The Rituals of American Hospital Birth by Anthropologist Robbie-David Floyd
“I can remember just almost being in tears by the way they would wheel you in. I would come into the hospital, on top of this, breathing, you know, all in control. And they slap you in a wheelchair! It made me suddenly feel like maybe I wasn’t in control any more.”
Why is childbirth, which should be such a unique and individual experience for the woman, treated in such a highly standardized way in the United States? No matter how long or short, how easy or hard their labors, the vast majority of American women are hooked up to an electronic fetal monitor and an IV, are encouraged to use pain-relieving drugs, receive an episiotomy, and are separated from their babies shortly after birth. Most of them also receive doses of the synthetic hormone pitocin to speed their labors and give birth flat on their backs. Over one third of babies are delivered by Cesarean section.
Many Americans, including most of the doctors and nurses who attend birth, view these procedures as medical necessities. Yet mothers in many low-technology cultures give birth sitting, squatting, semireclining—all positions far more physiologically efficacious—and are nurtured through the pain of labor by experienced midwives and supportive female relatives. What then might explain the standardization and technical elaboration of the American birthing process?
One answer emerges from the field of symbolic anthropology. Early in this century, Arnold van Gennep noticed that in many societies around the world, major life transitions are ritualized. These cultural rites of passage make it appear that society itself effects the transformation of the individual. Could this explain the standardization of American birth?
I believe the answer is yes.
I came to this conclusion as a result of a study I conducted of American birth between 1983 and 1991. I interviewed more than 100 mothers and many of the obstetricians, nurses, childbirth educators, and midwives who attended them. I realized that American society’s deepest beliefs center around science, technology, patriarchy, and the institutions that control and disseminate them, and that there could be no better transmitter of these core values and beliefs than the hospital procedures so salient in American birth.
Rites of Passage
A ritual is a patterned, repetitive, and symbolic enactment of a cultural belief or value; its primary purpose is alignment of the belief system of the individual with that of society. A rite of passage is a series of rituals that move individuals from one social state or status to another.
Rites of passage generally consist of three stages, originally outlined by van Gennep: (1) separation of the individuals from their preceding social state; (2) a period of transition in which they are neither one thing nor the other; and (3) an integration phase, in which, through various rites of incorporation, they are absorbed into their new social state.
In the year-long pregnancy/childbirth rite of passage in American society, the separation phase begins with the woman’s first awareness of pregnancy; the transition stage lasts until several days after the birth; and the integration phase ends gradually in the newborn’s first few months of life.
By making the naturally transformative process of birth into a cultural rite of passage, a society can ensure that its basic values will be transmitted to the three new members born out of the birth process: the new baby, the woman reborn into the new social role of mother, and the man reborn as father.
The Characteristics of Ritual
The following primary characteristics of ritual are particularly relevant to understanding how the initiatory process of cognitive restructuring is accomplished in hospital birth.
Symbolism. Rituals transmit their meaning through symbols. A symbol is an object, idea, or action that is loaded with cultural meaning. Instead of being analyzed intellectually, a symbol’s message will be felt through the body and the emotions. Thus, even though recipients may be unaware of incorporating the symbol’s message, its ultimate effect may be extremely powerful.
Routine obstetric procedures are highly symbolic. For example, to be seated in a wheelchair upon entering the hospital, as many laboring women are, is to receive through their bodies the symbolic message that they are disabled; to then be put to bed is to receive the symbolic message that they are sick. One woman told me:
[quote align=”center” color=”#999999″]I can remember just almost being in tears by the way they would wheel you in. I would come into the hospital, on top of this, breathing, you know, all in control. And they slap you in a wheelchair! It made me suddenly feel like maybe I wasn’t in control any more.[/quote]
The intravenous drips commonly attached to the hands or arms of birthing women make a powerful symbolic statement: they are umbilical cords to the hospital. By making her dependent on the institution for her life, the IV conveys to her one of the most profound messages of her initiation experience: in the contemporary American technocracy, we are all dependent on institutions for our lives, “umbilically” linked to them through the water and sewer pipes, electrical wires, and TVs that pervade our homes, through our banking accounts and credit cards, and increasingly through our laptops, cellphones, iPads, and the like. The rituals of hospital birth are not accidental—they are profound symbolic and metaphoric expressions of
A cognitive matrix. A matrix (from the Latin mater, or mother), like a womb, is something from within which something else comes. Rituals are not arbitrary; they come from within the belief system of a group. Their primary purpose is to enact and thereby transmit that belief system into the emotions, minds, and bodies of their participants. Thus, analysis of a culture’s rituals can lead to a profound understanding of its belief system.
A technocracy as I define it is a society organized around an ideology of progress through the development and increasing utilization of high technology and the global flow of information. Analysis of the rituals of hospital birth reveals their cognitive matrix to be the technocratic model of reality that forms the philosophical basis of both Western biomedicine and American society.
The technocratic model’s early forms were developed in the 1600s by Descartes, Bacon, and Hobbes, among others. This model assumes that the universe is mechanistic, following predictable laws that the enlightened can discover through science and manipulate through technology, in order to decrease their dependence on nature. In this model, the human body is viewed as a machine that can be taken apart and put back together to ensure proper functioning. In the 17th century, the practical utility of this body-as-machine metaphor lay in its separation of body, mind, and soul. The soul could be left to religion, the mind to the philosophers, and the body could be opened up to scientific investigation.
The metaphor of the body-as-machine was central in the development of modern obstetrics. Wide cultural acceptance of this metaphor accompanied the demise of the midwife and the rise of the male-attended, mechanically manipulated birth. The rising science of obstetrics adopted the assembly-line model of production of goods as its template for hospital birth. Accordingly, a woman’s reproductive tract came to be treated like a birthing machine by skilled technicians working under relatively inflexible timetables to meet production and quality-control demands.
As one resident explained:
[quote align=”center” color=”#999999″]There is a set, established routine for doing things, usually for the convenience of the doctors and the nurses, and the laboring woman is someone you work around, rather than with.[/quote]
The most desirable end product of the birth process is the new social member, the baby; the new mother is a secondary byproduct. Repetition and redundancy. Ritual is marked by repetition and redundancy. For maximum effectiveness, a ritual concentrates on sending one basic set of messages, repeating it over and over again in different forms.
In hospital birthing, the message is repeatedly conveyed that the laboring woman is dependent on the institution. She is also reminded in myriad ways of the potential defectiveness of her birthing machine. These include periodic and sometimes continuous electronic monitoring of that machine, frequent manual examinations of her cervix to make sure that it is dilating on schedule, and, if it isn’t, administration of the synthetic hormone pitocin to speed up labor so that birth can take place within the standard 12-24 hours. These procedures repeatedly convey the messages that time is important, you must produce on time, and you cannot do that without technological assistance because your machine is defective.
When humans are subjected to extremes of stress and pain, they may become unreasonable and out of touch with reality. Ritual assuages this condition by giving people a conceptual handle to keep them from “falling apart” or “losing it.”
Labor subjects most women to extremes of pain, which are often intensified by the alien and frequently unsupportive hospital environment. They look to hospital rituals to relieve the distress resulting from their pain and fear. One woman expressed it this way:
[quote align=”center” color=”#999999″]I was terrified when my daughter was born. I just knew I was going to split open and bleed to death right there on the table, but she was coming so fast, they didn’t have any time to do anything to me. . . . I like Cesarean sections, because you don’t have to be afraid.[/quote]
When you come from within a belief system, its rituals will comfort and calm you.
Order, Formality, and a Sense of Inevitability
Its exaggerated and precise order and formality set ritual apart from other modes of social interaction, enabling it to establish an atmosphere that feels both inevitable and inviolate. In tandem with this sense of inevitability, a “cascade of intervention” often occurs when one obstetric procedure alters the natural birthing process, causing complications and inexorably “necessitating” the next procedure, and the next. Many of the women in my study experienced such a “cascade” when they received some form of pain relief, such as an epidural, which slowed their labor. Then pitocin was administered to speed up the labor, but it suddenly induced longer and stronger contractions. Unprepared for the additional pain, the woman asked for more pain relief, which ultimately necessitated more pitocin. Pitocin-induced contractions, together with the fact that the mother must lie flat on her back because of the electronic monitor belts strapped around her stomach, often caused the supply of blood and oxygen to the fetus to drop, affecting the fetal heart rate. In response to the “distress” registered on the fetal monitor, an “emergency” Cesarean was performed. Countless mothers have found themselves thanking the obstetrician for saving their baby, when the danger to the baby came in fact from the interventions the doctor ordered.
The goal of most initiatory rites of passage is cognitive transformation: The symbolic messages of ritual fuse with individual emotion and belief. Routine obstetric procedures map the technocratic model of birth onto the birthing woman’s perceptions of her labor experience, aligning her belief system with that of society.
Take the way many mothers come to think about the electronic fetal monitor, for example. The monitor is a machine that uses ultrasound to measure the rate of the baby’s heartbeat through electrodes belted onto the mother’s abdomen. Observers and participants alike report that the monitor, once attached, becomes the focal point of the labor. One woman described her experience this way:
[quote align=”center” color=”#999999″]As soon as I got hooked up to the monitor, all everyone did was stare at it. The nurses didn’t even look at me anymore when they came into the room—they went straight to the monitor. I got the weirdest feeling that it was having the baby, not me.[/quote]
This statement illustrates the successful conceptual fusion between the woman’s perceptions of her birth experience and the technocratic model. So thoroughly was this model mapped on to her psyche that she began to feel that the machine was having the baby, that she was a mere onlooker. Soon after the monitor was in place, she requested a Cesarean, declaring that there was “no more point in trying.”
Affectivity and Intensification
Rituals tend to intensify toward a climax. The order and stylization of ritual, combined with its rhythmic repetitiveness and the intensification of its messages, methodically create the sort of highly charged emotional atmosphere that works to ensure long-term learning.
As the moment of birth approaches, the number of ritual procedures performed upon the woman will intensify toward the climax of birth, whether or not her condition warrants such intervention. For example, once the woman’s cervix reaches full dilation (10 cm), the nursing staff immediately begins to exhort the woman to push with each contraction, whether or not she actually feels the urge to push. Yet if the obstetrician has not arrived by the time the head starts to crown, the laboring woman is then exhorted, with equal vigor, not to push. Such commands constitute a complete denial of the natural rhythms of the woman’s body. They signal that her labor is a mechanical event and that she is subordinate to the institution’s expectations and schedule. Similar high drama may pervade the rest of her birthing experience.
Preservation of the Status Quo
A major function of ritual is cultural preservation. Through explicit enactment of a culture’s belief system, ritual works both to preserve and to transmit the culture. Preserving the culture includes perpetuating its power structure, so it is usually the case that those in positions of power will have unique control over ritual performance.
In spite of tremendous advances in equality for women, the United States is still a patriarchy. Nowhere is this reality more visible than in the lithotomy (supine) birthing position. Despite years of effort on the part of childbirth activists, including many obstetricians, the majority of American women still labor and give birth lying flat on their backs. This position is physiologically dysfunctional. It compresses major blood vessels, lowering the mother’s circulation and thus the baby’s oxygen supply. It increases the need for forceps because it both narrows the pelvic outlet and ensures that the baby, who must follow the curve of the birth canal, quite literally will be born heading upward, against gravity.
This lithotomy position completes the process of symbolic inversion that has been in motion ever since the woman was put into the hospital gown. Her normal bodily patterns are turned, quite literally, upside-down—her legs are in the air, her vagina totally exposed. The doctor — society’s official representative—stands in control not at the mother’s head nor at her side, but at her bottom, where the baby’s head is beginning to emerge. Interactionally, the obstetrician is “up” and the birthing woman is “down,” an inversion that speaks eloquently to her of her powerlessness and of the power of society at the supreme moment of her own individual transformation.
The episiotomy often performed by the obstetrician just before birth also powerfully enacts the status quo in American society. This procedure, which used to be performed on over 90% of first-time mothers (those who do not have a cesarean) as they gave birth, expresses the value and importance of one of our technocratic society’s most fundamental markers—the straight line. Through episiotomies, physicians can speed up the birth in accordance with our cultural value on time, and can also symbolically deconstruct the vagina (stretchy, flexible, part-circular and part-formless, feminine, creative, sexual, nonlinear), then reconstruct it in accordance with our cultural belief and value system. Doctors used to be taught (incorrectly) that straight cuts heal faster than the small jagged tears that sometimes occur during birth—but in fact, episiotomies often cause severe tearing that would not otherwise occur. (So much scientific evidence has accumulated over the past 40 years about the detriments of episiotomy that its use in the U.S. has dramatically decreased, yet it is still used in over 90% of vaginal births in most Latin American countries and in many others around the world where the practice is so ingrained that the evidence, if known, is simply ignored.) These teachings dramatize our technocratic belief in the superiority of culture over nature. Because it virtually does not exist in nature, the line is most useful in aiding us in our constant conceptual efforts to separate ourselves from nature.
Effecting Social Change
Paradoxically, ritual, with all of its insistence on continuity and order, can be an important factor not only in individual transformation but also in social change. New belief and value systems are most effectively spread through new rituals designed to enact and transmit them; entrenched belief and value systems are most effectively altered through alterations in the rituals that enact them.
15% of my interviewees entered the hospital intent on a natural childbirth and succeeded in reaching that goal, thereby avoiding conceptual fusion with the technocratic model. These women were personally empowered by their birth experiences. They tended to view technology as a resource that they could choose to use or ignore, and often consciously subverted their socialization process by replacing technocratic symbols with self-empowering alternatives. For example, they wore their own clothes and ate their own food, rejecting the hospital gown and the IV. They walked the halls instead of going to bed. They chose perineal massage instead of episiotomy and gave birth sitting up, squatting, or on their hands and knees. One woman, confronted with the wheelchair, said, “I don’t need this,” and used it for a luggage cart. This rejection of customary ritual elements is an exceptionally powerful way to induce change, as it takes advantage of an already charged and dramatic situation.
During the 1970s and early 1980s, the conceptual hegemony of the technocratic model in the hospital was seriously challenged by the natural childbirth movement. Birth activists succeeded in getting hospitals to allow fathers into labor and delivery rooms, mothers to birth consciously (without being put to sleep), and mothers and babies to room together after birth. They fought for women to have the right to birth without drugs or interventions, to eat and drink at will, to walk around or even be in water during labor. Prospects for change away from the technocratic model of birth by the 1990s seemed bright.
Changing a society’s belief and value system by changing the rituals that enact it is possible, but not easy. To counter attempts at change, members of a society may intensify the rituals that support the status quo. Thus a response to the threat posed by the natural childbirth movement was to intensify the use of high technology in hospital births. Starting in 1970, periodic electronic monitoring of nearly all women was introduced and became standard procedure during that decade, resulting in a dramatic rise in the Cesarean rate, from 6% in 1970 to 23% in 1979. By 2012, the U.S. cesarean rate had reached 33%. During the 1990s, although the routine use of episiotomy declined significantly and has continued to do so, the epidural rate shot up to 80% and remains there today.
6% of my interviewees completely rejected the technocratic model altogether and chose to give birth at home under an alternative paradigm, the holistic model. This model stresses the organicity and trustworthiness of the female body, the natural rhythmicity of labor, the integrity of the family, and self-responsibility. Although homebirthers constitute only about 1% of the American birthing population, their conceptual importance is tremendous, as through the alternative rituals of giving birth at home, they enact—and thus guarantee the existence of— a paradigm of pregnancy and birth based on the value of connection, just as the technocratic model is based on the principle of separation.
Every society in the world has felt the need to thoroughly socialize its citizens into conformity with its norms, and citizens derive many benefits from such socialization. Cultures often find ways to socialize their members from the inside, by making them want to conform to society’s norms. Ritual is one major way through which such socialization can be achieved.
American obstetrical procedures can be understood as rituals that facilitate the internalization of cultural values. These procedures are patterned, repetitive, and profoundly symbolic, communicating messages concerning our culture’s deepest beliefs about the necessity for cultural control of natural processes. Obstetric interventions also attempt to contain and control the physiological process of birth and to transform the birthing woman into an American mother who has internalized the core values of this society. From society’s perspective, the birth process will not be successful unless the woman and child are properly socialized during the experience, transformed as much by the rituals as by the physiology of birth.
This article was written by cultural Anthropologist Robbie-David Floyd, originally published in the book Berkeley: University of California Press,2nd edition, 2004.