“The Birthing From Within Holistic Sphere”: A Conceptual Model for Childbirth Education

Abstract

An expanded conceptual model of childbirth education is offered, proposing the benefits of balancing informative teaching processes with creative, experiential, introspective learning processes for parents. The application of these two teaching dimensions to exploring four different perspectives of birth (the mother's, the father's, the baby's, and the culture's) is discussed, along with examples from “Birthing From Within” classes. Implications for current practice and the evolving role of childbirth educator are noted.

“The Birthing From Within Holistic Sphere” is a model for childbirth class curricula that encourages freedom and creativity in the teaching process while promoting the expansion of childbirth education into wider and deeper areas of learning (England & Horowitz, 1998). It was refined during the past few years as the primary author traveled around the United States and Canada teaching and interacting with childbirth teachers from many different backgrounds. This article seeks to introduce childbirth teachers to the possibilities of this model.

Modern childbirth teachers need to use two kinds of teaching to facilitate two kinds of knowing. The first and most basic is primordial knowing—that innate capability of birthing that modern women have, but must rediscover (and learn to trust). The second, modernknowing, involves being savvy about the medical and hospital culture and how to give birth within it. “Birthing from within” requires both these kinds of knowing. One way to help parents develop both kinds of knowing is to offer introspective, experiential self-discovery processes to balance presentations of practical information. While both categories do not always get equal time, every session in this model offers parents something from each.

The Axis

To organize your classes with the “Holistic Sphere” in mind, envision a vertical axis, half of which is above ground, the other half embedded below. The visible half symbolizes the practical/scientific information you will present, while the lower portion represents what parents will learn from introspective, self-discovery processes. For example: It's one thing to tell parents it's okay to make noise in labor; but, by experiencing the powerful release that comes from making noise, parents understand its importance. In an exercise called “Coyote Circle,” parents practice vocalizing in labor as a group, which eases their inhibitions and desensitizes both mothers and fathers to the sounds of natural birth.

The Sphere

The second part of this model emerged from the primary author's critique of her own classes; she concluded their focus was too narrow. As with most teachers, her emphasis was on birth from the hospital's perspective (and sometimes the mother's), to the exclusion of presenting birth from the father's, baby's, cultural, or spiritual perspectives. For a mother to be prepared as a mother, not merely as a patient, she needs to contemplate birth from every angle.

Surrounding the axis, imagine a sphere divided lengthwise into four segments. In the Holistic Sphere model, the four segments represent four distinct perspectives of birth: mother's, father's, baby's, and culture's. Responding to this model, one workshop participant observed that spirituality would be the core of the sphere. In fact, spiritual preparation is both the core of this model and its guiding principle.

Within this model, teachers and parents visit one of the four perspectives each week, balancing the class with both practical and introspective processes. Examples of exercises parents have found particularly useful (while visiting each perspective) are presented below.

Birth from the Mother's Point of View

When mothers only learn from childbirth classes what being at a birth looks like, or what birth attendants will do, they learn about birth only from the outside, about birth from the professionals' point of view. But mothers aren't at their births, they're in their births— they're in labor, in a trance, in their body, in joy! So, even though women are eager to learn about the physiological process of birth and its medical management, the first night of Birthing From Within (BFW) classes focuses primarily on birth from the mother's point of view.

… mothers aren't at their births, they're in their births …

When mothers learn what their experience in hormonal/physiological “Laborland” will be like (e.g., nonverbal, spacey, internally focused, and vulnerable), mothers begin to envision labor and birth from their point of view. This is distinguished from learning about the “stages of labor,” which is labor as observed and monitored by outsiders.

If labor is taught from the “outside,” (e.g., complex physiology, complications, and what the hospital will do), parents are at risk of becoming intimidated, passive, or defensive. In contrast, teaching parents how to birth from the “inside” energizes them to take responsibility for protecting their birth space, respectfully practice “birth etiquette,” and pursue common sense measures, such as drinking fluids and walking, that facilitate normal labor.

One creative way to invite parents to explore their expectations of labor is to have them make birth art (e.g., drawing or painting). Here are two examples:

• Journey/Landscape of Birth. Parents are asked to consider the following: “Imagine your birth as a landscape; it could be water, earth, sky, a forest, desert, or something else. What's the weather like? What and whom would you want with you on your journey through the landscape of labor?”

• Being-In-Labor (or Birth). Parents are asked to consider the following: “When you think about being in labor, what image comes to mind? How does it feel for you to be giving birth? This drawing could express an emotional, physical, imaginary, or realistic experience.”

Making birth art is a powerful tool to help women transcend the limited (and limiting) image of birth as merely a medical or physiological event. The use of art and metaphor invites women to think of labor and birth in new ways, which creates opportunities for personal awareness. These exercises, and the discussions that follow, usually take at least 30 minutes.

Some childbirth educators, while welcoming the creativity and spirituality of the BFW approach, understandably are concerned about whether they will have sufficient time to cover essential didactic content if time is “squandered” on making birth art. However, once a teacher has witnessed the powerful insights and discussion generated by birth art, she comes to value it as a central tool in the teaching process.

A few other ways to help parents learn about birth from within include practicing pain-coping techniques at every class, exploring what “losing it in labor” means, and giving a “labor theatrics” performance to demonstrate what real-life, active labor often looks and sounds like.

Birth from the Father's Point of View

Even though fathers have re-entered the birth room, many still feel “invisible” at childbirth classes, as well as at prenatal visits and labor. Yet, for fathers to be emotionally present at the birth of their child, they need support both to clarify their role and have their concerns validated.

In BFW classes, fathers and birth companions get special time to do this. Part of one childbirth class (about one hour) is set aside for fathers to talk with each other and the childbirth teacher about their hopes, expectations, and fears. During this time the mothers enjoy talking with each other while working on an art or writing project in another room.

Men relish the chance to talk with other fathers about their private worries. Some of these concerns may include how they will respond to their wife's pain, the responsibility of participating in important medical decisions (especially the use of pain medications or an epidural), the possibility that their baby may not be healthy at birth, and facing impending changes in their marriage and finances. They often reflect on their own relationship with their father and try to imagine what fathering will be like.

In addition, tips are offered about labor etiquette and taking care of themselves during labor, as well as “sensitivity training” regarding the mother's needs immediately after birth and her feelings should their baby be taken from her to a nursery.

The special class for fathers and birth companions is usually offered during the third or fourth class. By then, fathers have learned enough to have concerns or questions, and have established rapport with the teacher and each other. (The development of rapport has been accelerated by the personal nature of the interactive processes that have taken place in previous classes.)

Often fathers are not yet emotionally connected with their unborn, unseen baby. One example of the powerful use of birth art with fathers to encourage prenatal bonding is the drawing assignment, “A Womb With a View.” In this assignment, fathers are asked to consider the following:

Imagine you could take a peek through a window in your wife/partner's womb. What is your baby doing in his/her womb all day? What does he/she look like? See? Hear? Feel? If there's one message you want to send to your baby now, include that in your picture. (Note: This art assignment does not take place during the special time when fathers talk alone, but along with the mothers at a different time.)

Other ways of involving fathers include an exercise called “The Footbath Ritual,” role-playing constructive communication with birth attendants, a discussion on how to create a nurturing birth environment, and active participation in learning pain-coping techniques.

Birth from the Baby's Point of View: Building a Partnership with Your Baby

Establishing a partnership with their baby often helps parents embrace the hard work of labor. Mental exhaustion and discouragement are more likely to occur when a person feels isolated during a difficult task. In the midst of her deepest withdrawal in labor, the close emotional and physical relationship between the mother and her baby is different from that with her loving husband or caring birth attendant, who are “out there.” Many mothers find that the image of a “little partner” going through labor with them creates comforting feelings of shared effort, purpose, and connection.

Establishing a partnership with their baby often helps parents embrace the hard work of labor.

There are many ways childbirth classes can help mothers and fathers do this, such as singing lullabies, conducting playful pre-labor planning with their babies, drawing “A Womb With a View,” and participating in an exercise called “The Unfoldment Process” (described below). All of these exercises help lay down positive tracks toward a cooperative loving relationship with their baby in labor.

The Unfoldment Process, a favorite among parents, is usually offered during the fourth or fifth class. This elaborate, guided visualization awakens the protective parents within and creates awareness of birth from the baby's point of view. This experience helps parents get a feel for how their baby might experience labor contractions, the water breaking, the mother's changing rhythm and sounds, and being pushed out into the world.

To begin, each couple decides who will play the part of the “uterus/mother” and who will be the “fetus/newborn baby.” The “fetus” curls up on the floor in fetal position. Then, the “uterus/mother” wraps the “fetus” in a sheet or blanket. Kneeling against the “fetus,” the “uterus” entwines his/her arms snugly around the “fetus.” The teacher guides couples through “labor” in a dimly lit teaching room, with soothing music in the background. The “contracting uterus” intermittently squeezes the “fetus.” On cue, the baby is “born,” then has its compressed limbs tenderly unfolded by the “mother.” The baby is gently greeted, cradled, and rocked in its “mother's” arms while the “mothers” tell their “newborn” what they would have liked to have heard when they were born, or would want to tell their own baby when he or she is born.

After the exercise, parents are asked to talk about what labor felt like as a “uterus,” then “mother,” or “fetus-baby.” They are also invited to relate what they learned and want to remember when they welcome their own newborn into the world. This profound exercise teaches experientially what parents could not learn from a book or lecture. The educator must allow 30-45 minutes for this exercise.

Birth from the Culture's Point of View

Women do not give birth within a personal bubble; every aspect of their birth is influenced by the culture within which their birth is happening. While birth is a universal experience, the rituals surrounding it are remarkably different across cultures and over time. Traditional birth rituals offer inspiration, illumination, and group support. In the West, however, few birth rituals work that way. What we do have are medical birth customs rich with symbols (although their significance usually goes unnoticed).

Uncovering the implicit communication of obstetric symbols.

Consider the symbols commonly found in a clinical birthplace, such as the clock on the wall, the fetal monitor, stirrups, hospital beds, gowns and masks, IVs, or the patient ID wristband. Similarly, a home birth has its own set of symbols, such as a familiar bed and cozy surroundings, pets, backyard, photos, and the aroma of food cooking in the kitchen.

Consider the symbols commonly found in a clinical birthplace, such as the clock on the wall, the fetal monitor, stirrups, hospital beds, gowns and masks, IVs, or the patient ID wristband.

In order to make ordinary symbols available for conscious scrutiny, parents are asked to list every obstetric symbol they can think of. They then examine the messages those symbols send, as well as the personal meaning the parents bring to them.

For example, when the fetal monitor is viewed as an obstetric symbol, something dramatic happens. Parents realize for the first time how that “symbol” indirectly but powerfully communicates the potential for crisis. That message affects their feelings, expectations, and behaviors (along with everyone else's). This new awareness usually leads to a lively discussion of how obstetric symbols influence labor, for better or worse.

During the final step of this process, parents are asked to assign a new meaning to each symbol (it can be positive, negative, or neutral). This task helps parents transcend their original, unexamined assumptions of what a particular symbol communicates. Parents begin to understand the freedom they have in responding to symbols in their medical birth environment.

Using birth art to explore birth from the cultural perspective.

To help parents explore how they have internalized our birth customs and routine practices, ask parents to draw an assigned theme called “Birth in Our Culture.” This process offers another opportunity for parents to learn how unconscious aspects of their beliefs and expectations about birth influence their emotional-psychological birth environment (and the physiology of the labor process itself). In this exercise, parents are provided the following directives:

Imagine you are an artist-historian showing someone from another planet or culture what birth in our culture is like. Your assignment is to record in a drawing how women give birth in this time and place. Draw the birthplace and illustrate the customs. If there are people, show what they are doing there. Try to be objective. This may or may not represent your own birth expectations or values, but it should represent current birth customs.

For examples of what two mothers drew, see Figures 1 and 2. After drawing Figure 1, the mother described what it meant for her:

This [picture] is a portrayal of hospital birth, the way some babies are born. Mothers (gray bodies) are not individuals, but seen as a herd of mothers. The idea is to get the baby out of them in the quickest, most efficient way possible … using equipment to accomplish that (instruments on right).

Birth is removed from the process. You are there as a specimen to be treated, worked on, handled. The object is to get the baby out of her. Here (upper margin) is the result. Babies lying in bubbles all in rows.

The colorful rainbow (lower left) is the vision of a terrestrial being looking down at our birth customs. The colorful family on the lower right is a family who chose to birth at home or in a birth center.

A View of Technobirth Customs

A Mother Confronts Her Underlying Anxiety About Hospitals' Proclivity Toward Efficiency and Intervention

A drawing and commentary like Figure1 leads naturally to a discussion of where and how the artist-mother wants to have her birth. This mother had had two successful home births and was planning another. However, a hospital transfer is always a possibility. Work with a woman like this mother would include preparation for birthing, even in a hospital, with integrity and emotional resiliency.

The second example, Figure 2, shows, among other things, that artistic talent is an unnecessary ingredient in the creation of psychologically significant birth art. The drawing is by a pregnant mother (a postpartum nurse) who described her first birth, in the hospital, as fairly positive. Nevertheless, she still believed that the hospital's primary concern was efficiency. Her anxiety about hospitals too readily intervening is represented by her written words “Let's just cut it out!” Even though she portrayed our birth customs this way, she didn't think this would happen to her.Here's what she said about her drawing:

This [picture] is not how I'm gonna do it. This mother is actually fine with this, she's uneducated, not aware that this is not helping her. I got the “Be Quiet” at my last birth. “Put your knees together … the doctor's not here yet.” Then they got the forceps out when the doctor came. I had to push fast—and didn't get the forceps. That's the doctor's arm [on the right] with a knife. The mother was making too much noise. “Tie her down—knock her out.” This birth's not natural, not normal. The doctor is saying “Be Quiet—Hurry Up” and “Let's just cut it out.”

This commentary shows that, even in a drawing assignment portraying a culture's birth customs, the personal concerns of the mother-artist can be inferred from the content and mood of the drawing. Once this information is brought to the surface, the stage is set to work more deeply with a mother's emotional /psychological preparation.

Implications

By presenting The Birthing From Within Holistic Sphere the authors hope to stimulate reflection about the mission and structure of childbirth education at this point in our cultural history. While traditional class curricula contain important information, it is proposed that parents and teachers alike would benefit from an expanded view of the possibilities of childbirth preparation.

It is hoped that this model will be seen as offering ideas that can complement and supplementcurricula and styles already being used by a wide variety of childbirth educators. At the same time it is acknowledged that some of the processes described above involve training, skills, and experience that are not part of every educator's background. To experiment with some of them will require a spirit of adventure, a willingness to undertake new learning, and a readiness to take a small leap of faith.

Also implicit in this model is the need for at least a partial shift in how the role of childbirth educator is conceptualized. As parents become more involved with active, creative self-expression in their learning, the teacher's role undergoes a transformation; she becomes less the expert from whom wisdom flows, and more the “midwife” to the parents' process of discovery and accessing their inner resources.

As parents become more involved with active, creative self-expression in their learning, the teacher's role undergoes a transformation; she becomes less the expert from whom wisdom flows, and more the “midwife” to the parents' process of discovery and accessing their inner resources.

Appendix

Note

Information about BFW training workshops and Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation (Partera Press: 1998), can be found at: www.birthpower.com. Birthing From Within can be ordered from the Lamaze Bookstore and Media Center (1-800-368-4404) or at major bookstores.