natural processes. They provide an ordered structure to the chaotic flow of the natural birth process. In so doing, they both enhance the natural affectivity of that process and create a sense of inevitability about their performance. Obstetric interventions are also transformative in intent. They attempt to contain and control the process of birth, and to transform the birthing woman into an American mother who has internalized the core values of this society. Such a mother believes in science, relies on technology, and recognizes her inferiority (either consciously or unconsciously) and so at some level accepts the principles of patriarchy. She will tend to conform to society's dictates and meet the demands of its institutions, and will teach her children to do the same.
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Yet it is important to note that human beings are not automatons. Human behavior varies widely even within the restraints imposed by particular cultures, including their rituals. As one woman sums it up:
It's almost like programming you. You get to the hospital. They put you in this wheelchair. They whisk you off from your husband, and I mean just start in on you. Then they put you in another wheelchair, and send you home. And then they say, well, we need to give you something for the depression. [Laughs] Get away from me! That will help my depression!
Through hospital ritual procedures, obstetrics deconstructs birth, then inverts and reconstructs it as a technocratic process. But unlike most transformations effected by ritual, birth does not depend upon the performance of ritual to make it happen. The physiological process of labor itself transports the birthing woman into a naturally transitional situation that carries its own affectivity. Hospital procedures take advantage of that affectivity to transmit the core values of American society to birthing women. From society's perspective, the birth process will not be successful unless the woman and child are properly socialized during the experience, transformed as much by the rituals as by the physiology of birth.
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Endnotes
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1. The full results of this study appear in Robbie Davis-Floyd, Birth as an American Rite of Passage (U. of California Press, 1992).
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2. In Holland, by way of contrast, most births are attended by midwives who recognize that individual labors have individual rhythms. They can stop and start, can take a few hours or several days. If labor slows, the midwives encourage the woman to eat to keep up her strength, and then to sleep until contractions pick up again.
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3. Nancy Stoller Shaw, Forced Labor: Maternity Care in the United States. New York: Pergamon Press, 1974, p. 90.
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4. For summaries of studies that demonstrate the safety of planned, midwife-attended home birth relative to hospital birth, see Birth as an American Rite of Passage, Chapter 4.
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