From infantilization to empowerment: The “conscious birth” and birth centers

Hospitalized birth care in Mexico is subject to statutes defined by the Mexican Official Norms—for example, in the Norm for Birth Care (NOM-007-SSA2-

2016) . These norms determine with great precision how to give birth, but without necessarily taking into account the autonomy of birthing women. Thus, by no means are these norms defined from a health and gender perspective. Rather, they contain a demographic discourse on maternal health achievements, combined with complex language and exhausting content, which raises question about how this kind of normativity operates in spaces such as the health sector, where the areas dedicated to Ob-Gyn care are often saturated or overcrowded.

Indeed, various scholars have reported on the different factors that prevent the expansion of maternity services in the country, despite the high volume of hospitalized births, combined with various official “justifications” for the precarious care given to women in these facilities. Numerous studies have exposed the indifference and even cruelty of the system to the majority of women and their families, who do not claim their rights but instead conform to simply escaping alive from the experience of hospital birth. (See for examples Cardenas 2014; Sanchez-Bringas 2014; Castro and Erviti 2015; Meza et al. 2015; Marquez-Murrieta 2019.)

In addition, the Mexican hospital system reflects the lack of a budget that is sufficient to achieve an adequate level of healthcare. This lack is attributable to the persistent professional and political immaturity that is not examined duly despite the unfortunate but evident national indicators; for example, the previously mentioned C-section rate and the slow reduction of the extensively studied maternal mortality in some of the poorest regions of the country (Heredia-Pi et al. 2013; Freyermuth 2014; Hogan et al. 2016; Pisanty-Alatorre

2017) . The situation revealed by those indicators is obviously coupled with an excess of interventions in women’s bodies during pregnancy and birth.

The societal transfer from homebirth to hospital birth had immediate consequences, such as the use of oxytocin to accelerate the birth. Oxytocin, a hormone produced in the body, helps to provoke uterine contractions and stimulate milk flow, but it is also pharmacologically prepared as a syntheticdrug, and used to induce labor, strengthen contractions, control postpartum hemorrhage and provoke milk flow. When oxytocin is used to speed birth, doctors electronically monitor the heartbeats of the baby and mother. The result is a labor and birth in which the woman is connected to a monitor, completely immobilized in the bed, on her back.

Since the administration of synthetic oxytocin often provokes contractions that are more painful than the physiologic ones, demand increases for pain relief during the birth. When lumbar or sacral epidural analgesia arrived on the market, painless birth became an option for birthing mothers. However, this drug prevents women from moving, thereby diminishing the sensitivity and strength of pushing. As a result, the time it takes to push out the baby increases, as does the use of instrumental “help” (Fernández 2014; Nascimento do et al. 2016; Sibrian, 2016: Arango et al. 2018; Hernández-Garré and De Maya 2019).

All these “technological innovations”—which benefit the pharmacological and clinical technology industries—have also favored and fostered medical interventions. In Mexico, they also require the constant presence of the obstetrician in the birthing theater. When medical attention is more focused on the gadgets and the uterus, there is no time or space to consider the woman’s own needs and capabilities. Perhaps the most unfortunate phenomenon in contemporary birth is that most women are not conscious of this abrogation of autonomy and body-territoriality. The sad part is that, in contemporary Ob-Gyn culture, the birthing mothers delegate all the responsibility for their births to the corresponding medical staff, including C-sections, as if they (the mothers) are passively assuming the infantilization of their own person during a natural, physiologic process. This critique applies to all those women who are not clinically diagnosed as at risk (Castro and Erviti 2015).

It is also important to mention that this excessive medicalization has opened doors to a phenomenon that has recently been denominated as “obstetric violence.” Although this phenomenon is not the principal focus of this chapter, I must note that Latin American researchers have published extensively on this subject (Silva da and Santana-Brito 2017; Barbosa-Jardim and Modena 2018; Diaz and Fernández 2018; Hernández-Garré and De Maya-Sánchez 2019 ; see also Chapter 5). “Obstetric violence” is not a globally recognized legal term. The term has legal roots, but thus far has been used in the legal system only in the Latin American context. Venezuela was the first country to legally define it and to classify it as an offense in Article 51 of the “Organic law on women’s right to life free of violence” (Ley orgánica sobre el derecho de las mujeres a una vida libre de violencia) in 2007. In 2009, Argentina enacted Law 26.485, “Law of integral protection to prevent, sanction and eradicate violence against women in which they develop their interpersonal relations” (Ley de protección integral para prevenir, sancionar y erradicar la violencia contra las mujeres en los ámbitos en que desarrollen sus relaciones interpersonales). Article 6 of the mentioned law defines obstetric violence (Belli 2013).

In Mexico, obstetric violence has also been explored in the fields of anthropology and medical sociology, particularly in terms of women’s testimonies about mistreatment during birth (Sánchez-Bringas 2014; Castro and Erviti 2015; Grupo de Información en Reproducción Elegida 2015; Meza et al. 2015; Pozzio 2016).

Mexico has the “General law of access of women to life free of violence” (Ley general de acceso a las mujeres a una vida libre de violencia), but the bill to classify obstetric violence was precluded in 2015. (“Preclusion” is a legal term referring to a trial that is divided into stages, each of which closes the earlier stage without possibility of reconsidering it.³) Therefore, obstetric violence is considered only in state-level legislation, in nine federal entities (Sánchez 2016, 209-216).

Various concepts are used to name and characterize obstetric violence. Nonetheless, for the purposes of this research and on the basis of previously cited research on obstetric violence from the viewpoint of gender and health, the concept refers to both emotional and physical violence:

Emotionally, obstetric violence refers to shaming, threats, humiliations, mockery, and discrimination on the basis of the woman’s appearance. It also refers to (for example) lack of respect for the opinions or knowledge of the birthing woman, and to the withholding of information related to the procedures carried out on her body—including when the staff does not speak the pregnant woman’s language. Physically, obstetric violence refers to invasive practices that include the use of unjustified drugs, routine episiotomy and pubic shaving, use of oxytocin to induce labor, enemas, excessive electronic fetal monitoring, and the use of forceps. Other forms of physical obstetric violence include not respecting the biological times and requirements of the birthing body, refusal to allow birthing mothers to eat or drink, and performing unnecessary C-sections. Obstetric violence also takes forms such as the application of temporary or permanent contraception without the woman’s informed consent. In extreme cases, obstetric violence can lead to maternal mortality or the death of the unborn or newborn baby, through abuse of power on the part of the medical staff or via their ignoring of the information women try to supply about their condition.

(Sánchez, Meza and Luna 2016, 21)

A contrast to births involving excessive medicalization or extreme obstetric violence is what has been called “humanized birth,” or “conscious birth.” The conscious birth refers to a labor that seeks to follow and learn from the logic of biological birth, coupled with a conscious childbirth education process carried out by the future mother and by the person who accompanies her through the process (partner, family or friends). In addition, that person—in the case of a midwife at her home, or in a birth center—is also adequately trained to accompany the process in the way that is best for the birthing mother, detecting any complications requiring a transfer to a medical facility.

Birth (parto) and childbirth (nacimiento [the baby’s birth]) represent the beginning and starting point of life, and they are, therefore, processes that affect the rest of human existence. Thus, the humanization of (child)birth constitutes an urgent and evident necessity. Therefore, we firmly believe that the application of humanization in the care provided at the beginning of human life will be decisive and definitive for human societies.

(Declaration of Ceará on Humanization of Birth, 2002)

In the two decades since this declaration, different kinds of studies have emerged on obstetric violence in Latin America, combined with research on “humanized” birth during the past five years (Campiglia 2017; Lazzaro 2017; Montero and Leida 2017; Borges et al. 2018; Muñoz-Dueñas et al. 2018). However, gender perspectives continue to be scarce.

“Humanized birth” has become a mere political label in some international platforms, without significant and real consciousness about the meaning of a “respected” birth. A respected birth is humane; birth cannot be humanized if there is no fundamental respect provided to the one who is the main actor in the birthing event—the mother. Given this context, in this chapter I have decided to use the concept of “conscious birth” instead of “humanized birth,” although the two can be considered as synonyms and used interchangeably. We all birth as humans, but I suggest that we also need to have consciousness and awareness for labor and birth. This means considering all our emotions and wishes (including the contradictory ones), but also understanding that we cannot involve ourselves in this process by instinct alone because, according to Bomzdina (2014), we lost much of that instinct as we modernized.

The conscious birth is based on the understanding that giving birth is an event that involves the fundamental components of human life: thoughts, feelings and will (Glokler 2009). In terms of thinking, the authenticity of knowing is embedded in the process of delivery and in the kinds of practices that are taking place in the corporeality of the woman and the baby. In terms of feelings, the love for birthing. And in terms of will, the freedom to be the star of the event as a woman who wants to carry it out herself.

As a consequence, the humanized (child)birth is founded in the emotional-affective world based on the individual desires and needs of its leading actor(s)—the mother, father/partner, baby—and in the freedom of the women or the couple to make the decisions about where, how, and with whom to birth in one of the most powerful moments in their lives (Burgos 2015).

The aforesaid necessarily implies the following (Lutz and Misol 2016):

Refraining from intervening or interfering in this natural process unless there is an evident situation of risk

• • Acknowledging and respecting the individual needs of each woman/ couple, and the way in which they desire to proceed with this experience (in an institution or at home)
• • Respecting the intimacy of the surroundings during the (child)birth
• • Favoring the freedom of position and movement of each woman during the (child )birth (squatting, water, semi-seated etc.)
• • Promoting a personalized connection between the couple and the assisting professional group
• • Respecting the needs of the woman in choosing the persons to accompany her in the birth (family, friends)
• • Attending to the immediate connection of the mother with the newborn, avoiding subjecting the newborn to unnecessary reviving maneuvers or examinations
• • Favoring a multi-disciplinary approach, with the participation of health professionals related to birth and maternity, such as midwives, obstetricians, neonatologists, nurses and educators
• • Favoring integral attitudes and paying attention to the differing intellectual, emotional, social and cultural needs of the women, their children and families, rather than reducing care to biological needs alone (i.e. culturally sensitive care)
• • Favoring family-centered care that addresses the needs not only of the woman and the baby, but also of the couple
• • Favoring appropriate means while paying attention to different cultural guidelines that allow achievement of the corresponding objectives
• • Bearing in mind the decision-making power of the women.

These elements form the basis of care provided by the BCs in Mexico. BCs are spaces headed by midwives with the help of doulas (a woman who is often the trainee of the midwife, but whose main task is to offer physical and emotional support during pregnancy, birth and puerperium). In BCs, the woman is usually in control of her pregnancy and birth, accompanied by the midwife, without the necessity of gynecological visits to doctors unless clinically required. The users are women with no previous pathology, and whose births tend to begin spontaneously.

Countries vary in their criteria for defining the kind of pregnant woman who can choose to birth in a BC. Generally speaking, BCs “exclude women with such previous pathologies as preeclampsia, multiple pregnancies, premature births, or women under 16 or over 42 years old” (American Association of Birth Centers 2015).

The BCs are an option for people who might otherwise choose homebirth, especially when the birthing mother’s household is not suitable for homebirth. Thus, the BCs provide a middle-ground solution that compensates for the deficiencies of conventional living, and which offers an alternative to the aggressiveness of the hospitalized birth.

Lucia Rocca and Cristina Alonso (2020) note yet another benefit that the BCs provide in non-hospitalized maternal healthcare: for pregnant women, it can always be considered risky to birth in hospitals given the possibility of contagious infections. That risk has become more acute due to the COVID-19 pandemic. Lucia Rocca and Cristina Alonso (2020) insist that BCs become pertinent, particularly in LMICs, as a way to guarantee a separation in the maternal health system from hospitalized attention that focuses on pathologies and diseases. In addition, the BCs obviously provide harmonious, safe spaces for sexual and reproductive health for women who seek it.

The BCs have been established in different ways globally. Some are autonomous units, as independent centers geographically separated but part of the hospitalized system, and as centers situated near hospitalized birthing theaters, or as mixed units. The BCs usually qualify as such as long as the responsibility of the space rests on the midwife, and the mother is respected as the leading actor of the birth.

The objective of these spaces is to generate a comfortable environment, similar to that of a home, where the woman can give birth according to her own rhythms with minimal external intervention, resorting only when necessary to the least invasive method first (Lutz and Misol 2016). Additionally, BCs offer a range of services to accompany the pregnancy and puerperium.