What exactly is “natural birth” anyway?

I’m done with my residency interviews. On to the rank list. So, as a distraction, how about diving in?

Last week on Twitter, one of the people whose feed I follow posted that it annoyed her when people refer to vaginal birth with analgesia as “natural birth”. I replied that I am annoyed when people, including health care practitioners, refer to any vaginal delivery, regardless of any interventions, as a “natural birth.” Looking back, I think she was reacting to Beyonce and Jay Z’s press release that their baby was “delivered naturally”, which may have been in response to rumors that the singer had a scheduled elective cesarean.

It is bad enough when the term is used by lay people. I have seen countless residents and even attending physicians conduct an obstetrical history on a patient by asking “was that a cesarean or natural birth?” (I’ve even seen it done in Spanish – cesario or parto natural?) Since I have been guessing others’ motives this whole post so far, I’ll throw in another assumption. I think these history takers are avoiding the term “vaginal” because of some level of squeamishness or decorum. I have yet to see “natural birth” instead of “vaginal delivery” on a medical history template, thank goodness.

It’s a nonspecific euphemism that means something different to everyone, and, to some, carries judgment or bias. It is not a medical term, and does not belong in a medical history. I don’t begrudge Beyonce and Jay Z’s people for using the term, but it does bother me when it is used by someone in the health care profession.

Or, someone who used to be in the health care profession. Especially when it is used to capitalize on the judgment tied in with the connotation purposely. The more imprecise and loaded a term is, the easier it is to demonize it.

So, when Amanda Marcotte linked to an article on Grantley Dick-Read being a misogynist, I clicked through unwittingly. I was halfway through the article when I began to get suspicious by the familiar straw man argumentation tactics. Then I scrolled up and saw who the author was.

Now, I am not here to defend the so-called father of natural childbirth and his views on the modern woman of the 1940′s any more than I feel the need to defend all of Margaret Sanger’s views. Dr. Tutuer’s claim that the central tenets of so-called natural childbirth advocacy is therefore built on sexism and racism is as ridiculous as saying modern reproductive rights advocacy has central tenets of racism and eugenics.

Like the terms we use to describe childbirth itself, the discussion of birth advocacy and birth choices is improved with nuance, not sweeping generalizations, stereotypes and villainization. Speaking as someone who considers herself to be part of the birth advocacy cloud, I have never, ever heard a privileged, first world so-called natural birth advocate use Read’s arguments about the pain of childbirth being a punishment for uppity career seeking women who don’t know their place as baby factories. It is hardly a central tenet in the movement. In fact, one of the most common criticisms of opting for an analgesia free birth is that one is choosing to suffer like a primitive woman from a developing country, with frequent conjuring of women of color squatting in huts, and batting about of the term “animal”. I find those comparisons to be more sexist and racist than advocating for birth choices.

I also don’t agree that a central tenet of so-called natural birth advocates that the pain of childbirth is “empowering” (which contradicts the argument that it is a punishment for being empowered). I do think that autonomy in birthing choices and true informed consent can be empowering. Accomplishing something thought of as difficult, such as an unmedicated labor and birth, can feel empowering to some women. But, the actual pain? No. Is a longer labor more “empowering” than a precipitous labor? Persistent occipital posterior with back labor the most empowering? Ridiculous.

Finally, although I do think planning on an analgesia free birth with preparation makes it a more tolerable experience than, say, having a analgesia free birth when one planned on an epidural but is somehow unable to receive one. But, do most “natural” childbirth advocates say that adequate preparation means a pain free labor? Absolutely not. That is a fabrication, as Dr. Tuteur deems it to be, but it is a fabrication on her part that it is a common claim in the “natural” community. I had two analgesia free labors, and they hurt. A lot. And, again, this contradicts with what she says is the other central tenet of “natural” birth advocates, that the pain is empowering. Is the labor pain free or is it painful and therefore empowering? Boy, we “natural” birth advocates sound like idiots!

Dr. Tuteur would be hard pressed to find contemporaries of Dr. Dick-Read who were not sexist and racist, considering how sexist and racist American society was at the time. If you read articles written at the time about twilight sleep, the main standard of care for “pain free” birth, you will also see troubling justifications and, frankly, fabrications. From the linked article “Twilight Sleep: the Dammerschlaf of the Germans” in the Canadian Medical Association Journal:

One can imagine what a special paradise of salvation this promise conveyed to that vast number of women who, as matrimonial candidates, are consciously unwilling, or unfit, for the claims of parturition; that vast array of modern womankind with no physical or mental training for the demands of motherhood; who are enmeshed, as Walt Whitman so well describes it, “in the incredible holds and webs of silliness, millinery, and every kind of dyspeptic depletion.” For such a prospective mother this method afforded a glimpse into a maternal paradise.

The article also presents claims that twilight sleep analgesia in labor reverses the biblical curse of original sin on women. The author also acknowledges the technique is inconsistent and does not always provide an actual pain free experience, but that the amnesiac qualities of the scopalamine solved that problem. Considering many of these women would receive episioproctotomies and mid to high forceps deliveries, I doubt the recovery was easy or pain free, much less a glimpse into maternal paradise. Does this mean that obstetric analgesia is built on central tenets of sexism and fabrication?

There is no such thing as “natural” birth. There is spontaneous onset of labor, there is labor without augmentation, there is labor and birth without analgesic medication, there is spontaneous vaginal delivery, there are births in which the moms are allowed to position themselves freely, there are births in which the moms push at will instead of being coached or forced into closed glottis Valsalva pushing, there are births where the cord is allowed to pulsate and blood transfer is allowed to occur instead of immediate clamping, there are births in which the baby is delivered on to the mom’s skin instead of a blue “sterile” drape and then is whisked to a warmer.

My first birth, I went into labor on my own. I was given Pitocin augmentation, labored on my back in a bed with continuous monitoring, amniotomy, had coached pushing, also on my back, immediate cord clamping, and my baby was taken from me immediately, and I didn’t get to see or hold him for more than four hours. I sure didn’t have any medical analgesia, and it hurt like hell. I didn’t feel empowered, and don’t think the term “natural” applies to that birth. My second birth, I went into labor spontaneously, I was able to change positions, I had no augmentation, had intermittent monitoring, but I pushed the baby out flat on my back, against my will with no urge to push, while being yelled at to hold my breath and push for a count of ten. Was that more “natural”? More empowering?

I think I share motives with many in the birth advocacy community. I think women should have autonomy in their birth choices. I think the burden of proof should be on interventions, which should ONLY be employed when medically indicated, and then should be offered with adequate informed consent. If I had to rank my priorities or “central tenets”, I am much more concerned about early elective inductions, forced repeat cesareans in good candidates of trials of labor after cesarean, routine episiotomy, routine deprivation of oral nutrition during labor, routine amniotomy, routine continuous monitoring, routine augmentation, routine episiotomy, aggressively coached Valsalva pushing without laboring down, and routine pushing in the lithotomy position than I am worried about epidurals. I am much more worried about women simply being told that Stadol “will just take the edge off” and epidurals “don’t affect the baby”, both of which I have heard as the entire informed consent for each.

ETA: Sorry I ended it so abruptly, but lunch break was over at the clinic.

We need more nuance, not more generalization. We need more empathy, not more vilification. I am all for critiquing historical figures through the lenses of feminism and anti-racism. But, let’s focus on truly empowering women instead of tearing them down.

48 Comments

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48 responses to “What exactly is “natural birth” anyway?

  1. Elana Kahn

    Beautifully put! (Although you put routine episiotomy twice…) ;-) We need more OB/Gyns like you out there. Although if all OBs were like you then we wouldn’t need midwives (like me eventually). :-D I hope that when I get a job as a midwife that we’re at the same hospital so I can refer high risk cases to you.

  2. Emily

    You give me some faith that perhaps there will be OB-GYNs out there who truly believe in a midwifery model of care! As a CNM, you are (will be) the kind of physician with whom I would love to collaborate…birth center, maybe? :)

  3. Angela

    I think I would just like to hear “informed, collaborative birth vaginal or csection”. I have had patients w extreme fear of birth, history of 4 th degrees etc w no plans for future kids who want a section , and I have had exactly opposite. It takes a lot of work to overcome the “you are an sOb” mentality for some, or “I am ‘ too posh to push’ ” mentality in others. I believe in education collaboration and getting my patient to understand that if I am recommending a section it is NOT bc I have a golf game or get paid an extra 100$. Bad apples can definitely spoil the barrel hope u aren’t disillusioned too fast during your residency!

    • MomTFH

      I hope I’m not too disillusioned, too. I believe in collaborative care and patient autonomy. I think there’s a fine balance between evidence based care, patint request, and the practitioner’s comfort level and conscience.

  4. Larissa

    I’m a former doula, current CBE and an aspiring OB (applying next year for med school). Thanks so much for this post! I never, NEVER use the phrase “natural birth” in my classes or with my clients. I prefer more accurate terms like “low intervention, unmedicated” to describe what most would refer to as a “natural” birth. Ugh, major pet peeve!

    I have lately become quite disillusioned about the birth advocate community – I think you might be more generous in your assessment of their motives than I have become. I think many do have chips on their shoulders, personal agendas and are judgemental of certain choices (like CBAC and unapologetic epidural use) and react with an “If only they KNEW BETTER” sort of attitude.

    • MomTFH

      I definitely hear you. There are judgmental pockets in every niche. I definitely have avoided certain gathering places that tend to be extremist echo chambers for a while. However, when I have interacted, virtually and in the real world, with the varied members that represent the heart of what I see as birth advocacy, I see a strong cry for information and options, and a desire for no one to be judged for reasonable choices.

  5. Jess

    I will try to comment more when I have time but I just have to say: LOVE!! You are going to be such an amazing OB

  6. MomTFH

    Thank you to everyone who has taken the time to comment! Yes, I mentioned episiotomy twice! Whoops, well, I guess I really mean it.

  7. Thank you. Times a million. The term “natural birth” makes me want to vomit, and you’ve done a beautiful job of articulating why.

  8. MamaPSU

    Hi. I’d like to ask you a few questions about this post. I see (from this post) that you are on twitter. May I contact you there or would you prefer emailing?

    • MomTFH

      Either is fine. Unfortunately, my time can be really limited – I’m a single mother in medical school, notice the dearth of blogging and answering replies on here – but I try to be responsive whenever I can.

      I am @momstinfoilhat on twitter and my email is on my “about” page.

  9. Thank you for writing this.

  10. We are also ranking our choices for match. It’s stressful for us and hubby is going into family medicine; I can’t imagine how stressful the OB world is to match into. But we need good OBs who understand that women need to be informed of their choices, who get that evidence-based medicine is the way to go, and who introduce interventions because they are needed, not just because it’s routine procedure. Keep up the good work, and keep writing!

  11. You sound like the kind of doctor I’d want if I were going to have hospital births when it’s finally my time to have kids! There definitely needs to be more of a balance between the highly-interventionalist birthing model used in many hospitals and the rather misleading and dangerous woo spouted by certain crunchier than thou folks who pride themselves on refusing all interventions, even medically necessary ones (like antibiotics for GBS and gestational diabetes testing).

    • MomTFH

      Thanks! I am all for medically indicated interventions. My paradigm tends to be less-is-more, but I absolutely support appropriate use of antibiotics when indicated, etc.

  12. Sarah

    Where will you be setting up your practice now that you are done with your residency? Can you come to Northern New York State, please? We need you. (You think i’m kidding, i’m not.)

  13. Pain can be demoralizing, wherever and however a birth happens. But I will say that my medicated birth was by far the most difficult and painful of my three deliveries (which is why it ended up medicated). My most “natural” birth, at home, was also quite painful, compared to my first delivery, and it took me a while to come to terms with just how painful it had been despite me doing everything “right” to have a peaceful, gentle birth.

    But by far, the most important factor in how I felt about the births of my children was the respect given to me (or not) by the people helping me. My first birth, not all that painful, happened with doctors and nurses who had no understanding of my priorities, and was infuriating and traumatic more because of how I was treated than how the birth actually felt.

    My last birth, a long, difficult pitocin induction with a failed epidural, restored my faith in humanity, because every single point of my birth plan was respected by the doctors and nurses who were helping me, every intervention was something I asked for, and common sense, not
    ‘hospital policy”, ruled.

    We transferred from a planned homebirth to a pitocin induction… the doctor receiving us was part of a program called “Stork docs”, doctors willing to handle homebirth transports, they actually okayed my birth plan in advance, before we got there, and I believe picked nurses for me who wanted to work with a mom who preferred a less interventive mode. Despite the interventions needed… I pushed my son out without coaching, on my side, into my husband’s hands, with my homebirth midwife doing perineal support (I did not tear), and the doctor standing back and watching. Her words were, “I’m here in the event of an emergency.” The cord was left alone until I asked to cut it. Despite the epidural, I was able to stand to deliver the placenta. And we left, NOT AMA, less than 8 hours after the birth. My son never left our sight. It was at least an hour before anyone outside my family touched him.

    With my first I had a goal of natural birth, and got “unmedicated”… but that was about it. My second was far closer to the “ideal”… catching my daughter in my hands in water in my home… but for that birth my goal was simply to keep things as low-tech as the situation required. With my third, the goal was the same, but an asynclitic head plus health issues for me meant we had less room for “watch and wait” than we might have.

    • MomTFH

      Thanks so much for sharing your birth stories. Pain and birth in general can be reflected on by the mother in such a variety of ways. I think respect, informed consent and a sense of autonomy are so important, as your examples illustrate.

      • Having sane policies for homebirth transport and reasonable docs who were willing to let me do my thing was so, so important, and made the transport decision easier.

        • MomTFH

          Absolutely. I think an adversarial atmosphere between out of hospital birth providers and hospital based providers can be really detrimental to mothers.

          I am so happy you had a good experience.

          • My whole pregnancy was co-managed by a CPM and a perinatologist, because I have risk factors that make pregnancy higher risk, but don’t actually affect birth all that much. My perinatologist said, when I told him who my midwife was, “Oh, I like her, she’s a great midwife.” And my midwife was happy to consult with him.

            One of the biggest problems with adversarial situations is that it makes people less willing to consult or transport, and that makes birth less safe. I’m not low risk… but having both modes of care available and living 5 minutes from a level III NICU, with friendly transport available, meant that I could plan for the lowest tech birth and add tech only as needed. Which we did.

            The research coming out of Canada, where the model is very cooperative, is showing great results for safety in homebirth when the transport model is supportive.

    • Micaela P.

      Jen, I immediately thought of you while I was reading this post so am very glad you read it too and shared your story. <3

  14. Micaela P.

    I’m glad I overcame my initial reluctance to read this post because it’s awesome! (I was dreading a holier-than-thou, judgey piece). May I ask in what context Amanda Marcotte linked to the Dr. AT post?

    I agree with the others that more OBs with your mindset are desperately needed!!!

    • MomTFH

      In the twitter link, she simply said the father of modern childbirth was a misogynist, and then had the link. No mention of the rest of the content of the article.

  15. I really, really enjoyed your point of view, here. Well said.

  16. alicia

    I’m a CNM with 16 years experience in hospital birth. We definitely need more OB docs with your attitude about birth. Hope your residency doesn’t burn you out. Don’t come to Mt Sinai in Chicago! OHSU in Portland would be really great, they still do breeches vaginally and have some great forceps teaching. I have a lot of gripes about OB education having been at teaching hospitals for the majority of my career. We need OBs who know how to do the right intervention at the right time. As far as “natural” – that is a loaded term with very little meaning at present. In the 1960s it did have a specific meaning. Of interest, Lamaze never claimed to be a ‘natural’ method but Bradley did. I know you don’t have much spare time but I would really recommend reading some of the books from the various eras of childbirth activism as well as some of the older medical and midwifery texts. There is a lot that isn’t being taught that should be. I had 6 births. WIth my first I had continouos fetal monitoring both internal and external, xray pelvimetry in labor, kept NPO because of a possible cesarean, one dose of nisentil (look that one up, it isn’t even available any more) and my newborn was taken away from me at birth and I saw her at 9 hours of age for 20 minutes and got her for 20 minutes every 4 hours after that. And that was considered a ‘natural’ birth. Oh, and I was never in pain, just had nausea vomiting and shakes for which the remedy was the drugs. But it was my second ‘natural’ birth that really made me a childbirth activist. No pain, but nurses that didn’t listen to me, a famous for natural birth MD who didn’t show up until literally 1 minute before the baby did, baby circumcised on the instrument table in the delivery room…….. No pain, no drugs, but no respect either. My next 2 were at home with midwives and my last 2 were in hospital with midwives and I learned there is no such thing as the perfect birth but that being respected and listened to makes all the difference in the world. My third was extremely painful (OP, thick mec, triple nuchal cord), my 4th was scary (shoulder dystocia and delayed PP hemorrhage) and my last 2 were just incredibly fast…..I guess my bottom line is that as a midwife I see myself as the lifeguard for the mom and baby and my job is to make things as safe as possible and to listen to what the mom and baby both need and want. The system makes that very difficult, though.

    • MomTFH

      Thanks so much for sharing your extensive experience from both sides of the birth!

      I wish I could go to OHSU. I met the program director at the ACOG annual clinical meeting once, and she said I would be a good match for their program. I completely agree. I also love the city. But, I am unfortunately very, very geographically limited and only applied to a handful of programs in the Southeast.

      • Ah, my experiences with OHSU have been universally miserable as a patient, but I”ve never used them for OB care. I wouldn’t send my worst enemy to Doernbecher’s after my experiences with the CDRC there for my daughter. (The branch in Eugene was fine. But up in Portland.. no.)

  17. Great post!!

    BTW, I haven’t heard anyone in my memory use “natural” to mean “vaginal” – in Spanish or English – but I do notice that the Spanish women use “parto normal” (probably also as an effort to involve saying “vaginal”).

    • Micaela P.

      the first time I gave birth was in Puerto Rico in 1991 and my vaginal birth — which included continuous internal & external monitoring, enema, pitocin, breaking my waters, and an episiotomy — was referred to by everyone as a “parto natural”. Imagine my surprise when I learned more about birth while preparing to have my 2nd child in Oregon in 2004!!!

      • MomTFH

        Thanks for sharing! PR is so close to here – I imagine we share a lot of terminology. I have heard “parto normal” also, mostly from patients, but “parto natural” more from practitioners.

        I hope your second birth was different than the first in a good way.

        • Micaela P.

          it was different & slightly better, but mostly because I knew more and had a supportive birth partner (my husband). Suffice it to say that I narrowly missed winding up with a C/S — I went from being “stalled” to completely effaced in the 10mins that they left me alone to go prep the OR. My husband trusted me and trusted my body, and in the end it was his reassuring voice that I listened to while I labored and pushed.

          Where in the Southeast will you be, do you know? I’m in the Charlotte, NC area now :)

          • Micaela P.

            um, I just reread that and feel I should clarify for the masses: *I* trusted my body but the medical staff was not respectful nor were they supportive. So when they left us alone for a few minutes the energy in the room totally changed, my husband & I were able to just really sync up and work together from that point forward so I could birth more on my terms. That part of the birth, the way we came together and he just knew how to support me and what I was doing was amazing & life-affirming for me. The rest of the hospital experience was only marginally better than the first time.

            We could talk for hours about the high incidence of prematurity & C/S in PR, but Jill has already covered some of that on her blog and I know you’re very busy ;)

  18. Wendy

    “Dr. Tutuer’s claim that the central tenets of so-called natural childbirth advocacy is therefore built on sexism and racism is as ridiculous as saying modern reproductive rights advocacy has central tenets of racism and eugenics.”

    Heck, I’m *pro-life* and I agree! I have to remind other pro-lifers that many of those early feminists who opposed abortion (Sanger actually opposed it, too, but that’s fodder for another conversation :-) ) and gave us the right to vote ALSO favored eugenics. That’s no reason to rescind women’s voting rights. James Madison owned slaves, but that doesn’t mean we shove the Constitution into the shredder. You get the idea.

    I do like your use of the term “birth advocacy community.” Henci Goer uses another title that I like, “childbirth reform.” Building from your post, the term that drives me batty is “Natural Childbirthers,” usually abbreviated as NCBers or referred to as the NCB movement. It takes the focus off of the central tenets of birth advocacy–namely, a push for compassionate, evidence-based care that respects women’s autonomy and voluntary, informed consent–and reduces the issue to simply whether or not to get the epidural. Also, the terms “NCB” and “NCBers” is usually used in the context of crass stereotyping and rendering snippy judgments against women for their birthing choices. (And to be fair, there’s a lot of judgment-hurling on BOTH sides of this inane and unfortunate Mommy War).

    I’ve had two midwife-attended, out-of-hospital births and am due to have another one soon. My ultimate motives have had nothing to do with a desire for “natural childbirth” at all costs. On the contrary, when I first looked into my birthing center (run by a team of CNMs and CPMs), my first response was, “Oh shit! No epidurals? I have to do WHAT???” I have to cut this short, but thank you for recognizing and writing about the *bigger picture* to birth advocacy.

  19. MomTFH

    Thanks so much for your great reply!

    You know, I did the opposite that you did with your first birth. I just knew I didn’t want an epidural or a cesarean. I didn’t know of any out of hospital providers. One person referred me to a CNM who delivered in the hospital closest to my house, which had just been picketed for the dubious honor of passing the 50% cesarean mark.

    I had a lot of interventions in my first birth that I didn’t expect and wasn’t informed about. I still remember asking the nurse about the pitocin as she set the rate on the IV – I most certainly was not consulted ahead of time. I didn’t have that epidural or cesarean, though. Now I know it is so much more than that.

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