I attended a birth recently: the second baby to an absolutely gorgeous family. The parents had contacted me during the last two weeks of the mother’s pregnancy. Their first child had been born in the hospital. When I first met with them, I could see clearly the weight that both mother and father felt, when contemplating a return to the medical birth model. Among the many violations the mother had experienced during her birth process, the episiotomy was, actually, and symbolically, devastating—as it is for so many women. We did some intense work together in the two weeks preceding the birth, discussing all aspects of the birth process, working through fears and potential complications, and getting to a point where the family was confident and excited, rather than worried and stressed. After receiving the call, I arrived at the family’s home early in the morning. The mother was close to welcoming their beautiful child, and after she stepped into the warm pool, it was less than an hour until her baby began to descend. With a few strong pushes, I could see the baby’s head bulging against the mother’s perineum. And there the baby waited, while time stood still.
Birth is a such a delicate dance between mother and baby, father and family, and the additional presence of anyone else must be acknowledged as the utmost privilege, and navigated with quietude and respect. The father had asked me to assist if necessary, with the baby’s emergence (catching, if this was required, although it so rarely is—in the majority of births I attend, mothers or fathers catch their own babies, and my hands don’t go near) and through three long pushing sensations with extended pauses between each, the baby’s head was held at the mother’s beautiful, integral, stretching perineum. This was such a precious moment; the child, veiled, sitting literally between one world and the next. The mother, breathing, caught in that most primal liminal place of intensity, sensation, love.
As usual, I did nothing, except to breathe with the mother, and when she exclaimed “It’s been there for a long time!” I said softly, “You have all the time in the world. Everything is perfect. Move your baby through your body when you’re ready”. Gently, fiercely, this beautiful woman did just that, and her child swam into the now, caught in his own mother’s hands, brought to the surface, peacefully, calmly, perfectly.
Afterwards, I couldn’t help but reflect on the poignancy of what had occurred, and on the converse experience that so many women have—that this mother herself had had two years earlier—in the hospital. Those long moments of stretching, the sense of anticipation, and the mother’s skin pulled taut over the baby’s head—it is during this tenuous moment at which an obstetrician makes the cut, and of course, yes, the baby immediately tumbles out, saved, by the miraculous power of modern medicine. With this, the mother has been rescued by the system, and the doctor or midwife preens over his or her agency, authority, the clarity with which they see their ability to “deliver” the baby, and the mother.
This surgical intervention however, not only severs the integrity of the woman’s sexual organs, but in many ways, severs also her own sense of capacity to live out her biology without an unneccessary brutality that so painfully underlines the incompetence she is designed to feel during industrial birth.
The word, “Episiotomy” is a euphemism for genital mutilation. “Episiotomy” is institutionalized, sanctioned sexual assault . The procedure consists of cutting the perineum—the skin between the vaginal opening and anus– of a woman during the birth process. The (misguided) idea is that episiotomy is sometimes necessary in order to widen the birth canal, thus allowing the baby to pass through quickly. The truth is that the impetus to cut a woman’s sex organs during childbirth is constituted and predicated on, practices that are in themselves unscientific, idiotic, lacking in evidence, and more importantly, lacking in any understanding of the fundamental biology of mammalian birth. If an episiotomy has been deemed “necessary”, one can be sure that the entire birth process preceding the cut, has been “managed” and interfered with to such an extent that the mother is terrified, exhausted, broken-willed, drugged, physically shut-down, humiliated or angry, or a combination of all of these. In recent years, “episiotomy” has been exposed as painful, useless, ineffectual and in many cases, resulting in long-term negative effects for the mother. (Oh the maddening redundancy and circularity and inanity of having to “scientifically prove” the harm of practices which are clearly, to anyone with even a rudimentary understanding of how birth works, completely counter to the physiology of the process.)
And yet, the American College of Obstetricians and Gynecologists, estimates that as many as 90% of women in the US giving birth to their first child in a hospital will have an episiotomy. ACOG’s official position is that “the routine use of episiotomy is not recommended as standard practice.” Episiotomy also occurs with shocking regularity at home, performed by midwives.In Canada, episiotomy rates declined from 37.7% in 199312 to 23.8% in 2001.1 Rates in Alberta were 20.1% in 2000 and 15.5% in 2004.13 Rates vary among hospitals and among providers. (http://www.cfp.ca/content/57/4/450.full). Nice that the numbers have dropped, but I speak with women almost every day, here in New Brunswick, whose sexual organs have been cut without their consent. For many clients who contact me, avoiding having their genitals cut is of primary concern. According to the Public Health Agency of Canada’s report on Canadian Hospitals Maternity Policies and Practices survey, 53 out of 322 hospitals surveyed “had an explicit policy to avoid episiotomies. The majority (74%) stated that they had no policy—it was up to the individual physician or midwife (emphasis mine). Women are purported to have equal rights in North American society. Women, in theory, possess the universal human right to bodily autonomy. Why then, would it ever be suggested by anyone—let alone the Public Health Agency of Canada—that the decision as to whether or not to a woman’s sexual organs would be sliced open (a practice that has no basis in science or reason and is emphatically not evidence-based) would be the decision of anyone *other* than that woman herself? The answer, unfortunately, lies in the totality of the foundation of obstetrics, in which the implicit assumption is that as soon as a woman enters through the hospital doors, she, in fact, has tacitly agreed to a wholesale stripping of her rights, and has been rendered semi-human and sub-adult.
“Hospital Birth Exposed” is an interesting, important, and problematic Facebook page, in which a nurse, who works for the American hospital system, “exposes” harmful obstetric practices anonymously, (while exposing her own shortcomings as far as fully understanding what birth freedom means and why it is essential for every woman, as evidenced by her early public statement backhandedly denying the legitimacy of unassisted birth). This anonymous nurse’s observations are frequently thought-provoking, as was an earlier post in which she mentioned that despite her many valid criticisms of the system, she is not *entirely* against interventions (the suggestion being that there is, in fact, a rabid contingent of birth “radicals” out there who would prefer death than submitting to the”the system”—although I have never come across these fanatics, myself). The nurse went on to say that she has, after all, seen first-hand how episiotomy in some rare cases, can be necessary. Well. I deeply question the validity of the suggestion that episiotomy is ever “necessary”, and I strongly believe, as a birthing woman, as a long-term student of birth, and as a birth attendant, that if women are truly supported in a physiological and biologically normal (left alone, unhindered) birth process, that there will *never* be a reason to cut her perineum.
Defending the episiotomy, is, in my view, a clear example of the insidious way in which, during birth, when redundant or harmful action is taken, and only the mother is overtly harmed, the practitioner proclaims that it was *because* of the harmful action that everyone survived, rather than *despite* that harmful action. Because, of course, it simply makes absolutely no sense to cut the healthy tissue of a birthing woman’s sexual organs.
The perineum is made up of highly elastic skin. The skin of the perineum does not impede or halt the progression of normal birth; the perineum is infinitely yielding, by design. The umbilical cord has incredible integrity, both in physical terms, and as a literal lifeline for the baby (but of course, in the hospital scenario, practitioners are still clamping and cutting the umbilical cord within seconds of birth, or even *prior* to the full emergence of the child, which is horrifically dangerous and counter to science, biology and sense). The uterus is arguably the strongest muscle in the human body. Anyone who has experienced normal birth will attest to the involuntary animal power of the fetal ejection reflex, against which the perineum provides no barrier. The skin of the perineum is designed to stretch, and if necessary, to tear. Episiotomy guarantees a tear, whereas the severity of tearing is much less with a natural rupture. Episiotomy increases the chances of infection, excessive bleeding, pain and sexual dysfunction following the birth. Natural tears rarely require stitching, and more often than not heal healthily, and spontaneously without tampering.
Despite these facts, many women continue to defend their own episiotomies, which must either be the result of being deprived of the facts and evidence, or an attempt to (very understandably) rationalize an experience that would, exposed in its stark actuality, be difficult to argue as anything but a humiliating, shame-inducing assault. When practitioners decide to cut women, informed consent is often evoked. However, when women are routinely misinformed, how valid is that “consent”?. How many women, if presented with the *actual* facts on genital cutting during the birth process, would consent to such a thing being done to them?
Hospital birth, and the violations that occur during that ritual experience, are not based on safety, science, or on the wellbeing of mother and baby. The policies and procedures of hospital birth—which, I will reiterate, overwhelmingly go against nature, sanity, common sense, decency and compassion—are about efficiently exerting power and control over the mother, reinforcing her submission to the system, and inculcating a new generation into a belief system based on the patriarchal regulation and control over women’s bodies, reproduction and fertility.
We live in a culture in which doctors are granted the highest authority of the land, and near total impunity—as evidenced by the innumerable women who come away from hospital birth having experienced what is correctly termed to be “birth rape”: the violation, penetration and/or mutilation of their sexual organs without consent, with minimal consent, or with consent given under duress or after being misinformed (which, of course, isn’t true consent at all). In any context apart from the “labour & delivery” room, when a stranger forces his hands or a foreign object inside a woman’s vagina, they would do time. Human rights in childbirth is such a foreign concept for most of us, that we don’t even possess, as a culture, an adequate language with which to describe how perverse the experience of childbirth has become. The actions of birth professionals, including obstetricians, nurses and midwives, often amounts to outright criminal, illegal behaviour, coded and excused by the veneer of respectability that medicine invokes.
In her work, cultural anthropologist Robbie Davis-Floyd discusses the various ways in which our technocratic medical model expresses not so much a paradigm of healing, but rituals that underscore, perpetuate and reinforce cultural concepts that super value technology over nature and institutionalized subservience over self-determination. In her article “The Technocratic Body: America Childbirth as Cultural Expression”, Davis-Floyd references the writing of Peter C. Reynolds who discusses the “one-two punch” of “mutilation and prosthesis which involves taking a highly successful natural process, render[ing] it dysfunctional with technology, and then fix[ing] it with technology”. Nowhere is this more evident than in the context of modern obstetrics. Episiotomy is just one variation of that phenomenon of mutilation and prosthesis, and is as starkly emblematic of the brokenness of a system that in so many ways, breaks birth.
Despite this, women are increasingly rising up and taking birth, literally, into their own hands. I sincerely applaud those who are working to humanize hospital birth, but for me and the amazing women I work with, the path to birth freedom lies in an entirely new paradigm of autonomy, rather than in attempts to make things nicer or prettier or more palatable within the current standard. The courage of mothers continues to inspire me every day.