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Birth

Introduction

Birth, the physiological process of childbearing, is both a biological and cultural event. In all societies, the universal physiology of birth is culturally shaped and managed. Jordan's (1978, 1993) groundbreaking work Birth in Four Cultures initiated the field of study now known as the anthropology of birth, or more broadly, the anthropology of reproduction. Following Jordan, anthropologists have focused on the study of birthing systems rather than on the comparison of individual and isolated "birth practices" which characterized the earliest anthropological references on this topic. The cross-cultural analysis of birthing systems has documented that birth is globally a culturally marked life crisis event that is socially patterned as well as being a biological phenomenon. The cultural patterning of birth includes beliefs and practices surrounding pregnancy; expectations regarding the circumstances in which pregnancy may occur and who may legitimately reproduce; prescriptions and proscriptions affecting expectant mothers, their partners, and families; the management of labor, including the circumstances under which interventions occur and the characteristics of such interventions; and treatment during the postpartum period. Birthing systems range from low-technology systems exemplified by the Maya of Central America (Jordan, 1978) or the Bariba of West Africa (Sargent, 1982, Sargent, 1989) to the high-technology biomedical systems of most industrialized societies. Generally, birth practices within a particular society are consensually shaped, with a low level of variation within any given system, but considerable variation across different societies. As Jordan (1978) observed, "we find that within any given system, birth practices appear packaged into a relatively uniform, systematic, standardized, ritualized, even morally required routine" (p. 2).

Early Ethnographies and Surveys

The earliest anthropological attention to birth is contained within ethnographies devoted to other topics, rather than studies focusing directly on birthing systems (for further discussion, see Browner & Sargent, 1996). Exceptions include Montagu's (1949) discussion of Australian aboriginal understandings of fetal development and Malinowski's (1932) commentary on ideas and practices concerning birth among Trobriand Islanders. A few comparative surveys on human reproduction such as that by Ford (1964) basically provide lists of reproductive customs from societies around the world, and include some detail on pregnancy, delivery, and the postpartum period. For example, references to pregnancy in Ford's compilation on 64 societies include mention of seemingly illogical food taboos, sexual regulations, and tabooed acts to prevent miscarriage, birth defects, or stillbirth. With reference to birth, world surveys such as Ford's offer brief descriptions of techniques of delivery in preindustrial societies, noting such details as delivery position (women may sit, kneel, or squat; occasionally a standing position is reported); the role of the birth attendant in providing physical support to the parturient; restrictions on who may attend the delivery; and the location of delivery. Reflections on the topic of pain in childbirth are found from the earliest ethnographic reports, perhaps indicating widespread interest in the question of pain management as well as the speculation that childbirth may be less painful in some societies than others. Key among these is Freedman and Ferguson's (1950) consideration of painless childbirth in "primitive cultures." Principle means of addressing pain and suffering during labor include ritual performances, prayer, and sacrifice. However, in the early ethnographic accounts and surveys, little mention is made of herbal or other techniques of accelerating labor or intervening in complicated births.

In contrast, more interest is expressed in the widespread concern with disposal of the placenta, or afterbirth. Dating from early reports such as that by Malinowski (1929), anthropological publications from numerous societies include reference to the powerful meanings associated with the placenta. Techniques of expelling the placenta, such as massage or pressure, and the ritual disposal of the placenta, have been widely described. Disposal of the placenta is rarely random or careless. Often it is burned, or buried in a significant location. Sometimes the placenta is preserved to later create a medicine or to use in ritual practice. Early discussions of the placenta also mention methods of cutting the umbilical cord (knife, arrow, other sharp implement), preferred timing of cord-cutting (after the placenta is expelled, for instance), and means of tying the cord. Little information is available in the earliest studies regarding treatment of the mother postpartum, except to indicate that she may wash, and is often secluded for a ritualized period of time. A few societies are described as employing techniques to prevent excessive bleeding. Dietary proscriptions and prescriptions are also noted, as are sexual restrictions during the postpartum period. Approximately half the world's societies in the ethnographic record have lengthy postpartum sex taboos, sometimes encouraging abstinence for as long as two years (Whiting, 1964).

Regarding the regulation of postpartum sexuality, Whiting notes that in many societies, a brief period following the birth of a child is identified during which sexual intercourse is taboo, to allow the mother to recover from childbirth (Whiting, 1964, p. 518). In those societies practicing a more extended period of sexual abstinence, the explanation usually focuses on the well-being of the infant, suggesting that if a nursing mother were to become pregnant, her breastmilk would be contaminated, thus placing the infant at risk. The prolonged postpartum sex taboo may thus represent a cultural means of protecting the well-being of infants by prolonging the nursing period and encouraging adequate spacing between births.

Toward an Anthropology of Birth

Subsequent to 1970, increased anthropological interest in birth assistance and midwifery practice moved the field beyond brief ethnographic accounts and surveys to more contextualized analyses of birth. This growing attention to the ways in which pregnancy and delivery are culturally shaped generated an important literature on the management of birth in industrialized societies. From the 1970s, more women anthropologists entered the field. Inspired by the second wave of feminism and with greater access to information about birth practices derived from empirical observations, they began to explore birthing systems as local systems of knowledge and praxis, grounded in broader cultural and social contexts (see Davis-Floyd & Sargent, 1997, for a thorough review of this literature). Among the cutting-edge research from this phase in the anthropology of birth is McClain's (1975) work on cognition and behavior regarding pregnancy and birth in Mexico in which she introduced the term "ethno-obstetrics" and approached birth as a cultural system in the process of transformation.

One aspect of the cultural patterning of birth that elicited attention in the emergence of the anthropological study of birth was the issue of variations that exist in the characteristics of those who are allowed to attend births and offer specialized assistance to the parturient. In most societies, a woman is attended by other women, often kin, who provide emotional support and generalized knowledge regarding labor and delivery. Some societies also have a specialist to assist at birth. In the anthropological literature, this specialist is usually referred to as a midwife, although the World Health Organization has favored the term "traditional birth attendant," to differentiate those who are biomedically trained from other birth specialists. A few societies encourage women to deliver alone, without the participation of a midwife or indeed any companions (see, e.g., Sargent, 1982, Sargent, 1989; Trevathan, 1987).

Cross-cultural comparison of the characteristics of midwives has focused on recruitment to the role, acquisition of skills and knowledge, status, and the midwife's role in prenatal care, at delivery, and in the postpartum. Cosminsky (1976) provided the first substantial review of existing data on this topic. Cosminsky's review, based on a variety of secondary ethnographic and medical sources, surveys the role of the midwife in providing prenatal care, delivery assistance, treatment of the newborn, and postnatal care. Subsequently, her own ethnographic research provided systematic and in-depth analyses of Guatemalan midwifery (Cosminsky, 1976, ???1982).

Cosminsky found that worldwide, most midwives are female, postmenopausal, and have had children of their own. Recruitment to the role of midwife may be based on spiritual calling, inheritance, or personal inclination. Dreams or visions are sometimes used as signs that a woman should be a midwife. For example, in Guatemala, Cosminsky reports that a midwife usually has suffered ill health and a shaman may divine the cause as a warning to take up the calling of midwifery or risk severe consequences from God. Most commonly, midwives acquire training by means of apprenticeship, a pattern documented in Africa, Latin America, Asia, and the United States. While midwives usually occupy a respected position in society (e.g., in Jamaica, peninsular Malaysia, and much of Africa), exceptions exist; in India, for instance, the position of midwife (dai) is allocated to low-caste women, because of the association of birth and bodily fluids (Jeffery & Jeffery, 1993). Similarly, Rozario describes the position of the dai in Bangladesh as very low status. The dai is usually very poor, elderly, with no formal education or training (Rozario, 1998, p. 161). There is often little or no remuneration for her work, although the dai are recognized as experienced and useful as birth attendants. The case studies Rozario presents indicate that the dai does not provide prenatal or postpartum care, but initiates her involvement during labor. She suggests that the Bangladeshi pattern is typical of the region, and probably of most of South Asia. Worldwide, proliferation of biomedical facilities has often resulted in a decline in respect for local midwives, as women increasingly seek care from biomedical practitioners.

The landmark 1978 publication of Jordan's Birth in Four Cultures inspired a generation of anthropologists to pursue empirically based comparative studies of birth and legitimized the grounded study of human reproduction (Ginsburg & Rapp, 1991). Jordan referred to her own approach as "biosocial," with an emphasis on the feedback between biology and culture. Prior to Jordan's work, there was a distinct lack of data useful for a holistic comparison of childbirth, and almost no research based on direct observation of normal births. Medical reports presenting cross-cultural examples tend to focus on physiology, and often on abnormal features of birth. Jordan sought to emphasize the social interactional aspects of birth, such as the nature of the decision-making process during parturition, and the extent of material and emotional support for the woman during pregnancy and labor. Broadly, she proposed a biosocial framework for the collection and analysis of data, that would integrate local meanings of birth with associated "biobehaviors." Accordingly, she developed a methodology to isolate features of the birth process that would serve as units for cross-cultural comparison.

As the specific cases employed in her book, she compared birthing systems in Sweden, Holland,Yucatan, and the United States, thus illustrating the possibility of cross-cultural analysis in this domain of inquiry. Methodologically, she proposed that the study of birth requires direct observation. Given that birth involves bodily functions and bodily displays, collecting data by survey or primarily by structured interviews is fundamentally inadequate. In contrast, anthropological participation is recommended as an explicit methodological device "intended to give the investigator access to the knowing how of birth, that is to say, to the behaviors in which participants engage as competent performers of system-specific ways of doing birth" (Jordan, 1978, p. 8). Participant observation, combined with standard structured means of data collection, provide the foundations for a holistic representation of the birth process.

In addition to providing ethnographic detail about each system, Jordan's research offered policy recommendations to encourage accommodation between biomedical and indigenous birthing systems that would acknowledge the perspectives of both systems. Most significantly, she argued that birth is always a cultural production. She applied this perspective to biomedicine as well as to local birthing systems, thus generating an enduring interest among anthropologists of reproduction in the cultural shaping of biomedical obstetrics.

During the 1980s, anthropologists followed Jordan's groundbreaking work with detailed ethnographic studies conducted in many parts of the world. The first edited collections focusing on pregnancy and birth in cross-cultural perspective date from this period (Kay, 1982; MacCormack, 1982/MacCormack, 1994). Ethnographic research in this phase portrays viable local birthing systems, confronted with challenges from an imported biomedical system, usually legitimized by the state. Correspondingly, numerous anthropologists have detailed the resistance and accommodation of local practitioners and women seeking maternity care. A substantial body of research examines the impact of birth technology on local practice, and the global exporting of the biomedical (American), technocratic model of birth (Davis-Floyd, 1992; Davis-Floyd & Sargent, 1997).

Contextualizing Birthing Systems: Global and Local Perspectives

Among the principal studies of local birthing systems from the decade of the 1980s are those by Sargent, Laderman, and MacCormack. These studies are characterized by ethnographic detail as well as careful articulation of childbirth as an event with broader sociocultural issues such as gender ideology, domestic power relations, professional specialization, and the components of particular ethnomedical systems. Sargent's (1982, Sargent's 1989) monographs on birth among the Bariba of Benin contextualize Bariba understandings and behaviors surrounding birth by detailing Bariba religion and cosmology, gender roles and ideology, occupational hierarchies, local medicine, and the structure of state-sponsored health services. Local ideas concerning the order of the universe are linked to diagnosis and management of problematic births. Sargent uses case studies of Bariba births that she attended to analyse patterns of delivery assistance, the meaning of therapeutic "efficacy" for clients and midwives, and features of the decision-making process for pregnant women.

In one case, for example, Ganigi, a woman experiencing her tenth pregnancy, confronted complications during labor that challenged local healers. Ganigi initially adhered to the Bariba ideal of delivering alone but called her mother when she delivered the umbilical cord prior to the birth of the baby. Her labor then stopped. This unusual circumstance led the family to call a respected local midwife, known for her spiritual powers. The midwife diagnosed the protrusion as a woman's affliction known as tigpiru, and offered a herbal remedy. When that failed to accelerate labor, a second midwife and the anthropologist were called. The second midwife tried abdominal massage, herbal smelling salts, and a herbal drink served in a gourd, to no avail. Ganigi, in a state of great anxiety that her problems might result from witchcraft, finally allowed the anthropologist to transport her to the nearest maternity clinic, where the nurse diagnosed a prolapsed cord and assisted Ganigi in delivering twins, one of which was stillborn. The consensus of the family and community was that witchcraft-fortunately thwarted by the involvement of the anthropologist-was at the root of the problem (Sargent, 1982). This case illustrates important Bariba concepts, such as the widespread understanding that witches can take the form of unborn children who may kill their mother. Birth serves as the occasion to detect witchcraft, by identifying signs of abnormality such as breech births or other anomalies such as the prolapsed cord. Childbirth is therefore a time of ritual danger as well as physical risk. Extended case analyses of Bariba birth not only generate an ethnography of the local birthing system, but also shed light on broader aspects of Bariba culture and society.

Similarly, Laderman (1983) uses extended case studies, survey research, and nutrient analyses to illustrate the management of birth in Malay culture, as well as to illuminate broader Malay cultural and social principles. Laderman describes the Malay humoral system, beliefs, and behavior surrounding food in relation to ecology, ideas about conception and pregnancy, and the management of birth by traditional and government midwives. The Malay birthing system is thus carefully contextualized. In one case, for example, Laderman describes how an unborn child is thought to be afflicted with a wasting disease, caused by the destructive spiritual influence of a corpse. Early in her pregnancy, Rohani was startled by the sight of a young cousin's corpse. When her month-old baby began to lose weight and became increasingly sickly, retrospective analysis led to the suspicion that the infant's sickness resulted from her mother's prenatal experience. An alternative diagnosis by a local healer attributed the sickness to a birth trauma (the baby was born with the umbilical cord around its neck) which can cause ritual danger to the child. The healer also suspected another affliction caused by disembodied spirits associated with the placenta, amniotic fluid, and the blood of childbirth. In spite of several therapeutic efforts-the baby's name was changed to another more harmonious one, ritual acts were performed to symbolize a spiritual rebirth, and on the anthropologist's advice, the family eventually consulted a pediatrician-ultimately the baby died (Laderman, 1983, pp. 96-101).

In her discussion, Laderman addresses issues of generalized anthropological concern by means of the analysis of childbirth. She explores the relationship between belief and behavior as she investigates Malay food restrictions during pregnancy and the postpartum period. In addition, as the case of Rohani indicates, important features of Malay ideology emerge from the ethnography of birth.

In her edited volume, Ethnography of Fertility and Birth, MacCormack (1982/MacCormack 1994) presents an ethnographic collection that illustrates state-of-the art research in this time period. Her own research on midwifery in coastal Sierre Leone analyses the Sande society, a women's organization concerned with maintaining health and fertility. Sande practitioners provide maternal and child healthcare, including midwifery. Like other anthropologists of this decade, MacCormack was interested in demonstrating that birth is a cultural and social, as well as a "natural" or medical process. Thus she examines the role of the Sande society initiation, including clitoridectomy and ritual adolescent fattening, folk meanings of fertility, midwifery practice, social support during childbirth, and infant mortality. In addition, she discusses the flexibility of the local conceptual framework in order to propose that Sande midwives are open to adopting theoretical tenets about birth drawn from biomedicine. She suggests that an effective primary healthcare system should draw on biomedical as well as local models of health, fertility, and birth.

An Anthropology of Western Childbirth

The anthropology of Western childbirth has represented a core element in studies of birthing systems from Jordan's comparative research through the 1990s. A consistent theme in this body of research emphasizes that the dominant cultural definition of birth in the United States is a medical one, in which pregnancy is viewed as a pathological state, requiring specialist attention and hospital delivery. Accordingly, the medicalization of childbirth, characterized by use of technological interventions during birth, such as episiotomy (a surgical incision of the vagina to widen the birth outlet), intravenous medication, and the lithotomy (suppine) position for delivery, have become standard procedures (Davis-Floyd, 1992; Jordan, 1978; Romalis, 1981). This widespread use of technology has led Davis-Floyd to suggest the term "technocratic birth," in her classic study of birth as an American rite of passage. Technocratic birth predominates in the United States, where 98% of women give birth in hospitals. In many hospitals more than 80% of women receive epidural anesthesia, and at least 90% receive episiotomies (Davis-Floyd & Sargent, 1997, p. 11). In some hospitals, the cesarean, or surgical birth rate has reached 30% or higher (Sargent & Stark, 1987). A minority of American women-less than 2%-rely on midwifery and home birth. A revival of interest in midwifery in industrialized societies has generated research on such topics as the history of midwifery, regional traditions of midwifery in the United States, and the politics and professionalization of midwifery (Fraser, 1995; see Davis-Floyd & Sargent, 1997 and Ginsburg & Rapp, 1991, for specific citations).

The impact of the medicalization of birth in the United States is illuminated in Emily Martin's (1987) exploration of how women talk about their birth experiences. Martin examines scientific and medical representations of women's bodies and reproductive processes. She analyses the medical treatment of birth in relation to the development of Western thought and medicine, in particular the emergence of the notion of the body as a machine and the doctor as the technician who repairs it. Based on semi-structured interviews with a sample including working-class and middle-class women ranging in age and racially diverse, Martin presents women's narratives about pregnancy, labor, and delivery. In talking about their birth experiences, women describe a sense of alienation and fragmentation, produced by the reliance on technological interventions and specialist monitoring. She documents both acceptance of biomedical control and acts of resistance and opposition.

Correspondingly, a principal theme in the anthropology of Western birth has been women's progressive loss of control over birth in conjunction with the transfer of childbirth from home to hospital, and the shift from reliance on midwives as birth assistants to obstetric specialists. An alternative perspective focuses on the limits of the "control model," and argues that the narrative of personal control reflects 20th century Anglo-European notions of individualism. However, infertility, pregnancy loss, and disability exemplify experiences that test the limitations of models that emphasize individual decision-making and control, as several anthropologists have argued, building on personal narratives of pregnancy or neonatal loss (cf. Ginsburg & Rapp, 1999; Layne, 1999).

Birth and Authoritative Knowledge

The American biomedical model of birth has been exported to much of the developing world, and anthropologists have documented the accommodation and resistance of local birthing systems to encounters with imported biomedical obstetrics. Following Jordan's comparative approach, anthropologists have explored variations in the use of obstetric technology in numerous countries, and have documented cross-national variation in the ways birth is managed within European medical systems. The persistence of midwifery in the Netherlands, where midwives attend 70% of births, the home birth rate is still 30%, and maternal and child health outcomes exceed those of neighboring countries, has attracted considerable anthropological interest. As Jordan initially documented, the comparison of biomedical systems among industrialized societies effectively illustrates the ways in which obstetrics is culturally influenced and shaped.

In the context of contested power relationships, a number of anthropologists have employed Jordan's concept of authoritative knowledge, the interactionally displayed knowledge on the basis of which decisions are made and actions taken, to investigate birth as a social process (see Davis-Floyd & Sargent, 1997, for a collection of ethnographic accounts; also Ginsburg & Rapp, 1991, for a review of related literature).

The anthropological interest in contested power relations surrounding pregnancy and birth evident in theoretical discussions of authoritative knowledge reflects a longstanding focus in the field on the politics of childbirth. Since the 1970s, influenced by the feminist movement, anthropologists studying birth have explored the shifting power relations implicated in struggles for control over childbirth, in both industrialized and pre-industrial societies (cf. Handwerker, 1990). Within the United States, Lazarus (1996) describes a two-class system, in which poor women and middle-class women experience pregnancy and childbirth under different circumstances. Her work serves as a reminder that social class generates differences in power, authority, and resources among women that structure access to knowledge about birth and shape the birthing process.

Diverse ethnographies of birth demonstrate how authoritative knowledge about birth is produced, displayed, and challenged. Trevathan's (1987, Trevathan's 1996) work is unique in proposing an evolutionary perspective on human birth. She argues that for millions of years the birthing female was the most important figure at the time of birth, although today her knowledge about her body is likely to be suppressed and devalued.

Local/Global Perspectives

Three decades of ethnographic and theoretical work on birthing systems have produced a substantial and empirically grounded anthropological literature. Case studies from North America, Europe, and societies of Asia, Africa, and Latin America have generated the material for anthropological analyses of multiple "ways of knowing" about birth. Anthropologists have begun to address not only the encounter between low- and high-technology birth systems, but also the diverse paradigms of maternity and birth held by different categories of women within heterogeneous societies (Browner & Sargent, 1996, p. 232). In addition, a scant but important literature explores the topic of men in relation to childbirth (e.g., Ebin, 1994; Romalis, 1981; Whiteford & Sharinus, 1988).

In spite of the global spread of biomedical obstetrics, a substantial body of research illustrates the continued viability of midwifery and low-technology birthing systems. Biomedicine has emerged as the dominant state-sponsored system worldwide; local midwives are often subordinated to government nurse-midwives and hospital births increasingly have supplanted home births. Nonetheless, local birthing systems have demonstrated remarkable resilience in contesting high-technology obstetrics (Daviss, 1997; Kaufert & O'Neil, 1993). While much of the anthropology of birth has worked to validate midwifery and low-technology birthing systems, the risk of an anthropological romanticizing of traditional childbirth has also been identified (Rozario, 1998). In the 1990s, influenced by postmodernism and feminism, the anthropology of birth has moved to include reflexive narratives that represent birth as a subjective experience, in addition to continuing empirical and theoretical investigations of birthing systems in relation to broader social structures and ideology.

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