Friday, March 28, 2008

Fear of fear

I find Kneelingwoman's latest post and Navelgazing Midwife's latest post to be thought provoking. One of the things that intrigued me the most was the following from Kneelingwoman (quoted approvingly by Navelgazing Midwife):
We have gone overboard in telling women to trust their bodies and birth and we have not done a good job educating women about the inherent wildness and unpredictablity of birth. We seem to not know how to backtrack on this position without risking a wholesale return to the idea of allowing fear to dominate women's thinking about birth and the resultant potential "loss" of midwifery clientele. My response to this is, very clearly, "we have to find a way" because babies are dying and women are suffering because they are not taking any risks into account when they plan these births.
She elaborates:
I truly believe that this is a public health issue that Direct Entry Midwifery needs to take the lead in addressing and researching and, most importantly, healing. Sometimes, there are unintended consequences to even the best ideas. I think this is one of those times.
Personally, I think the source of the problem is this: the fear of fear.

The absolute centrality of beliefs about fear is very damaging to direct entry midwifery for three reasons: it is based on a claim that is an out and out lie (and racist to boot), fear of childbirth is a beneficial response and is probably evolutionarily advantageous, and it justifies and encourages ignorance as a virtue.

The origin of the problem is very clear. It comes directly from Grantly Dick-Read, and he made it up. The idea that primitive women do not fear childbirth is a complete and utter fabrication. The anthropological evidence tells us that ALL cultures fear birth, and with good reason. Birth is and has always been a leading killer of young women and babies in every time, place and culture.

Dick-Read was deeply influenced by British eugenics in the years before the Second World War, and was responding to what he perceived to be impending "race suicide". He felt that the "better" classes of white women were not having enough children, and he ascribed that to fear of labor pain. His solution was to "train" women to believe that there was nothing to fear. In other words, though women were completely justified in fearing the dangers of childbirth (and the pain), Dick-Read felt that the ends (more children from the "better classes") justified the means (lying to women about childbirth). This view of women is misogynistic in the extreme; women are merely baby factories, and they needed to be tricked into increasing production. The fact that both maternal and perinatal mortality rates were enormous during the years that Dick-Read promulgated his theories was irrelevant to him.

I cannot stress this point enough: the idea of "childbirth without fear" is totally fabricated, utterly false, and training women not to fear childbirth in order to encourage them to have more children is sexist (and racist).

Second, there is a growing body of bioanthropological evidence that fear in childbirth is beneficial. Yes, you read that correctly. Fear is beneficial. That's not suprising; many other natural fears are beneficial, too. The fear of wild animals protected early humans from being mauled and consumed. The individuals who were wary of wild animals were more likely to survive than those who approached them eagerly. The fear that young children have of strangers is beneficial. Primitive human children who were not afraid would wander off with strangers and possibly meet a dreadful end.

According to Karen Rosenberg (a paleoanthropologist who studies human birth) and Wenda Trevathan (a biological anthropologist trained midwife) writing in Scientific American special edition, New Look At Human Evolution, 2003:
... [W]e suggest that natural selection long ago favored the behavior of seeking assistance during birth because such help compensated for these difficulties. Mothers probably did not seek assistance solely because they predicted the risk that childbirth poses, however. Pain, fear and anxiety more likely drove their desire for companionship and security.

Psychiatrists have argued that natural selection might have favored such emotions—also common during illness and injury—because they led individuals who experienced them to seek the protection of companions, which would have given them a better chance of surviving. The offspring of the survivors would then also have an enhanced tendency to experience such emotions during times of pain or disease. Taking into consideration the evolutionary advantage that fear and anxiety impart, it is no surprise that women commonly experience these emotions during labor and delivery.
In other words, not only is fear in childbirth not a social construct, it is a necessary and beneficial response to childbirth. This fits with what we know about childbirth and fear. Contrary to Grantly Dick-Read's assertion that fear in childbirth is a social construct, present in some cultures and absent in others, fear in childbirth is universal, occuring in all times, places and cultures, and providing a very real benefit for women.

Just as an aside, the subgroup of homebirth advocates which suffers the highest perinatal and maternal mortality is the unassisted childbirth advocates. Their commitment to unassisted childbirth is a corollary of their claim that there is nothing to fear about birth. They are the childbirth equivalent of reaching into the lion's mouth, and they get bitten more than anyone else.

Finally, indoctinating women that fear of childbirth is harmful serves the interests of direct entry midwives both psychologically and practically. It is ironic that direct entry midwives point proudly to historical appellations like sagefemme (wise woman) without understand the import of what they are saying. In many cultures, midwives were called "wise women" for the obvious reason that they carried a great deal of culturally accumulated wisdom. They had the broadest knowledge base and could wield the latest technology (herbs, fundal massage, etc.) They knew what special techniques were needed for breech babies, for babies who got stuck, or for women who bled after birth. In short, they were the obstetricians of their time, and obstetricians are their intellectual heirs.

Ancient midwives were among the most educated women of their societies. In contrast, American direct entry midwives are among the least educated. Ancient midwives did not "trust" birth; they would have been fools to trust what was clearly not trustworthy. They did not strive to accumulate "folk wisdom". What is quaintly called folk wisdom in our time was the technology of their time, and they discovered, invented and mastered it to the best of their ability. A sagefemme would be appalled by contemporary assertions that very little education is needed to be a midwife because "birth is a natural process". Those women were respected, venerated, and sometimes even feared because they were recognized as being highly educated women. A sagefemme would be appalled by contemporary rejection of technology in birth. They were constantly searching for new and better technology. A sagefemme would have viewed unassisted birth as a form of stupidity. Even 100,000 or a million years ago, anyone who knew anything knew that women required assistance in labor.

The direct entry midwifery exhortations to "trust birth" and to banish fear serve to rationalize the grossly deficient education, training and experience of American direct entry midwives to themselves and to their patients. Sagefemmes were the PhD equivalents of their society. American direct entry midwives often have nothing more than a high school diploma.

Direct entry midwifery needs to go back to the drawing board and examine its claims an assumptions about fear in childbirth. Midwives should stop being so afraid of fear and recognize it for what it is: hard wired into human beings, evolutionarily beneficial and a spur to new knowledge and technology. The current spate of preventable neonatal deaths due to direct entry midwifery and unassisted childbirth are the direct result of their fear of fear.

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