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Birth and Maternal Health Around the World

Corbis

In America, where 99% of births take place in the hospital and the national c-section rate is at an all-time high of 34%, we’re pretty used to the medical model of childbirth. Well, it turns out that we’ve exported this model to the far corners of the world; in Japan, Korea and China, Western-style hospital births have all but replaced traditional home birth in the last few decades. But in other countries and cultures, old ways and rituals remain. In the book Childbirth Across Cultures, edited by my very own mom, Helaine Selin gathers portraits of the new ways of giving birth, as well as the old, in the non-Western world. Here, she shares fascinating childbirth traditions from around the world, and be prepared: they range from sweet to shocking.

Uganda: The Women’s Battle

In, Uganda, Western-style birth is on the rise, but home birth is still the norm; around 60% of women give birth outside the hospital. Here, childbirth is called Lutalo Lwabakyala, or women’s battle—pain is expected, normal and natural, but women are expected to transcend it, to win the battle. Childbirth, according to Ugandans, is a test of endurance.

Women are expected to be stoic during both pregnancy and childbirth, showing no fear or weakness, and you won’t get any sympathy for morning sickness, sleeplessness, or any of the other physical side effects of pregnancy, let alone the emotional ones. Fear is considered a childish emotion, weakness is unacceptable, and a pregnant woman who can’t perform her normal chores and duties is sent back to her parents’ house until she feels stronger. They have a saying: A man likes you when you are healthy. 

Birth here is everybody’s business, not a private family matter. The highest honor is reserved for women who deliver naturally and alone; a c-section is seen by the entire community as a failure. If a woman dies during pregnancy or childbirth, it’s viewed as her own fault, a result of her weakness. Thus, while maternal mortality rates are slowly reducing here, they’re still high: 310 deaths per 100,000 live births.

China: The Importing of C-Sections

China has been getting steadily more urban and Western, and along with capitalism, America has exported its medical approach to childbirth here. Hospital birth has almost completely replaced home birth, except for the poorest and most rural of women. (Families are responsible for their own birth costs).

The wealthiest of urban Chinese women give birth in luxurious private hospitals, which have a c-section rate as high as 90%; these are seen as “status births”—the most western, modern and desirable way to give birth. Members of the emerging middle class tend to give birth at state-run hospitals, where they have no choice of doctor and are placed in a room with other birthing mothers during active labor. In large towns, woman-baby hospitals, the equivalent of freestanding birth centers here, are attended by zhuchanshi, midwives who do everything from perform abortions to c-section surgery. C-section rates are around 40% at these facilities—high, but nothing compared to the private hospitals.

Yet the postpartum tradition of zuoyuezi—“to sit the month”—persists. After birth, most Chinese women spend a month “lying in,” where they do little more than breastfeed their babies while female relatives attend to their needs. Women often travel back to their mother’s home for this tradition, no matter how far away they’ve moved.

While this sounds like the world’s greatest maternity leave, lying in has its downsides, too. Some women are forbidden to get wet (even brushing their teeth or washing hair), go outside, eat raw veggies or cold drinks. But they’re also forbidden to do household chores, which probably sounds just fine to most American women.

Sweden: A Model For The Rest Of The World?

Sweden has some of the highest breastfeeding rates and lowest infant mortality rates in the world, so they must be doing something right. It’s ranked as the third best place to be a mom by Save the Children, following Iceland and Norway, due to its access to skilled maternity care and low c-section rates. Midwives generally manage births, and doctors are reserved for times when medical intervention is necessary; they usually give the baby a check-up after birth, but do little before. Prenatal care is free.

Birth is considered by Swedes to be an intensely fulfilling personal experience, and even though almost all Swedish births occur in hospitals, those institutions tend to be homey and comfortable. There are labor lounges where women can snack, chat, read or watch TV as labor progresses. A mom’s birth team consists of the midwife, the midwife’s assistant and a non-specialist attendant of her choosing—a relative, husband or friend—and she can labor alone with her attendant for long periods if she wishes.

What Swedish birth offers is choice. Unlike in some Scandinavian countries, where medication is discouraged, Swedish women are educated about medications—the possibilities, the side effects or possible complications—and can decide for themselves, without pressure either way, if they want them.

Bangladesh:  Birth As Family Affair

“Please Grandma, put your big toe on my anus.” Yes, this is something a Bangladeshi woman might say during labor, where women give birth surrounded by their female relatives and friends who assist them physically, emotionally and with pressure applied to certain parts of the body, which is supposed to help ease the pain. Childbirth is something women do in a group, and companionship is part of the process. Women share their own birth stories as the mother labors. 

Home births are still common: 85% of births were outside of medical facilities, by last count. Women are allowed and encouraged to move around, go to the bathroom, walk, rest, and hold onto poles or ropes during the labor. The expression of pain is still discouraged, and they emphasize moner shahosh (mental strength) and shoriler shakti (physical strength) during birth. Muslim women may recite verses from the Koran for comfort and inspiration during labor.

While laboring, women can eat warm rice and they’re encouraged to drink warm water or milk. A warm compress is placed over the perineum, and the birth attendants, or dainis, massage the woman’s head and abdomen, shake her waist, and line her perineum area with oil, which is supposed to help the baby slide out.

Hospital births are rare—many women don’t have money for the transportation to them, let alone for the bills—and something women fear. And with good reason: women may be induced or cut open without their consent, and are rarely communicated with. Reciting the Koran is usually not allowed, movement is restricted, and women might be disgraced or ignored by hospital staff. Modern is not conflated with better here, and there’s a social stigma from being cut open by a doctor, either for a c-section or episiotomy.

Korea: Stoicism Instead of Epidurals

Koreans believe that the pregnant mother’s thoughts and experiences have a direct effect on the baby, so they need to take in as much beauty, and feel as much positivity, as they can—the more beauty you take in while pregnant, the more gorgeous your baby will be. They go so far as to avoid eating any breakable foods, like cookies or crackers, for fear it’ll make their baby sick, and they don’t eat duck, for fear that their kids will have webbed feet.

But the ancient beliefs are largely shelved during delivery, 96% of which take place in hospitals since insurance now covers childbirth. Female relatives attend the birth, while husbands generally stay in the waiting room until it’s over.

Koreans prize stoicism, and women are expected to withstand the sensations of childbirth and not express pain. Instead of pain medication, they tend to use methods like aromatherapy, acupressure and music to reduce both the pain and the anxiety about the pain. Most women are forced to receive episiotomies, since they don’t know that they can ask the doctor not to perform one.

After the birth, Koreans have a lying-in period called San-ho-jori, usually at their home or their mother’s home. For 21 days they eat, sleep and nurse while relatives attend to all other needs. The practice offers both freedom and confinement. While the old practice of preventing women from cooling off or touching water (they were not to bathe or brush their teeth) is gone, women still aren’t allowed to be in air conditioning, no matter how hot it is.

 Navajo: The Revival of Ancient Traditions

While most Native Americans give birth at Bureau of Indian Affairs hospitals, there’s a movement to revive traditional home birth, which is serene, private and full of ritual. 

When a woman goes into labor, her husband ties a rope or Navajo sash to a log or pole inside the home—the sashes are colored red, white and green, decorated with designs of Navajo deities. The husband may put down smooth sand from a streambed on the floor, then cover it with sheepskin and clean cloth—a comfy, safe spot on the floor on which to rest. Then he stands behind the laboring mother with his hands over her breasts and belly, tightening the embrace during contractions. The woman wraps the sash belt around her—that, coupled with the husband’s embrace, keeps her upright during contractions.

As labor progresses, the father keeps tending to the fire and makes juniper tea, the aroma of which fills the air. The mother takes her hair down and removes her jewelry, and a traditional healer performs the ancient Blessingway ceremony, which includes chants and songs for the safe passage of the baby, along with a ritual of eagle feathers dipped in pollen. The healer never touches the couple during labor;

giving birth is something they do alone, together.

Tibet: The Old Ways Remain

As in many developing Asian countries and cultures, Tibetan woman tend to give birth alone, although sometimes a mother-in-law or husband might help. And, as is many developing Asian countries, women who have just given birth are considered dirty or polluted, which is why when they cut the umbilical cord—which new mothers do themselves—they often use an unclean knife, and clean it after, to remove the pollution of childbirth. Of the 66% of Tibetan women who have home births, many will give birth in an animal pen.

These are some of the reasons that infant mortality is so high here—as many as 20% to 30% of Tibetan children will die within their first 12 months of life. Even if mothers wanted to give birth in hospitals or clinics, it would be hard. Because of the topography, geography and economics—it’s poor, mountainous and rural—there is little access to either skilled birth attendants or emergency services.

Once a baby is born, and before the first nursing, he eats a paste of butter, honey, saffron water and musk water, thought to protect the child from harmful spirits. Then a respected religious figure in the community comes and gives the baby his name.

Nigeria: A Solo Struggle

In Nigeria, a woman’s chance of dying in childbirth is 1 in 18. Home birth is still the norm; 58% nationally and 85% of women in some rural regions have babies outside a medical facility. If they want to give birth in a hospital or medical facility, they have to have at least one prenatal check-up, at which they’re given a voucher for admittance to the hospital.

For those delivering at home, customs are still in place. Women generally give birth alone. They’re provided with a stool on which they should kneel as much as possible. Lying on your back is thought to be bad luck, letting all the good spirits float away. The birth attendant comes after the woman has given birth, to cut the cord, clean the baby and bury the placenta. Then the mother is bathed with bunches of leaves cleaned with boiled water, and fed a pap of potassium and spices that is supposed to encourage breast milk production.

Nepal: A Loss of Control

In rural, traditional Nepal, men often purchase their wives, and because of the price they fetch, women have no say in what happens in their reproductive lives; that’s up to their husband and their mothers-in-law.

Women require permission from mothers-in-law to travel away from home, so seeking prenatal care, or an alternative to home birth, is pretty unusual. Most births occur at home, where women are placed by birth attendants and/or their mothers-in-law in a squat position, hanging by both hands from a ceiling in a dark room.

The attendant will massage the upper part of the uterus, otherwise known as fundal pressure, although this has been found to be potentially dangerous (it can tear the anal muscles). Sometimes the attendant will order the woman to push, even if it’s not time. And if the placenta doesn’t follow after delivery, helpers hang spades from the walls until it emerges—they believe this will bring a downward motion to the afterbirth. Sadly, there are many documented cases of women bleeding to death because this method didn’t work.

After birth, women are isolated for 11 days and sequestered in a dark room; the sun represents masculine energy and women are not to interact with men after birth. They’re given high-energy foods made of ghee (a kind of butter) and molasses, and caraway soup, to encourage milk production. Vegetables are forbidden during this time; villagers believe they cause diarrhea, though health professionals assume it’s the contaminated water that does that.

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