There are two visions of childbirth that dominate the popular conversation. The first perspective is that unmedicated, natural birth is painful, scary, dangerous – even primitive. According to this way of thinking, to counteract the pain and danger of childbirth, we need to throw everything we can at it. Modern medicine delivered in a hospital – inductions, epidurals, C-sections – ensures the safety and often survival of babies and their mothers. Anything less is dangerous and irresponsible.
The other perspective: birth is a natural, physiological event; if there’s anything to be feared, it’s not labor and birth, but the consequences of messing with nature. This version of birth has many patron saints, among whom the midwife and author Ina May Gaskin may be the best known. According to this perspective, birth isn’t about getting eaten by a dragon; birth is about becoming the dragon, relishing the fullness of the embodied experience.
When I prepared for my daughter’s birth in 2016, most of the advice coming my way arrived from that second camp. Without being able to attribute it to anyone in particular, I understood unmedicated birth as morally and experientially superior. Although my doula suggested it, I didn’t seriously consider home birth – that felt too dangerous, as I live 25 minutes from the closest hospital – but to the extent that I thought about C-sections at all, I believed a “natural” birth would help me avoid the operation. Epidurals fell into the cascade of interventions that I understood ended inevitably with a caesarean, a fear my doula seemed to share.
I announced my intention to have a “natural” birth at Rosh Hashanah dinner. I looked down the table at four generations of women, including my own mother. At 33, I was the last grown-up woman among them to start a family. I can still see the restrained looks on their faces, these women who had birthed some 20 children over 40 years, who’d changed thousands of diapers and cooked tens of thousands of meals, who’d seen children off to kindergarten and college – all while holding jobs outside the home – and who knew intimately about the many varieties of pain and love that compose the ballad of the parent.
To their credit, the women said nothing. Possibly my reputation for making off-road decisions weighed in my favor. Then my mother broke their polite silence. “Go for the drugs,” she said with a laugh. At the time, I remember feeling misunderstood, in what seems to me now an adolescent sort of way: you don’t get it, Mom. For me, birth would be different.
My mother knew what she was talking about. She’d had two children. But she’d also once told me that birth was better than any orgasm you’ve ever had in your life. So I was confident I wouldn’t need an epidural.
When it comes to birth, the term “natural” is fuzzy and imprecise. Does it mean vaginal? Vaginal and unmedicated? At home? In the water? Regardless of the definition – which changes depending on whom you ask – it most definitely doesn’t include C-sections. Though it would not become a regular part of obstetric practice in the US until the early 1900s, one of the earliest known mentions of caesarean birth, in the late 13th century, referred to it as “artificium”, meaning artificial.
But to get at what “natural birth” means now, and why its power is among the reasons C-section mothers can feel cast out, we have to go back to its roots. That means visiting two people: Grantly Dick-Read, the British obstetrician who introduced the term “natural birth” to Americans; and Gaskin, credited as the latter-day mother of it all.
Dick-Read’s books Natural Childbirth and Childbirth Without Fear appeared in the US in the early 1940s, introducing the term “natural birth” to the American lexicon. At the time, demand for medication to relieve labor pain was widespread in the US, among women and doctors both. Yet despite its popularity, obstetric anaesthesia was inchoate; the epidural as we know it wouldn’t become widely available until the late 1960s. Instead, many of the pain relievers used in the early and mid-20th century created more problems than they solved. The anaesthetic ether, for instance, increased risks of hemorrhage, lung irritation and kidney damage for mothers, and asphyxiation for babies. Morphine, another popular pain reliever, caused breathing problems in babies, who could be born needing to be resuscitated.
Other medications numbed the pelvis so completely that women could not feel how or when to push. That meant that obstetricians more often needed to use forceps to drag babies out.
Though forceps had been used since the 1700s to deliver stuck babies and save mothers’ lives, in the wrong hands – for instance, among physicians who didn’t really know how to use them – they could lacerate a mother and damage the baby, too. Many maternity hospitals also used restraints, in part because a once popular labor medication, given with morphine for “twilight sleep”, scopolamine, caused some women to climb out of windows during labor. My mother remembers having her wrists put in restraints during labor.
In the search for how to relieve the pain of labor, Dick-Read’s books stood out because he asserted that women could birth without the need for medicated pain relief – if they practiced calming their minds. “Primitive” women, he wrote, knew instinctively to do this. White women had forgotten how. But they could learn, he assured his readers. In that way, he forged “natural” birth as a goal that white, middle-class women should pursue, an idea that has stuck around – and which I found myself echoing at that Rosh Hashanah dinner.
But for this technique to succeed, he wrote, women needed continual male accompaniment during labor from their physicians and, in many cases, their husbands. This was radical: at the time, women who gave birth in hospitals labored alone, their husbands banished to the waiting room. But it was also profoundly anti-feminist: a calm, unmedicated labor wasn’t something women could handle independently – they needed men to make it work.
Dick-Read also asserted that by being fully conscious and emotionally present for birth, women could achieve “the perfection of womanhood”. Labor and childbirth were among the most important aspects of a woman’s life. In that way, he yoked “natural” – meaning unmedicated – labor to what he saw as women’s biological imperative and the ultimate expression of female identity.
By the 1970s, second-wave feminism claimed natural birth as part of the overall project for women seeking to reclaim autonomy over their bodies. This was right around the time Ina May Gaskin was co-founding the Farm, a commune and midwifery center in Tennessee that remains a destination for mothers seeking an unmedicated, “natural” birth.
In the late 1960s, Stephen Gaskin, a former professor of English at San Francisco State University, launched Monday Night Class, a free lecture series open to anyone. His talks on spirituality, God, non-violence and anti-materialism eventually attracted upwards of 1,500 people a week. In 1970, Gaskin went on the road to deliver his sermons. Several hundred followers joined, packed into repurposed school buses and bread vans. A pregnant Ina May and her young family were among them. Ina May would go on to divorce the father of her child and marry Stephen.
To realize their dream of living collectively and in tune with the earth, the group of about 300 people in the caravan decided to buy about 1,000 acres near Summertown, Tennessee.
Ina May, along with other women, served as a midwife, attending births among the group and from a nearby Amish community. The need for midwifery grew quickly, because Stephen discouraged birth control; pregnancy is often the outcome of “natural” family planning. In time, Ina May’s influence on natural birth, and midwifery, would resonate throughout the US and across the world.
The foundation of Ina May Gaskin’s approach, and of some of its contemporary spin-offs, is that birth needn’t – indeed shouldn’t – be medicalized. Women’s bodies are capable of birth, and most women can birth their babies without intervention. They need encouragement far more than they need drugs.
Reading Gaskin’s Guide to Childbirth when I was pregnant, the idea that pain was only pain because we called it that resonated with me. It made sense that fears around childbirth were overblown, and to some degree socially constructed, by a society that often stereotyped women as weak, hysterical and incapable.
In an email I wrote to a friend at the time – who was also pregnant – I gushed: “I don’t feel scared of delivery in part because I read Gaskin’s book on birthing (not Spiritual Midwifery, the other one). It has tons of birth stories and basically makes the point that we construct birth as something to fear in the US, and that doing so makes the process unnecessarily hard.” But what also drew me to Gaskin – what attracts many people – was her exceptional birth outcomes. Of the more than 2,000 births on the Farm between 1970 and 2010, only 1.7% have been C-sections.
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Since 1970, seven babies born at the Farm have died, including Gaskin’s own – the one she was pregnant with when she was traveling around by bus. The Farm has not lost a single mother.
I didn’t see it at the time, but the natural-birth ideology Gaskin personifies, and that her acolytes emphasize, leaves out a lot. Like so much of the culture around birth, it’s used to emphasize what you, the individual, can do. How you can reject the medical model. How you can prepare your mind. How you can say no to intervention. “Your body is not a lemon,” Gaskin writes. “You are not a machine. The Creator is not a careless mechanic.”
The solution to the problem, as much of today’s natural-birth discourse suggests, isn’t to change society. It’s to stick up for yourself. Never mind that when Black birthing people stick up for themselves by declining medical intervention, as a 2019 study by Laura B Attanasio and Rachel R Hardeman shows, they are more likely to be stigmatized “as non-compliant, aggressive or as the ‘angry Black woman’”.
That same insistence on focusing on yourself when facing adversity shows up in self-help books, women’s magazines and wellness culture. It sounds empowering, but when it comes to solving systemic problems like the overuse of C-sections, or structural racism, it’s a losing battle.
Society’s embrace of “natural” childbirth began to wane during the 1980s and 90s, while induction and C-sections became more common, thanks partly to technological changes like external fetal monitoring, which measures a baby’s heart rate.
By 1992, about half of birthing women in the US had an epidural, up from 22% in 1981. In addition to enjoying pain relief, women began embracing technology, and medicalized birth, in part because hospitals had adopted some of the demands to make birth more humane. They permitted men in delivery rooms; they stopped using restraints. But as we know from the sizable minority of people who experience mistreatment during pregnancy and birth today – about 17% – the culture of hospital birth did not entirely transform.
The pendulum has started to swing back. The current obsession with “natural” birth (and parenting, and pregnancy) began to take hold again in the early 2000s. Home and birth-center births in the US have been rising since 2004, most significantly among white and college-educated women. Gaskin’s Guide to Childbirth was published in 2003 and is consistently among Amazon’s 10 bestselling books on pregnancy and childbirth. Ricki Lake and Abby Epstein’s 2008 documentary The Business of Being Born offered a capitalist critique of hospital birth, which furthered the conversation advocating for non-medicalized home birth. Then Covid hit, and home and birth-center births suddenly became more sought-after – because they offered an alternative to birthing in a hospital, and possible exposure to coronavirus – that midwives had to turn people away. While the surge has abated somewhat, a fundamental acceptance, even adoption, of the natural-birth ideology was already ambient.
One reason for this shift toward “natural” births is the sheer number of C-sections we’re doing, and the reality that most first-time moms don’t want surgical births. Embracing “the natural” – and the ways of being pregnant that go along with it – seems like a good (if not the only) way to avoid a C-section.
The imperative to manifest a good birth is seductive. To be sure, getting yourself in the right headspace is important; labor and birth require tremendous mental persistence. It is important to believe that your body can birth safely and – if it’s your intention – vaginally.
But you can’t think your way out of a broken system, or one that only appears to grant mothers freedom of choice: not when there aren’t enough midwives to meet demand; when hospitals and insurance companies promote and reimburse epidurals and electronic fetal monitoring, not low-tech, high-touch skills to promote vaginal birth; and when an estimated one in five hospitals forbid mothers who’ve already had a C-section from attempting a vaginal birth after caesarean (Vbac). Believing that you can think your way out is a trap, especially when it turns out that you can’t manifest the birth you want – no matter how smart or good at thinking you may be.
I didn’t know any of this when, the day before my due date, I went into labor in the middle of the night. For 12 hours, back labor walloped me, hammering me with what a nurse at the hospital would describe as “monster” contractions. The desire I’d had for “natural” birth quickly evaporated.
I asked for an epidural, which the anesthesiologist had to redo three times to get right. Another surprise: that epidurals could fail. Then my daughter started to have heart rate decelerations, and the midwife called a C-section.
Recovery was hard for many reasons, among them that I had to reckon with lies I’d absorbed about C-sections, which suddenly – because I was a C-section mom – seemed to apply to me: that they are a second-class way to birth; that they happen to mothers who are lazy, or who fail to sufficiently want to birth vaginally; that surgical birth indicates something wanting about a mother’s character. These ideas, I’d come to find out, derive from a long history that has associated C-sections with impoverished, enslaved and othered women. Women who, unlike white and middle-class mothers who are supposed to strive for “natural” birth (and who are rewarded for being “natural” mothers), have often been derided as poor or unfit mothers.
The truth is that birth is not a reductive dichotomy between natural and not. It’s so much more complicated: difficult, frightening, exciting, painful, sublime. During my “unnatural” birth, I imagined a new image, so real and palpable, and nothing like the fantasies I’d entertained during pregnancy: my baby and me during labor, under a black sky dotted with stars. Alone, one body, two people. Sundered from the plane of regular life, together we touched eternity. Never again will we work this way together, in such unison, at a single, most primal task. This was the truth of my birth, the most honest understanding of it I could reach. What that generation of women was trying to tell me at the Rosh Hashanah table, but that until I’d been through it myself, I couldn’t see.
Rachel Somerstein is the author of Invisible Labor: The Untold Story of the Cesarean Section, out from Ecco on 4 June
