Birthful

Best of Birthful: What You Need to Know About Birth Models

Episode Notes

Welcome to the Best of Birthful. Creator and host Adriana Lozada curated  and edited each selection in this play list of the most popular episodes. It's a tailored  introduction to the expansive catalog she amassed over the first five years of Birthful's 300+ shows.

Medical anthropologist Robbie Davis-Floyd explains why we’ve gotten so obsessed with machines and numbers, how things are changing back to models that work in various parts of the world, and what you can take from those models to improve your experience.

Here's the original episode in full.

For more Birthful, visit the show page. For new episodes out each week, subscribe to Birthful. You can connect with us on Instagram @birthfulpodcast and email us at info@birthful.com

Episode Transcription

Adriana Lozada: 

Hey, mighty one. With nearly 300 Birthful episodes in over five years, it may be hard to know where to begin listening to the show. To make it easier, we’ve put together the Best of Birthful series, which showcases some of our favorite or most relevant episodes. This is one of those. If you enjoy what you hear, make sure you subscribe. It’s free, and that way you won’t miss a thing. Enjoy. 

Hello, mighty parents and parents to be. As always, thank you so much for listening and for all the love you give the show. Today, I am incredibly honored to have on the show Robbie Davis-Floyd, who is a world-renowned medical anthropologist, international speaker, and researcher in transformational models in childbirth, midwifery, and obstetrics. Robbie, it is such a delight to have you here. 

Robbie Davis-Floyd: 

Thank you. I’m happy to be here. 

Lozada: And I want to tell you, I’m so inspired by your work because I feel that you are out there in the trenches, sort of observing different birth cultures around the world and seeing some significant change happen in places where it would be easy to think that all hope was lost, even though I might be being a little bit overdramatic. So, before we get into the details of birth models, would you mind talking a little bit and walking us through the change that you’ve seen in Brazil, sort of painting us a picture through that example? 

Davis-Floyd: Well, Brazil is a very interesting mixed bag. On the one hand, they have an ever-increasing cesarean rate, which has now reached 57%, which is the highest it’s ever been, and it has done nothing but increase steadily over the past decades and it has never… There’s never been a downward tick. In contrast to the United States, where our cesarean section rate has held steady at around 33% for the last four or five years, which makes me… which gives me hope. I think our docs are finally listening to women’s outcries about the excessive cesareans.  

But Brazil, the doctors are untrammeled in their use of cesareans, even though the Ministry of Health and all the birth activist groups are decrying that massive overuse of cesareans. So, the contrast there in Brazil is on the one hand you have this highly technocratic medical system that is bound and determined to do as many cesareans as possible and to stamp out home birth. They’re literally on a campaign to stamp out home births. Very unsupportive of birth centers. And on the other hand, Brazil has the most active, and populous, and progressive social movements for the humanization of birth in all of… in probably the Americas, really. The most organized. They have an organization in Brazil called ReHuNa, which in Portuguese, which I don’t speak very well, is Rede pela Humanização do Parto e Nascimento, which means Network for the Humanization of Birth. And ReHuNa was officially founded in the late 1990s. They put on their very first conference in Brazil in the city of Fortaleza in the state of Ceará in the year 2000. They chose that city because WHO had its landmark conference there in 1985 when they came out with their goal of a 15%, no higher than 15% cesarean rate for even tertiary care centers, which of course hardly anybody meets anymore. Just a few countries manage to do that. 

But they put on this conference in Fortaleza in November of 2000, and I was one of five international speakers invited. There was Marsden Wagner, and Lesley Page, a wonderful midwife from the U.K., and Ina May Gaskin, and me, and José Villar, who was at the time the head of MCH for WHO. And on the first day of the conference, we were expecting around maybe 600 people, and we were in this huge auditorium, and we noticed that it kept filling up, and filling up, and filling up, until there was like standing room only, and people were sitting on the stairs, and became a fire hazard, and by the next day we discovered that almost 2,000 people had shown up for what became… It was called the First International Congress on the Humanization of Birth, and it became the spark that set off the social movement for the humanization of birth all over Latin America, because many other countries followed suit having their own international conferences on the humanization of birth all around Latin America after that conference. 

So, that was an amazing start. 

Lozada: But it’s interesting to me how maybe because of these extremes, of that cesarean rate growing and growing, that created some outrage, and having a lack of not so much home births, and maybe not so many midwives, that the OBs sort of… Do you think they stepped into this role trying to go back to their instincts of why they became OBs in the first place? 

Davis-Floyd: Well, that’s a very good question. I was immediately intrigued by these holistic obstetricians as they called themselves. The good guys and the holistic OB were the two labels for themselves. Good guys and girls, because there are some women, and so I, in the subsequent years that I went to Brazil, I began interviewing them with my colleague, Nia Georges from Rice University. We’re trying to figure out their motivations. What makes one doctor ignore scientific evidence in favor of abandoning episiotomy and another doctor just do episiotomies right and left? And it’s really hard to get out what makes that difference, but some of them had a sort of compassion for others in childhood. Some of them read the scientific evidence and actually were swayed by it, actually… One of them, Roxana Knobel from Florianópolis in Brazil in the south, she led a study that clearly demonstrated that episiotomy was a really bad idea, that all it did was increase perineal tearing. 

And so, she quit doing episiotomies, and immediately all the other residents and her bosses, her attending physicians, jumped her case. They were all over her. You’ve gotta cut, you’ve gotta cut. If you don’t cut, the perineum is going to explode. And she said, “But look, I’m doing these births and the perineum isn’t exploding and the women are fine.” And they gave her so much grief about just stopping episiotomies that she started to wonder what else they were defending, and she started to realize that everything that she was doing was contradicting the scientific evidence in favor of normal physiologic birth. So, she was swayed by the evidence. Other doctors were swayed by experience. 

One of them, Paulo [Last Name], went to Sweden. He got a fellowship and he wanted to learn about normal birth. He didn’t know anything about it, because he’d done 3,000 cesareans at that point in his life and very few normal births. And he watched Swedish midwives attending these beautiful normal births, and vertical births, and he came back and said, “Okay, I’m ready. I’m gonna be a cool postmodern obstetrician and I’m gonna do vertical births.” And the first new client that came to him was a French woman who said she wanted a vertical birth and he said, “I’m cool with that. I can do that.” But he’d never done one before. He’d seen them done, but he’d never actually done one. 

And so, to give you a clue of how hard it is to change practice, she was walking around in labor, and she was leaning over, and she was squatting down and standing up, and at one point she asked him to check her and he had to get down on his hands and knees, which is very challenging for a lot of doctors to be so low status, and he had to get down on his hands and knees and check her from underneath. And he said, “Robbie, I honestly didn’t know what my fingers were feeling. I’ve checked thousands of women for dilation, but always standing above them, and I didn’t know. I couldn’t read the information in my fingertips, because I was coming from a completely different angle.” So, he said he just guessed. He said, “Okay, four. You’re good. Everything’s coming along fine.” 

Fortunately, that birth turned out really well, and he began then to do more and more births like that and to abandon all the normal procedures. Every one of these obstetricians, we’ve interviewed 32 of them so far, has a different story. They’re all fascinating stories, but each one of them has a different tipping point, or catalyst, or some particular event that made them realize that what they’re doing is wrong. I

I’ll offer one more example. Ricardo Jones has become a good friend of mine. He runs a home and hospital practice, home birth and hospital birth practice in Porto Alegre in the very far south of Brazil near Argentina, and he was an Air Force resident, and he was like a first year resident, and a nurse comes running up to the room where the young residents are waiting to be called, and she said, “Doctor, Doctor, there’s a woman who’s in labor. She’s walked in off the street. She’s about to have her baby. You’ve gotta come quickly.” So, he went down there, and he pushed open the door and didn’t see anyone on the table, so he turned to the nurse to say, “Are you teasing me? Are you trying to make a fool out of me?” And she said, “No, Doctor. Please open the door further.” And then he saw the woman squatting in the corner. 

And he went over to her and squatted down and lifted up her skirt and he saw that the head was crowning. And he said, “Señora, what are you doing? Get up. Get off the floor. You’ve gotta get on the table to have this baby.” And he said, “She looked right through me as if I were made of glass.” She was in that altered state that Michel Odent calls it going to another planet. I call it going deep down inside. But you enter a deep delta state, and she was in that state, and she just could barely even perceive him. She just looked right through him. And he had to catch the baby without even gloves on, which he’d never done before. 

So, he catches the baby and he’s like, “Ew, gross!” And he hands it off to the nurse, who rushes it off to the NICU because of course it’s contaminated, because it was born on the floor. And then she bursts the placenta and he’s yelling at her, “Look at the mess you made! All this blood all over the floor!” And finally, he gets her up on the stretcher and they wheel her off to recovery, and later that afternoon… The birth kept bugging him. All day he kept feeling weird about it. And later that afternoon, the nurse came who had called him, came to him, and said, “Doctor, what a good thing you were here. What would have happened if you hadn’t been here?” And he stopped dead in his tracks, and he thought about it and it hit him. “Oh my God. If I hadn’t been there, she would have reached down and caught her own baby, and she would have had a perfect birth. And all I did was yell at her and do my best to disturb this intimate, innate process that she was in the middle of doing, and I’m an idiot.” He used a stronger word which I won’t say on the air. He used the A word. I’m an A-you-know-what. And he just… That was his turning point. He just got it that he had to change. 

And of course, he didn’t know how to change, so it was a very long process. 

Lozada: Sure. 

Davis-Floyd: But today, half his births are home births and half are hospital. He has a cesarean rate of around 15%. It’s been a long road for him, but it took him a long time to get the courage to do home births. But change is possible. Doctors just have to be open and willing to look at the evidence and to honor women’s requests, and to understand and appreciate the normal physiology of birth. Unfortunately, their education doesn’t support them in that at all, so if they want to find out about it, they have to learn on their own. 

Lozada: And that is very interesting to me, because you can see how pervasive these birth models and these paradigms are, of how culture affects us, and how hard it is when these doctors step out of their comfort zone and have something like this happen to them, and actually look at it from mindfully, with open eyes, and realize, “Wait.” Maybe question a bit of how they’re doing things, because it’s what they’re seeing is not adding up with what they “know.” And I do want to talk more about the technocratic, holistic, and humanistic models that you see, and so Robbie, let’s talk about the models that you see and how they affect birth. 

Davis-Floyd: Well, back when I was doing my first book, Birth as an American Rite of Passage, I had read Barbara Katz Rothman’s work. She was a decade ahead of me. And I had read her work on the medical and the midwifery models, but I was looking for terms for those models that more deeply connected them to what I saw as the core value systems of the American technocracy. I didn’t even know the word technocracy at the time. A colleague of mine named Nicole Salt brought that word to my attention. And I had been calling it the technological model of birth, because it’s so focused around technology, but technocracy, I came to understand it and to develop my own definition of it. 

For me, a technocracy is a society developed around an ideology of progress through high technology and the global flow of information through high technology, and also of course business, and making money, and capitalism, and all of that. So, I started calling it the technocratic model of birth, because it’s a money-driven model, profit oriented. It defines the body as a machine. If you read any obstetric textbook, it’ll say the peritoneum is covered by serosa. Birth is the expulsion of the fetus from the uterus. I mean, in very mechanistic terms. 

And so, it defines the body as a machine. It separates mind from body. It focuses on the patient as an object. There’s a gall bladder in room 212, a cesarean section in 313. Not as a human being in relationship with other human beings. It’s all about aggressive intervention with emphasis on short-term results, so there’s what I call the technological imperative. If you can do it with technology, you will do it with technology. You must do it with technology. So, in that model, patience is not a virtue. We employ interventions as much as possible to get the baby out as quickly as possible. 

Hospitals that run entirely under this model are basically assembly lines, and you don’t see that as much in the United States anymore. You see it most dramatically in developing countries that are under-resourced, and they have hospitals with 10, 11,000 women giving birth a year. I recently read an ethnography of a hospital in Mexico, where doctors actually manually stretched the cervixes of the women in labor because they have such a high volume and they’ve got to get the women through, so they put the women through hell. 

Lozada: Oh, wow. 

Davis-Floyd: They’re screaming in agony as the doctors are like ripping their cervixes to get them to 10 centimeters as quickly as possible to extract the baby as quickly as possible. All that is justified under the technocratic model, because the body is seen as a machine and you’re not looking at how to support or enhance normal physiology. So, that’s what I call the technocratic model of birth. It has 12 tenets. You can go to my website, Davis-Floyd.com, and you’ll find the article there. The Technocratic, Humanistic, and Holistic Paradigms of Birth and Healthcare. 

The humanistic model in contrast defines the body as an organism, so right away we’re looking at reality, because the body is in fact an organism. It is not a machine. The body as machine is a convenient metaphor, because it justifies all kinds of interventions with other machines, but when you define the body as an organism, you start to look at normal physiology and try to figure out what that is, and try to take an evidence-based approach to birth. Many more American hospitals these days are humanized much more than they used to be back in the ‘60s, when everybody was under scopolamine and out of it. 

People are treated, in the humanistic model, you treat the woman as a relational subject, not as an object. She’s Mrs. Smith with 5 kids, whose husband is ill. You try to get to know her personally. It’s a relationship-centered model, where relationships become important. Caregivers try to establish relationships with patients. There’s a big difference, though. Humanism is easily co-optable, because you can paint the labor room nice colors. As Barbara Katz Rothman said, you can hang a plant on an IV pole and call it humanistic, you know? So, that’s what I call superficial humanism, where you paint the room all nice, and you have pretty covers, and the hospital’s beautiful, and the food is good, and people are treated kindly, and the cesarean rate at one hospital I visited that was just like that in Brazil, the cesarean rate was 100%. 

You know, so the women were treated with dignity and respect after they’d had their cesarean, you know? So, that’s what I call superficial humanism. And then deep humanism is where you truly honor the deep physiology of birth, and patience is a virtue, you wait on the labor process to unfold, you don’t aggressively intervene.

And then the other extreme is the holistic model, where the body is not just an organism, but it’s also that it’s more importantly an energy field in constant interaction with all other energy fields. So, in the holistic model, you talk about the oneness of mind and body and also spirit, God or spirit comes into the equation in holism. Holistic healers believe that if spirit does exist, that it must be the most powerful force for healing in the universe, so why wouldn’t you employ it in your caregiving process? Intuition counts in holism, because it’s a form of energy, of energetic knowing. In holism, it’s a place where most obstetricians, most doctors don’t want to go, because it’s a big jump to think of the body as an energy field. The second you do that, you can understand alternative modalities like homeopathy, or Reiki, or massage therapy, or Ayurveda, or Chinese medicine. All of these are holistic energy-based modalities. If you don’t get the concept of the body’s energy, they won’t make any sense to you. 

The most important thing about understanding the body’s energy is that you start to deal with the energy around the birth and you understand that if you intervene at the level of energy, you don’t have to intervene at the level of technology. So, you can simply change the energy in a birth process. A great example I like to give is of a midwife friend of mine who was working as a volunteer doula in a hospital in Alaska. She was sent in to attend a young 17-year-old girl who was an unwed mother, who was terrified, and all tensed up, and she was stuck at four centimeters, and the hospital sent this doula in to help her, and she tried to engage the woman in conversation, but the woman was too scared and she was just all balled up. And so, my friend Lucia just crawled on the bed behind the mother and embraced her in her arms and let their energy fields merge, and the mother was rocking back and forth, and she was moaning, “Oh, God! Oh, God,” with each contraction in this really high, tight voice. 

Well, in holism, if the body is energy, midwives postulate that there’s an energetic connection between the throat and the cervix. So, if you want the cervix to open, and be loose, and let the baby come, the throat must also be open and loose. So, the first thing Lucia did was start rocking with her to entrain their energies, to merge their energy fields, and then she began to whisper in the woman’s ear. As the woman was screaming, “Oh, God!” Lucia would whisper in her ear in a very low, guttural voice, “Oh, good. Oh, good.” And the mother began to take that up, and she kind of melted into Lucia’s arms, and she began to relax. She began to naturally lower her tone of voice. “Oh, good,” she began saying as contractions came. “Oh, good. Oh, good.” And all of a sudden she was pushing, you know? 

And Lucia had to jump down and run around and catch the baby, even though she wasn’t supposed to as a doula. What had she done in that birth? She simply changed the energy. That made a massive difference in the outcome of the birth. 

Lozada: That’s fantastic. That’s such a great story. So, Robbie, let’s say that a pregnant person will soon be giving birth in a hospital with a traditional OB in a very technocratic environment. Is there a way to make that birthing more humanistic or holistic? What are some things that could help in that situation? 

Davis-Floyd: My advice to mothers, especially first-time mothers, first of all it’s very important to know what you want from this birth. And it’s important to know what you’re afraid of and what you’re not afraid of. Some women are afraid of the hospital. If you’re afraid of the hospital, don’t go there to give birth. Walking in the door is gonna make your body tense up in fear. If you’re afraid of not being in the hospital, then you need to be in the hospital. If you perceive the hospital as your safe place, the place where the doctors and the technology is gonna save you and your baby if there’s a problem, then that’s where you need to be. So, you need to know yourself in order to make the choice. 

You don’t choose home birth out of some, “Oh, it sounds like it’s such a lovely idea.” You choose home birth because it’s a firm belief that you have that home birth is safer for you and your baby than hospital birth. And it is in many ways. Home birth provides less, gives you less iatrogenic intervention, not to interfere in the birth process. Statistics clearly show that home birth outcomes are just as good as those with low-risk hospital outcomes. And so, there’s no added danger or risk to home birth. It’s just as safe as hospital birth with its plans, with a skilled midwife in attendance. 

But you should only do that if you’re firmly committed to that ideology and if you truly believe in your power as a birth giver, or you want to believe in your power as a birth giver, and it’s really important to you to do it yourself. That sense of empowerment that women get when they birth completely on their own, there’s nothing like it in the world. You can’t achieve that in the hospital. If you want a normal, vaginal birth in a hospital, you’re very well advised to have a doula. I mean, a midwife and a doula. In some areas, nurse midwives aren’t available, but generally they’re much more available than they used to be, so you want either a very humanistic obstetrician. How you find out if your obstetrician is humanistic or not is you look at his cesarean rates, especially for first-time births. If they’re higher than 15% or 20%, you really don’t want the guy. A lot of obstetricians have cesarean rates of 50%. If you want to schedule a cesarean, he’s your guy. But if you want a normal, vaginal birth in the hospital, look for someone with a relatively low cesarean rate and with a compassionate attitude. Someone who’ll spend time with you during your prenatal visits and not shush you out the door in five minutes without answering your questions, you know? 

So, you’re well advised to have a doula who comes to your home as soon as you go into labor. You want to establish a relationship with that doula before you go into labor. Meet with her several times during the pregnancy. And then have her come to your house, and the doula will know when it’s time to go to the hospital. If you go to the hospital too soon, the classic scenario is you get to the hospital at one or two centimeters and you think you’re in labor, but you’re really not. You’re in what midwives call the latent phase of labor, and that can last until five or six centimeters. 

It can take two or three days to get past four centimeters and that’s normal. Then you want to stay at home with your doula and your midwife if you have one. You want to eat and drink as much as possible, as much as you want to, to not get exhausted, because labor is hard work. You need nourishment during labor. You want to be in and out of the tub or the shower. You want to be walking outside. And then your doula will know if you really want a hospital birth when it’s time to go, because your contractions will change. The nature of labor will change. And when you enter the active phase of labor, which is five or six centimeters and beyond, at that point there’s not a lot they can do to you in the hospital that will slow labor down. 

If you go to the hospital at one or two centimeters, they’re likely to want to put you on Pitocin to speed labor up, and that produces contractions that are more painful, and so then you’re gonna want the epidural. If you give the epidural too early, that slows labor. Then you need more Pitocin to speed labor up again. Then the baby goes into distress because of the added stress of the Pitocin-induced contractions and then you end up with an emergency cesarean, and you say, “Oh, doctor, thank you for saving me and my baby,” when it was the hospital interventions that caused the problem in the first place. 

So, to avoid that and to have a normal vaginal birth in the hospital, you want to bring with you your doula. You want to have a nurse midwife with you if at all possible or if you want that, and then you want to go to the hospital and when you’re well into active labor, well past five centimeters, go to the hospital then, and then you want a hospital that hopefully offers labor in water, at least the option of being in showers. You want to avoid being hooked up to the monitor continuously, because the essence of the successful labor is movement. You need to be moving during labor. The monitor and the epidural hold you still. They imprison you. They tether you. 

And I should say that with a caveat. There are some very savvy doulas and nurses who know how, if you have an epidural needle in your back leading to a tube, you can move a few feet away from the bed, so you can actually get out of bed, even with a monitor belt on, and you can sit on a birthing ball and rock back and forth, rock your pelvis. You want to move your body, because the more movement during labor, the more the baby descends easier, the easier the descent is, and the more successful the contractions are at pushing the baby down. So, you want to be moving as much as possible. You want to be… Don’t let anybody tell you not to eat or drink. Smuggle food in. When you’re truly, truly in active labor, you won’t be hungry. If you’re hungry, that means you’ve got some more hours to go. You want to eat to keep up your strength. 

So, take the doula, don’t go to the hospital till you’re five or six centimeters, go with your doula, and make friends with the nurses. Be nice to them so they’ll be nice to you. And that’s the best way to achieve a normal vaginal birth in the hospital. 

Lozada: Correct me if I’m wrong. I have heard that there seems to be in the near future, we’re looking at a possible shortage or decrease in OBs in the U.S.? 

Davis-Floyd: We do not need as many OBs as we have, at least not for birth. OBs should be attending the 15 to 20% of actually high-risk births that actually need a professional’s, a skilled specialist’s care like that. Midwives are skilled specialists in normal birth. OBs are skilled specialists in pathology. Well, most births are not pathological. But an obstetrician will turn almost any birth that he can into something pathological because he’s trained to only foresee pathology. 

Midwives, on the other hand, are trained in normal, and so they recognize deviations from normal, because they know normal, so they know when to call an OB, because they see that it’s not normal. Whereas the OB generally sees only pathology and doesn’t know how to keep birth normal, because that’s not his training. His training is in pathology. So, honestly, OBs should be doing no more than 20% of the birth in any given country and midwives should be the primary birth attendants. That’s how it ought to be. The shortage of OB doesn’t bother me the least. I just hope we get more midwives. We need more midwifery programs, more funding for them, more women entering them, all of that. 

Lozada: Yes, and hopefully more of a collaborative model between the OBs working together with midwives, and then they can see less pathology and observe a little bit normal, and have this… more humanized OBs, like your groupies and holistic OBs, like your groupies in Brazil. I know you love to do it, but I love listening to you talk. 

Davis-Floyd: Thank you. I appreciate you having me on. 

Lozada: You’ve been listening to a Best of Birthful episode and there are many more where this came from. Look for episodes with the words Best of Birthful in the title to continue your deep dive to inform your intuition. You can find the in-depth show notes for this episode at Birthful.com. You can also connect with us directly on Instagram. We’re @BirthfulPodcast. 

Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Virginia Lora is the managing producer. Cedric Wilson is our lead producer. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen. Listen every week for more ways to inform your intuition.   

CITATION: 

Lozada, Adriana, host. “Best of Birthful: What You Need to Know About Birth Models.” Birthful, Lantigua Williams & Co., September 30, 2020. Birthful.com.