The Agony and the Ecstasy: Reframing birth narratives to humanise birth
The stories we tell, which are shaped by the stories we consume, help to create life’s sense of unity and of meaning (Miller, 2000) and we rarely question that meaning unless prompted to do so.
Alys Einion, Associate Professor of Midwifery and Women’s Health, Swansea University
The stories we tell, which are shaped by the stories we consume, help to create life’s sense of unity and of meaning (Miller, 2000) and we rarely question that meaning unless prompted to do so. Narratives of birth shape people’s expectations of birth. Education and preparation for the birth experience are largely dependent on existing medicalised narratives, which contribute to fear of childbirth and disempower women (Einion, 2019) but they also represent the reality of our contemporary culture of birthing. The focus of this article is on understanding the nature of birth stories and their power, and how we might change current narratives to support women to reclaim their authority and autonomy over birth, acknowledging both its agony and its ecstasy.
Human life is storied (Miller, 2000). We are surrounded by and immersed in so many stories, we are often unaware of their existence, or their power in shaping how we view the world. Not only is the majority of human communication shaped as stories, but these are purposeful narratives, with the goals of the storyteller at the forefront of their construction. As Labov (2006:43) observes, ‘narratives organize and transform events in the interests of the narrator’.
NARRATIVES OF LABOUR AND BIRTH IN THE WESTERN WORLD
What makes a story is ‘its excellence at a particular way of organizing events into an intelligible whole’ (Velleman, 2003:1). A story provides an ‘interiorized rendering of experience’ (Lodge, 1972:3). It is how we make sense of the world. Expectant parents seek out and reflect on stories about labour and birth in order to educate themselves. However, the majority of these stories are negative, fearful, limited in their vision, and framed in ways that do not empower birthing mothers and parents. Pain, extreme distress and loss of control are the most frequent themes. They perpetuate medicalised beliefs and expectations around birth (Einion, 2019; Einion, 2015). Birth narratives exist as personal narratives, told by one person to another; also as professional narratives, recounted by midwives and doctors, and as public narratives, communicated by television programmes, books, films, newspapers and social media stories. Each of these narratives is created with a particular purpose, and adheres to a specific discourse. Health professionals need to be aware of the types of stories they share about birth and how these enable others to make sense of birth, both in anticipation and in retrospect.
The plots of birth stories tend to characterise people in particular ways, with medical personnel as the heroes and the birthing woman and her unborn child as victims of their current circumstances, requiring rescue from the imminent danger of the birth (Einion, 2019). Fear of childbirth exists even for women whose pregnancies are entirely normal (Aksoy et al., 2015). Not that birth is without risk, but in the developed world, risk is given unnecessary emphasis in the birth room and in Western birth stories, themes of risk and rescue dominate. In most of our birth stories, we have forgotten the single, inalienable fact of our biology, namely that the female body is designed to give birth and to give birth powerfully, under the right conditions (Buckley, 2015).
Understanding the impact of birth narratives begins with recognising their pervasiveness. Socially constructed birth stories, such as those featuring in popular television programmes, present what is in fact, a carefully edited ‘reality’, constructed so as to present a compelling story (de Benedictis et al, 2019; Einion, 2019). These stories represent women in ways that perpetuate stereotypes of women’s role in society, focusing a great deal on the pregnancy (such as when the woman’s pregnant belly is the focus of the camera angle, and her face is invisible) or on those around her (Einion, 2019). Women’s role is seen as subordinate to their reproductive function and in relation to others involved in their pregnancy. The dominant cultural narratives within the Western, biomedical model suggest that women need rescuing, often from their own purported lack of knowledge and understanding of labour and birth, and perpetuate the ideal of the highly feminised mother submitting to the authority of the medical system in order to perform pregnancy and birth in appropriate ways.
ALIENATION OF WOMEN FROM BIRTH
Birth narratives in the public sphere remain closely associated with fear. Yet fear is antagonistic to a positive experience of labour and birth (Buckley, 2015; Haines et al, 2012). Midwives
know that the majority of stories pregnant women will hear about birth are ‘horror’ stories that exaggerate or emphasise challenging aspects of the experience. Yet there are untold millions of stories in which women’s power, their physical endurance, and their pleasure and satisfaction at the experience of birth are evident.
In ‘reality’ television birth stories, women are not shown ‘birthing’; they are shown having their babies delivered by professionals. Katz-Rothman (2000:105) states that ‘the alienation of the woman from the birth, and more fundamentally from the body, is….the most important and consistent theme in modern obstetrics’. This betrays the birthing woman’s centrality in the experience of birth. As Katz-Rothman (2000) argues, we should not be portraying midwives, whose very name means that they are ‘with’ the birthing woman, as professionals who ‘deliver’ babies.
Women birth babies. Midwives’ role is to support them to do that. Narratives of birth should represent midwives as working ‘with the labour of women to transform, to create, the birth experience to meet the needs of women. (Midwifery) is a social, political activity, dialectically linking biology and society, the physical and the social experience of motherhood’ (Katz-Rothman, 2000:116-117).
THE STORIES WOMEN TELL
Why is it that women themselves frame their births in terms of risk and hardship? The ‘problematic’ nature of pregnancy as a symbol of a woman’s journey into herself is that it can both represent submission and simultaneously, womanhood and empowerment. Feminist discourses focus on the womb and the reproductive organs as a site of oppression. Maher (2007:21) describes ‘a common cultural assumption that pregnancy is fully defined by the disciplinary regimes imposed upon it. Appropriate adult femininity, heterosexuality, and women’s place in a patriarchal society come together in the future of the pregnant woman and seem to suggest its inertia and compliance’. It might be that women telling their own birth stories try to exercise agency by creating stories that are culturally acceptable; they may seek to gain validation as women who have successfully negotiated the rite of passage of birth to assume the mantle of motherhood by demonstrating appropriate feminine behaviours.
REFRAMING LABOUR AND BIRTH
How do we go about using positive stories, and positive language to reframe our birth narratives? We need to create the space, language and opportunity to enable the valuing of embodied and experiential knowledge alongside scientific knowledge (Walsh, 2009). It would be a starting point, therefore, to consider how midwives and birth educators can create and share stories which validate women’s experiential, embodied knowing and which emphasise women’s autonomy, strength and mastery of and in the act of birth. Walsh (2009) argues that we need to step away from binaries – natural OR medical, home OR hospital and so on. Instead, we need to encompass a more holistic vision of birth as private and personal and at the same time engaged and supported by medicine, and we need to frame birth as a collective experience, characterised by collaborative decision making (Walsh, 2009).
Walsh (2009:495) suggests that we should ‘[leave] the childbirth milieu free for the multiplicity and fluidity of women’s experiences’. This means moving away from sharing the common features of recurrent stories and instead focusing on plurality and on seeking out and sharing diverse stories. When representing childbearing, we could focus on emancipatory stories that do not simply repeat binary themes of resistance and submission.
Childbirth education should focus on emancipatory stories
Long (1999:2) speaks of a ‘feminist method for telling lives’ in which the narrator becomes the most important entity, with different narrators representing different truths. This aligns with the concept of humanisation as applied to childbirth, and the provision of care which is respectful, trustful, woman-centred and salutogenic (Newnham & Page, 2019). The starting point for humanistic birth is where women’s stories and women’s embodied knowing and experiential wisdom add to the professional knowledge of caregivers.
What is required is to share stories that capture the inner reality of each individual woman and acknowledge the value of the details that she wishes to share. Women are defined by other women, and by their relationships with each other, and stories which emphasise the value of respectful, relationship-based care speak to the way in which ‘the female subject often situates herself in a web of relationships, or tells the story in terms of relationships’ (Long, 1999:49).
Stories that derive from salutogenesis would bring to the fore women’s capability, rather than emphasise risk. The theory of salutogenesis, first conceived by Aaron Antonovsky, describes what it is that supports people to develop and sustain a healthy and positive view of self. Health is presented on a continuum and is affected by ‘generalized resistance resources’, which are any characteristic of a person, group, or society that is able to facilitate tension management, so allowing the individual to be as healthy as possible. These resources can be internal (knowledge, mind-set) and external (including social support, professional services) (Perez-Botella et al., 2014). A person’s belief that they have some control over their health and the factors that contribute to it, and that they have access to appropriate resources is described as ‘sense of coherence’ (Perez-Botella et al., 2014). Offering education to expand knowledge and understanding of the self, the body, physiology, available resources and human rights could help
bring about new forms of narrative sense-making around birth. Educational frameworks likely to assist women’s narrative sense-making reinforce the woman’s autonomy. These frameworks should include education on the basic physiology of birth and the conditions that support it (Buckley, 2015). Exposing women in antenatal programmes to a wide variety of birth stories, especially those which tell of positive birth experiences, would support a shifting of women’s narrative expectations towards a more comprehensive way of knowing and understanding birth and its potential.
Women will put their stories into narrative time, selecting inciting events that precipitate the story as a starting point, and demonstrating movement through the narrative’s emotional sequences towards closure (Velleman, 2003). It is this ordering of events that allows the woman to characterise the narrative in the way that she chooses. So one way of making sure that women’s stories are told in ways that afford them agency and support them in owning their story and its associated sense-making, is to enable them to identify for themselves what are the ‘constituent events’. Abbot (2008:24) describes these as ‘events that are necessary to the story, driving it forward’ as opposed to ‘supplementary events’ which ‘do not drive a story forward and without which the story would remain intact’. Externally constructed stories, such as those dominated by themes of medicalisation, risk and rescue, suggest to women and caregivers the events which should be viewed as significant. Instead, women need the space, perhaps in individual encounters with health professionals or in parent education groups, to state which events were significant to them, and to decide for themselves the start and end points of their own stories.
Recognising the iterative, powerful and pervasive nature of the stories surrounding labour and birth can help us to understand how to reframe birth in a way that supports the strength, autonomy and capacity of women and resists the dominant narratives that trap birthing women and their families in roles that lack power and agency.
Medicalised discourses have become the dominant narratives of pregnancy and childbirth, and non-medicalised discourses of birthing are seen as oppositional and alternative. Yet both are simply ways in which to frame experience. Employing a positive framework of storying birth would enhance the education and preparation of women and their loved ones for the childbirth experience. It should be inherent in the work of midwives, doctors and educators to prepare people for an experience of birth as one of great physical and personal change, mediated by personal power and autonomy, knowledge and trust in the physical self and the support network that exists to optimise birth. This preparation should also include a critical awareness of the stories that have set up false expectations for pregnancy and birth. Educators can thereby help to ‘shatter the mirror that has so long reflected what every woman was supposed to be’ (Gilbert & Gubar, 2000:76). The stories we share should enable birthing women to overcome the bounds of convention and empower themselves for the birth they want, a birth that may involve agony or ecstasy, or both, or neither. If our lives are constituted from stories, we should at least have some power to decide our role within them. There is scope for the woman to see herself as the hero, and for the midwife to act as the guide, the birth partner as the helper, and so on. Reframing birth will include every aspect of the birth experience, but will always keep the narrative centred on the most important person, the main character, the protagonist - the mother.
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