Before I became involved in global health, the idea that fear of childbirth was about anything other than fear of pain was basically an afterthought. Sure women used to die in childbirth, but that was long ago and didn’t really affect women’s views today. Sure some babies die, but not many so that didn’t really affect women’s views today. In my uninformed philosophy, it was easy to discount the objections I read to home birth and and the praises of cesarean because in my world the problems of childbirth were rare and relics of the past. As my knowledge grew, I began to see some basic conditions of that existed that made my philosophy seem true only existed because I lived in a place where women have access to quality health care.
The first problem was that I failed to understand or accept that bad outcomes do happen, and are not as rare as I think. Globally, 1,000 women die daily during pregnancy or childbirth – only 15 years ago this number was 1/3 larger.
The second problem was that I didn’t really know why women die in childbirth or pregnancy. While I knew poverty played a role, I assumed the role it played was nutrition, education and a balance of exercise and rest — the same things I taught as important to pregnancy health where I live. The reality is that poverty limits women’s access to the type of care that can help when there is a problem.
The third problem was that I failed to understand that the improvements in birth outcomes we have seen in the past 20 years are due to “health care improvements”. While most women have healthy experiences, ensuring access to care for women who are experiencing complications or emergencies has been key to reducing both maternal and neonatal morbidity and mortality around the world. This isn’t simply having a hospital or training traditional birth attendants. Instead it is having a total health system where the woman can get whatever care she needs during pregnancy (whether that be malaria protection or folic acid supplementation).
Finally, I believed the lie that non-industrialized women don’t feel pain during childbirth, and its companion lie that they are not afraid of giving birth. I had a very romantic image in my head of women in a hut laboring away as they go about their normal life, squatting to give birth, and then continuing on with their day. I have yet to visit a developing country/community where the women experience no pain in labor. What I have seen is variations in how that pain is expressed, which is due to cultural expectations and the belief that expressing pain in labor shows weakness.
Ironically, I see the least fear about the process of childbirth among the women in developed countries who trust that if something goes wrong or they feel too much pain, someone is there to help them. It is almost as if the “fear of pain” has been removed from the equation because pain is no longer something that must be experienced. In some women this confidence seems too strong, that they have no acceptance of the idea that childbirth may be difficult or may ever end in a poor outcome.
I want to draw your attention to a cultural parallel between two different ways to think about fear, pain and childbirth, and why a woman should labor “calmly” and “in control.”
The first idea is that the woman should not feel pain during labor, because the pain is caused by fear or the rare major problem. The second is that women should not show pain during labor, because if she shows the pain it is because she is weak and afraid.
Think about how a woman “succeeds” in childbirth with each of these ideas. Then think about what it means if a woman has pain, and expresses pain with each of these ideas.
This is really just skimming the surface of the problems, ideas and changing ways of thinking I have experienced in the past 7 years of working internationally. Because my thinking is constantly challenged in this regard, I don’t want to post a “this is what I think now,” comment. In just the past month my thinking has been challenged twice — so how can a static blog post keep up with that! But I will say I stay open to the reality that what I consider to be “the truth” about how fear and birth intersect is likely to change as I learn more and experience more. Because I live in expectation of changing ideas, I am more open to being with women as they work through whatever interaction of fear and childbirth they may be experiencing.