Imagine a woman in a rural South Asian village laboring to give birth. She is at home, surrounded by her extended family. She walks and rests intermittently; the choice is hers. Her birth attendants place a flower near her, telling her softly that as the petals unfold, so will her cervix open. The atmosphere is one of quiet ceremony and celebration. When she is fully dilated, she squats, supported from behind by another woman. The midwife encourages her to push when the time is right. There is no cutting into her body. She is neither medicated nor monitored. She trusts herself to bring her child into the world.
Now look at what is happening to another woman - a more educated, sophisticated woman who is giving birth in a city in Thailand. She is admitted to the hospital, where her clothes and personal belongings are removed. She is immediately hooked up to an intravenous drip for hydration and the possible administration of medication). Her genitals are partially shaved and an enema is administered. She will most likely be hooked up to a fetal heart monitor. She will be offered drugs "to take the edge off". Perhaps she will be given the stimulant Pitocin to speed things up. If she delivers vaginally, her perineum will be cut, then stitched. But if her cervix does not dilate as quickly as her doctor thinks it should (or if he grows impatient waiting), she may well be subjected to a Caesarean section (C-section).
The contrast between these two births could not be more profound. In the first case, the birth environment is one of confidence and natural forces at work. In the second, a medical atmosphere suggests that something is - or may be - amiss, something that technology can fix or prevent. In fact, that technology is quite likely to be unnecessary in most cases and could be harmful in others.
For example, a C-section is a major surgery and carries with it the attendant risks, including infection, pulmonary embolism (blood clot in the lung), and anesthesia complications. Fetal monitoring can provide erroneous information, which leads to unnecessary interventions, such as surgery or forceps delivery. Drugs are often administered prematurely, slowing down the progress of labor, another justification for performing C-sections, which are known to carry a risk two to four times higher than vaginal delivery. (The World Health Organization - WHO - estimates that maternal mortality after C-section is two to 11 times higher than that after vaginal birth.)
So how did the medicalisation of childbirth occur, and why are Asian women increasingly buying into it?
The highly respected Boston Women's Health Book Collective and other women's health advocacy groups internationally have long documented the medical establishment's cooptation of childbirth. In the US, it began in the 19th century, when surgeons realized there was money to be made by treating birth as a debilitating medical event. As one nurse-midwife put it in the Collective's classic book 'Our Bodies, Ourselves' (OBOS) (Simon & Shuster, 1992), "There was no longer any place for most of the natural aspects of birth, like blood, sweat, feces, movement and sound."
Women began to be encouraged "for your own good" or "for the good of the baby" to accept medical intervention and something of a factory approach to birth ensued. That approach focused on efficiency and practitioner profit rather than individual experience and preference.
Over time, women in America and Europe themselves began to internalize the medical model of childbirth. Frightened, they were no longer confident of their ability to give birth. This is how one mother put it in OBOS: "It was like our confidence was a big piece of material. When little holes of fear and doubt began to appear, the medical mentality made them larger and larger until the once-beautiful cloth was nothing but gaping holes."
That lack of confidence is one big reason that urban, affluent women in many Asian countries are choosing C-section births at an astounding rate. In a Thai urban hospital, 30 per cent of first births - and 40 to 50 per cent of subsequent births - are C-section.
The overall C-section rate in the country rose from 15.2 per cent in 1990 to 22.4 per cent in 1996, according to the WHO Regional Office for Southeast Asia. In 1996, private hospitals in Thailand were found to have a C-section rate of 51.5 per cent. The WHO says that, under normal circumstances, C-sections should not make up more than 15 per cent of births.
Several women in Thailand interviewed for this article, all of them pregnant for the first time, reported that they had already informed their doctors they wanted a Caesarean birth because they didn't want to experience any pain. Other women elect to have C-sections so that their child will be born on an auspicious or convenient day. Some think it will help them "keep a honeymoon vagina".
Physicians are only too happy to comply, often for reasons of convenience or economic gain. For example, when asked why epidurals are overshadowed by C-sections in her hospital, one delivery nurse in Thailand reported that anesthesiologists and obstetricians "don't like to hang around waiting".
The conventional wisdom among the medical establishment is "once a section, always a section", although objectively there is no reason, in most cases, why subsequent births cannot be vaginal. What's more, fetal monitoring, IVs, 'prepping' (shaves and enemas), episiotomies, and drugs are all part of the arsenal of medicalised childbirth. Dr Frederick LeBoyer captured this arsenal and mindset in his 1975 classic book 'Birth Without Violence': "The orthodoxy reflects an anxious view of birth...as a treacherous course mined with sudden unexpected disasters requiring the medical equivalent of a military alert."
The issues related to participatory and woman-centered childbirth go beyond medical intervention at delivery. For example, Asian women are foregoing breast-feeding or are nursing only for short periods in an attempt to retain their figures or to resume daily activities without the demands of nursing an infant. Only a fraction of them take advantage of prenatal classes offered by hospitals. They willingly defer to their doctors for decisions that many advocates feel are rightfully theirs.
Such practices suggest that the wholesale adoption by mothers as well as medical personnel of western, medicalised standards for labor, delivery and post-partum care increases as women become more educated, affluent and urban. Time will tell whether or not those practices are useful in Asia, even as statistics and patient preferences in the West suggest otherwise.