Finding the Path

Abstract

In this guest editorial, the challenges and pain of childbirth are presented as essential components of important life transitions. The role of pain in childbirth is explored. Childbirth is discussed as a “flow experience,” and recommendations for assisting women to meet the challenges of labor and birth are presented.

EDITOR'S NOTE

This editorial was adapted from a keynote address Kathy McGrath first presented at a Lamaze International Annual Conference. The issues she raises and the insights and recommendations she suggests continue to be relevant as well as inspiring.

HEROIC BIRTH

I've been a childbirth educator and a doula for many years. Throughout my birthing career, a question I've continually struggled with is… Is pain a necessary part of childbirth? I set out on a journey to find some answers, to try to clarify what exactly I do and what I believe—and this is what I came up with. I call it “finding the path.”

I wrote this after a couple of unrelated events. The first was when a hospital where I do a lot of labor support started advertising their “new and improved ‘Paradise Epidurals.’ ” Their newspaper ads proclaimed, “Take a trip to Paradise. Now, we can offer you ‘natural childbirth’ without pain!” With a “Paradise Epidural” (also called a “walking epidural”), a woman can be awake and aware, somewhat mobile, assume a variety of positions, and push fairly effectively. So, when it came time for me to teach “pros and cons” of medications in my childbirth classes, most of the cons had been stripped away, and pretty much all I had left was a list of positives. But that didn't feel right….

“Natural childbirth without pain.” How could I encourage women not to choose “a trip to Paradise”? And perhaps the even harder question—why would I encourage women not to choose it?

The second event that set me on this journey was a birth at a local hospital. I was doing labor support for a woman who had very much wanted an unmedicated birth. It was a tough labor—she had pitocin, back labor—the whole works. She was managing pretty well under very tough circumstances. Not easy, but nevertheless well. Her kind and well-intentioned nurse came in after a particularly tough contraction, got up close to the woman's face, and said gently, “Don't you think you've done enough? Why won't you let us help you? Times have changed. There is no reason for labor to hurt anymore. Come on now…we don't need any heroes here.”

For me, that statement sums up the difference between those of us who believe that there is power in birth, and those who don't. We do need heroes here. Giving birth is heroic. Having life pass through you is heroic. Becoming a mother is heroic.

We do need heroes here. Giving birth is heroic. Having life pass through you is heroic. Becoming a mother is heroic.

I wanted that mother to feel like a hero. She was birthing that baby under extremely difficult circumstances—intuitively moaning and moving and rocking and working that baby from her womb into her arms. What she was doing was nothing less than heroic.

What is it about our culture that wants to take that away? That not only doesn't value the process of working through a tough labor, but in many ways demeans it? When did we, as a culture, decide that birth should be easy? When did we decide that it doesn't matter how we birth, that if we get an outcome of “healthy mother and healthy baby,” that's quite enough?

BIRTH AS A RITE OF PASSAGE

Birth is the beginning—the beginning of life, the beginning of parenthood, the beginning of family. Every woman who births must make the journey—cross the boundary—into motherhood. No two women will do it exactly the same way. Each of us must find our own way, our own path.

Birth is the beginning—the beginning of life, the beginning of parenthood, the beginning of family. Every woman who births must make the journey—cross the boundary—into motherhood.

In any discussion of life's boundary crossings, the phrase “rite of passage” comes up. A rite of passage is a series of events that help a person move from one life stage to another and, in the process, transforms them.

In any rite of passage, you leave one life place—a place that you know—and enter another, a place that you don't know. Crossing a life boundary is never an easy time. We're not sure how life will be on the other side. The rules and expectations will be different there. It is a risk to make the crossing. It has been said, “A rite of passage is the opposite of insurance.”

In all life transitions, there is fundamental change, but nowhere is it more evident than in childbirth. For many women, giving birth is the bridge from childhood to adulthood. In the crossing of that bridge, a woman's identity changes, her self-image changes, her priorities change. She goes in having a mother, and she comes out being a mother. In doing this, she must transform herself—to think and act and be different than she was before. Life's demands on her will have changed completely. You can't give birth and stay in the same place. It requires an internal journey the likes of which she may never before have experienced.

You can't give birth and stay in the same place. It requires an internal journey the likes of which she may never before have experienced.

The normal process of childbearing is an event unlike any other. Laboring and giving birth are likely to be the most intense physical and emotional—and, some would add, spiritual—experience of a woman's life. Besides the obvious physical processes, it also includes high levels of stress, anxiety, and pain. A woman in labor is truly in an altered state.

Then, there's the natural rhythmicity of labor—the way it builds and intensifies, getting stronger, more powerful, and requiring ever more of her as the hours pass by. The experience is so new, so different, and so powerful that it doesn't fit into the brain's established systems to be handled in an automatic way. The entire system, therefore, goes on alert and becomes very open to new information and new learning.

A laboring woman is in an intensely open, affective state. She is at once both powerful and vulnerable. And she is as receptive to new learning as she will be at any other point in her life. The learning can be either positive or negative—and they're equally important lessons. She can come out of birth feeling powerful or powerless. Feeling fulfilled or disappointed. Feeling strengthened and nurtured—or let down, and even betrayed by those she entrusted to care for and support her. The psychological impact of birth, be it positive or negative, can last a lifetime.

The psychological impact of birth, be it positive or negative, can last a lifetime.

We can look to the research to tell us what factors contribute to whether or not a birth is experienced as primarily positive and satisfying or primarily negative and disappointing. As it turns out, it has less to do with the clinical aspects of the experience—the length of the labor, the number of interventions required, even the amount of pain she experienced—and more to do with the emotional aspects: how she was treated, whether or not she felt listened to and respected, whether or not she felt a sense of being in control (Hodnett, 2002).

We haven't had a lot of success getting this message across to caregivers, many of whom think this is “much ado about nothing.” If the mother gets a healthy baby, then what's the fuss? Again, the answer can be found in the research. When mothers come out of birth feeling a sense of pride and accomplishment, it spills over into their mothering. Women with positive birth experiences are more confident mothers, are more affectionate with and responsive to their babies, are more likely to breastfeed and breastfeed for a longer period of time, and have less postpartum depression (Hodnett, Gates, Hofmeyr, & Sakala, 2003).

There's not much to reinforce the idea that birth works. The cesarean rate in the United States is nearly 1 in 3. Inductions are epidemic. The epidural rate is above 90% in many hospitals. Intravenous lines, continuous electronic monitoring, and restrictions on eating and drinking are routine in most places. In spite of all our efforts, unmedicated, normal, natural childbirth is statistically just as rare as it was 30 years ago.

Not long ago, I received a registration form from a couple starting their childbirth classes. On the form—under the heading “Anything Else You Want Me to Know?”—they wrote this:

This is a baby that is longed for. We want so much to do what's best for her and for us, but we're scared. Scared of the pain, scared of something going wrong, scared that nobody will listen to us, scared of not being able to handle it.

Originally, we thought we wanted “natural childbirth,” but now we're not so sure. It seems like nobody really does that anymore. Maybe it's unrealistic to think we can do it. But we are hanging on, hoping you will lead us in the right direction….

I cried when I read that—cried out of sorrow and frustration. Cried because, in my heart, I know she represents a lot of women in our culture and in our times. Women—and men—who view birth as something to be frightened of, something to be endured more than experienced, something not likely to be accomplished without the help of medicine and machines. It has become uncommon for women to believe that birth could and should be joyous, triumphant, challenging, changing, life-giving—not just for the baby, but for the mother as well.

We have a lot of work to do.

Not long ago, I was speaking at a hospital in the Midwest and was given a tour of their sparkling, new “Family Maternity Center,” an elegantly furnished unit with parquet flooring, candle sconces on the walls, equipment hidden behind framed pictures, floral comforters on the beds—beautiful rooms where women labor, give birth, and recover.

But what happens to the women that birth there? More than 90% have an epidural, and nearly as many have pitocin. Every mother is continuously monitored, has an IV, and is strapped to a blood-pressure machine. There is a computer at every bedside for nurses (who are caring for three patients at once) to key in vital information, which is sent to a central station. The babies are whisked to warmers that are attached to the wall across the room where they are evaluated, washed, shot, ointmented, footprinted, and swaddled before being returned to their mothers some 15 or 20 minutes later. The warmer is only 10 feet away, but it might as well be a mile.

When I commented that it was a shame that the babies weren't able to be with their mothers for the first 20 minutes of their lives, the nurse said, “Most mothers aren't really ready for them until then. Anyway,” she continued, “after that, we usually allow [note her word choice: “allow”] the babies to stay with their mothers for a full 60 minutes of ‘bonding time’ before being sent up to the postpartum floor.”

Perhaps most disturbing of all, every postpartum room is outfitted with a VCR so that mothers can learn baby care and breastfeeding the modern way—from a video (no humans required). I'm disturbed that this is considered “state of the art.” I'm more disturbed that we aren't all more disturbed. Recently, a friend of mine, after describing her birth experience, said, “You know, it's shocking what we've come to accept as normal.” And she's right.

But what does any of this have to do with pain in childbirth?

If you buy the idea that, for the most part, physical pain is unrelated to birth satisfaction, then why not make everybody comfortable? What purpose could the pain serve? Part of the answer lies in simple biology. Pain is part of nature's way of getting the baby out safely.

We now have a better appreciation than we once did for the important role pain plays in the process of labor and birth. The pain of labor acts as a guide. It helps the laboring woman find her way. She responds to what she's feeling with movement, position changes, and a breathing pattern that matches the intensity of her contractions. By so doing, she not only comforts herself but also helps her baby settle in the pelvis and move safely and efficiently down the birth canal.

As the pain of labor intensifies, so does the mother's supply of endorphins—nature's potent pain-relieving remedy. The more pain she experiences, the more pain-relieving endorphins her body provides her. The rising level of endorphins contributes to the shift from a thinking, rational mindset to a more primal, instinctive one. She is exactly where she needs to be: Her rational, logical, left brain turns off, and her instinctive, intuitive, right brain—the part of us that innately knows how to birth—takes over.

The same oxytocin that causes contractions to strengthen and labor to progress will help the mother fall in love with, nurse, and care for her tiny infant.

When the pain of labor is removed entirely, nature's feedback system is disrupted, causing a chain reaction of compromises throughout the process of labor, birth, and beyond.

For birth to work the way nature intended, women need to be willing to actually feel their labors. They need the freedom to respond to contractions in the way that feels best to them. They need to be free to move, to change positions, to walk. They need to be free to eat and drink as they desire. They need to be encouraged, comforted, and supported emotionally and physically by knowledgeable, trustworthy birth attendants. Too many women are being deprived of these freedoms and the support they need to birth normally.

For the other part of the answer to why have pain in labor, we need to go back to rites of passage. In all cultures, in all rites of passage, there are elements of challenge and suffering along the way: trials and obstacles that must be encountered and that help in the transformation. Overcoming a challenge inevitably leaves us feeling more capable.

When we're up against a great challenge, we really find out who we are. Challenges of all kinds—physical, emotional, and spiritual—force us to the edge of our limits and help us discover that we have within ourselves the wisdom and the resources to deal with whatever is on the other side—useful qualities for a new mother.

The physical and emotional upheaval of birth is a normal and necessary part of nature's grand design. Giving birth is meant to be overwhelming. Giving birth is supposed to shake us right down to our roots and leave us in awe of the power of the experience—and of the power in ourselves for getting through it.

Giving birth is supposed to shake us right down to our roots and leave us in awe of the power of the experience—and of the power in ourselves for getting through it.

The hardship is not in vain. It is necessary and filled with meaning. As much as we might want to rescue women from the pain and upheaval of labor, we can't. And, in fact, we shouldn't, because to deny the pain is to deny the growth.

In any rite of passage, a person is confronted by her own fears. A major task is to learn how to deal with them. It doesn't help to run from our fears. When we do, they are likely to spill out and affect us more in later life. Instead, we must turn around and face them. When we (as humans) are invited to move—in a protected way—toward what we fear, it often comes as a relief. It gives permission for our fears to be worked through rather than avoided.

As Ina May Gaskin has said, courage is the antidote for fear. To cross a life boundary requires courage. It requires self-esteem. It requires that we be in touch with our own power.

We must help women discover their own power. Removing the challenge may not be the best way to do that. Dealing with the pain will not be easy—labor was not designed to be easy. We don't find ourselves when things are easy. There will be many crossroads in labor when a mother must decide whether to stop or push forward. By presenting her with the opportunity to make discoveries about her self, we express our confidence in her and in her ability to stand on her own.

But it must be an invitation—it can't be forced.

PAIN AND SUFFERING AS PART OF BIRTH

When we move from one life place to another, there's usually hell to go through. Pain—useful pain—is almost always part of it.

I want to distinguish the important difference between pain and suffering. Actually, the dictionary defines pain as “suffering.” And defines suffering as “pain.” But for our purposes, they are different. Pain is the very real and unavoidable part of labor and has a physiological basis. Suffering is more. Suffering in labor results from not being respected, not being listened to, not having basic needs met. Women in labor can be in a lot of pain and not be suffering. They can also be suffering while experiencing very little pain. No woman in labor should suffer.

In our society, which despises pain and unpleasantness of all sorts, we try to protect people from pain. It doesn't work.

We speak in this culture only of pain relief:

• “Feel a headache coming on? Take some Advil.”

• “Maybe you're anxious or worried or stressed. A couple of drinks will fix you right up.”

This is the response to pain that many of us have been taught. Pain is wrong. The only way to make things right again is to stop it. Get rid of it.

We don't have much of a context in this society for learning from pain. Many other societies are not so pain avoidant. Native Americans view pain as a source of important information. Figure out what causes the pain and, then, choose if you want to eliminate the source. In our society, if you have a tension headache, you try to block it out with your drug of choice instead of trying to identify where the stress might be coming from.

It would be far more helpful if we could help women accept the pain, make sense of it. Help the woman see that pain is the byproduct of her own strong muscles doing powerful work. That in labor, every part of her will work together in a coordinated way to allow her baby to be born safely. That the pain will give her important information—it will tell her what to do next.

As long as we view labor pain as bad—something to be gotten rid of—we will shield ourselves from it. But we must ask ourselves, “At what cost?” The pain itself may be a call to a deeper adventure.

Birth was designed to include both agony and ecstasy. When we dull and diminish one, the unintended result is that we often dull and diminish the other. An epidural numbs more than the pelvis. I watch the reaction of mothers when they first greet their newborns, and I see real differences in those who have been challenged by labor and those who have not.

Birth was designed to include both agony and ecstasy. When we dull and diminish one, the unintended result is that we often dull and diminish the other.

How challenging should labor be? If labor is too easy, the potential for self-growth is minimized. But if labor is too difficult, or the challenge too great, the woman is likely to become overwhelmed and give up.

The answer is that women are all different. The right amount of challenge for one may be too much or too little for another. An unmedicated birth may be in the realm of possibilities for you, but in “torture territory” for me. The trick is to find out the right amount of pain in the right setting for it to be useful. Not an easy task, particularly in our “one size fits all” culture.

Many years ago, when I was a novice at labor support, I was with a couple having their first baby. They were a lovely couple in their 30s and had struggled for years with infertility and many disappointments before achieving this pregnancy. Not surprisingly, the woman didn't have much faith in her body's ability to get through labor, and she decided ahead of time that she wanted an epidural as early in labor as her doctor would allow it. And that is exactly what she got. In fact, she got it before she had any contractions that she really had to work through.

This couple had a longstanding Sunday morning tradition of making a big pot of coffee and reading The New York Times together. It was a special time that they looked forward to having together each week. So, it being Sunday, and she feeling no pain (in fact, she was so numb that she couldn't even tell she was having contractions; several times, her leg actually fell off the bed, and I had to lift it back on for her), her husband went down to the coffee shop and brought back The New York Times and two cups of coffee (one for him and one for me; she had ice chips) and we read together.

Every once in a while, one of us would read something amusing aloud, and we'd talk about things that were interesting. Periodically, the husband would say, “Switch!” and we would rotate our sections of the paper. It was a lovely morning.

But at one point, I looked up and saw that, behind the newspaper, there were tears streaming down the wife's face. “Susan, What is it? What's the matter?” I asked. She just looked at me sadly and said, “This isn't what it's supposed to be like, is it?”

I knew just what she meant. No, this isn't what it's supposed to be like. We were acting as if this were just any other Sunday morning. But it wasn't. This was the day her child—her long-awaited child—was to be born. This was the day she would finally become a mother. And for us to treat it like it was any other day was to dishonor that baby, that mother, and that experience. We were wrong.

I looked over at the monitor and saw that a contraction was just starting. I took the woman's hand in mine and said quietly, “Susan, a contraction is starting. Breathe with me.” We slow-breathed through it. When it was over, I placed my hand on her forehead and said, “That one's over. Now you can rest.” And that's what we did for the next several hours, breathing through contractions she did not feel. Afterwards, she told me how very much it meant to her.

That experience changed my way of thinking about how we care for women with epidurals. When a woman is medicated, she often needs more, not less, help if she wants to stay connected to the labor and connected to her baby.

FLOW EXPERIENCES

There is a wonderful book written by Dr. Mihály Csikszentmihalyi (1990) titled Flow: The Psychology of Optimal Experience. The book summarizes decades of research on optimal, or “peak,” experiences—those times that stand out as the most wonderful and fulfilling moments of our lives. Moments that are treasured and remembered.

Dr. Csikszentmihalyi spent more than 20 years interviewing thousands of people all over the world—athletes and performers and artists, as well as everyday men and women—in an effort to understand more about the phenomenon of peak experiences. He refers to being in a peak experience as “being in flow.” When you're in flow, everything comes together in just the right way. Your mind is clear and focused. Your creative juices are flowing; there is exhilaration. There is a clear sense of purpose, a clear understanding of what you must to do. You have the confidence you need, the required skills. There is total involvement.

Think of a dancer on stage…a writer, her mind racing with an idea…an artist, when the colors on the canvas begin to take form…a mountain climber near the peak of a great summit…a laboring mother, during those last powerful pushes.

Flow experiences are growth experiences—they teach us that we are strong and powerful. They leave us feeling good about ourselves.

Flow experiences are growth experiences—they teach us that we are strong and powerful. They leave us feeling good about ourselves.

For many, but certainly not all women, giving birth is a peak experience. But why for some and not for all? We've already discussed the fact that the clinical features of the labor don't explain it—the research is quite clear on that.

Then what does explain it? Why is it that some women experience birth in almost ecstasy-like terms and others don't? What accounts for the difference, and how can we increase a woman's chances of being in flow for her labor and birth? The answers—at least in part—lie in the research about peak experiences.

Interestingly, one feature present in almost all peak life experiences is that they happen around a physical or emotional challenge of some sort—one in which a person's body or mind is stretched to its limits in an effort to accomplish something deemed difficult or worthwhile.

Flow experiences are not necessarily pleasant at the time they occur. In fact, often it is just the opposite. An Olympic swimmer, trying to win her event, may feel her muscles ache, may think her lungs are about to explode, may feel dizzy with fatigue; yet, she quite likely will look back at that event as one of the best moments of her life.

So, how can we help women get in “flow” during childbirth?

First Component: Respect Expectant Mothers' Desires

The first step to helping a woman get in flow during childbirth: She has to want to do it. For the right reasons. And the right reasons are her own. Flow only occurs when the goals are ones she herself has chosen to pursue.

The decision of which path to choose in labor—to use pain medication or not—is very personal, and it is not a right or wrong decision. It will be based on many factors, some of which are set far in advance, including the woman's feelings about birth and her body, her past experiences with pain, and her family history.

Choices about how best to get through labor are hers and hers alone. She must—and we must—respect her inner wisdom. Labor and childbirth are not endurance tests; rather, they are opportunities to discover deeper resources about ourselves.

In the final analysis, the ultimate goal for those of us who work with childbearing women is much bigger and grander than “healthy mother and healthy baby.” We want every woman to come out of this experience loving…herself.

For some women, whether or not to use medication is not an issue. For their own good and compelling reasons, childbirth does not need to be challenging to be satisfying. They say, “All that matters is that I have a healthy baby. How it gets from here to here doesn't matter that much.” Although these women may very well have happy and healthy and satisfying births, they are not likely candidates for birth to be a flow experience, because when a woman is in flow, she is interested and involved not just in the outcome—the baby—but in the process of labor as well. She values the labor for its own sake.

For some women—many women—getting to 5 centimeters without an epidural is enough of a challenge. For a woman with a history of abuse or other pressing psychosocial issues, maybe getting into labor at all is enough. We all know of births in which an epidural is entirely appropriate and, in fact, the only humane choice.

This is one of the trickiest aspects of our work: striking a balance between giving those women who choose natural birth the confidence they need to try it without meds while, at the same time, honoring the choices of those who want to be medicated. We walk a tightrope on this one all the time. I don't want any woman to view her birth as a pass/fail test of her strength.

Every woman in labor knows herself better than anyone else. What does she really want? This is such an important part of the doula's job—to empower each woman to make her own choices by helping her sort through her options, figure out what she needs from her labor, and then pull together whatever resources she needs to get there.

What's important, I think, about the whole issue of medication is not so much the decision as the decision-making. When a woman chooses an epidural, I want her to choose it from a position of power. I want her to choose it because it is the very best thing for her to do—for her circumstances, for her birth—not because she thinks something in her was lacking or that she didn't have other options.

And then we need to listen and respect her choices. We do whatever we can to make her expectations a reality, regardless of how different they may be from our own. Flow can only happen when a woman acts freely, when the goals are her own.

For many of the women I work with, they really want a more natural childbirth, but they are scared. Scared of the pain, scared of failure, scared of setting themselves up for something that they might not achieve. Better not to get your hopes up too high. These are the women who I most want to reach. These are the women who have the most potential for self-growth. There is no moment more satisfying than when a woman, shaking and in tears after the birth of her baby, says, “I did it!”

Second Component: Reasonable Chance of Success

The second step to helping a woman get in flow during childbirth: There must be a reasonable chance of succeeding. We, as humans, tend to run from challenges if they're not contained properly. We need to feel like we've got a reasonable chance of pulling it off, because, when in flow, there is just the right amount of challenge.

For women to navigate through childbirth, they must be well prepared. They must strengthen and develop whatever resources they'll need to deal with the realities of labor and birth. This means they'll need solid, realistic information; lots of coping and pain management skills; and a plan for support.

To “up” their chances of accomplishing their goal, women also have to have a clear idea of what the rules are. This is a key ingredient of a flow experience. Unclear or inconsistent rules put us on edge. They make us anxious and less productive. This is a big issue in hospital birth.

For the couples I work with, it's not the uncertainties of labor that are so distressing (they've been prepared for those); rather, it's the uncertainties of the medical care. Can the woman get out of bed and move freely? Spend time in the shower or tub? Deliver in a squatting position if she chooses? That depends to a large extent not on her medical condition, but on which doctor is on call, and whether or not she is assigned a supportive nurse.

Recently, I provided labor support for a woman whose baby—her first—was in a breech position. She was in a practice of four physicians. Two of the doctors in the practice thought she was an excellent candidate for a vaginal breech birth, and two of the doctors thought that vaginal breech births were inherently unsafe for primips. So, whether or not she would be allowed to labor or would be sent in for a cesarean as soon as contractions started depended upon which doctor was on call when labor began. This poor woman carried around a paper with the doctors' call schedules, which she looked at each morning, so she could attempt to mentally prepare herself in case labor began that day. “The worst part,” she told me in tears one day, “is that two of the doctors are wrong, and two are right, and I have no way of knowing which are which.”

We can't underestimate the tremendous amount of stress this kind of uncertainty and unpredictability causes women in labor, and how much it sabotages their efforts.

Third Component: No Distractions

The third step to helping a woman get in flow during childbirth: She must be able to fully concentrate on what she is doing. It sounds so simple… .

This is one of the most universal and distinctive features of a peak experience, and one that any of you who work with laboring women—particularly with hospital births—know well. There are so many distractions in labor that don't support a woman's need to focus all of her energy on her work.

When a laboring woman is in flow, her concentration is intense. She becomes totally immersed in what she is doing—nothing else matters. Her sense of time becomes altered. Hours pass by in minutes, and minutes seem like hours. Body and mind are one. She stops being aware of herself as separate from the labor. I'm convinced this is one of the secrets of home birth. There are simply fewer distractions.

We know that every piece of information a laboring woman receives gets evaluated on a conscious or unconscious level. Does it support her goals or threaten her goals, or is it neutral?

When a woman in labor is in flow, all the information she receives is congruent. All of her energy can be put toward getting her where she wants to go. There is no disorder to straighten out, no threat to defend against. She is not under the gun of time constraints.

When a woman in labor hears distracting or negative information, it forces her attention to be diverted. Eventually, when there are enough negative messages, she will become weakened to the point that she no longer has enough energy to invest in getting to where she wants to go. Many of the negative messages made to laboring women are subtle. Doctors sometimes say, “Well, you can go ahead and try it without pain meds…”—their very words projecting an expectation of failure.

Think about how a woman's confidence in her ability to birth is often undercut by what is said to her in labor. Some of the statements I've heard are:

• “Let's go ahead and put in the IV so it's ready if a problem develops later.”

• “When you're in pain like this, the baby's not having any fun either.”

• “I know you want to ‘go natural,’ but I think it's only fair to tell you that most first-timers do end up with medication.”

• “You want to keep going? Okay, no problem. Just tell the nurse when you've had enough.”

• “We don't need any heroes here.”

As Penny Simkin has often said to me, “Negativity is like poison to birthing outcomes.” It's important for birthing women not to be surrounded by people who don't believe in her or her ability to birth.

Fourth Component: Genuine Support

The fourth, and perhaps most important, step to helping a woman get in flow during childbirth: She must have support—genuine support.

Genuine support assumes the woman is competent. Genuine support is honest, encouraging, and, most of all, unconditional. Genuine support means not dictating to women the way they ought to think and feel and choose their way through childbirth. To do so would be to deny them the adventure. Instead, we simply offer women the benefit of our knowledge and experience and trust that they will learn what they need from what we have to offer.

There is something in psychotherapy called “the holding presence.” The holding presence is one who acts as a support and a guide for a person who is facing a challenge, watches over the other person, creates a safe passage, allows others to do the work that needs to be done, and holds the waters back.

The holding presence is usually not a loved one; rather, it is one with a greater perspective. A loved one may want to protect the person too much from the pain. But the holding presence is not afraid of the pain, understanding that it has a purpose. The holding presence understands that growth comes from working through pain.

Every birthing woman needs the guidance of a holding presence to help create a time and a place within which the whole experience of birth—including the pain—can be expressed and experienced in physical and emotional safety.

That's what each of us must be: a “holding presence.” We believe in the laboring woman. We trust that she can do it. We support her and encourage her and strengthen her so that she can do the work and cross the boundary. We don't cross it for her; instead, we provide her with the resources she needs to cross it herself. Our role is simply as a guide, to help her find her way.

FINDING A PATH—HELPING WOMEN CHOOSE

So where does that leave us? How do we know if a woman is on the right path? Again, the answer is simple: We don't know. Only she knows.

• If the woman believes it to be the right path and her heart is in it…

• If she feels safe and focused as she moves toward her destination…

• If she has the resources she needs for whatever she must face along the way…

…then she is probably on the right path.

And if she is on the right path, her birth will very likely lead to that place of confidence, empowerment, and triumph that we wish for all birthing women. To my way of thinking, that's not a bad description of “a trip to Paradise.”

Every woman in labor must find her own path and walk it for her own reasons. Finding her path in labor takes great courage. It requires listening to her own voice, facing her fears, and strength to stand for her own convictions.

Finding her path in labor often means moving ahead without a map, facing unpredictable obstacles. It means resisting the ever-present temptation to walk someone else's path. Perhaps an easier one, or one better marked. The way is difficult, but failure to walk her own path may be more difficult still.

I've done a lot of thinking about it since my long-ago encounter with the labor nurse who said, “Times have changed.” She was right, of course. Now, we do have the ability to control labor, to contain it. To start it and stop it, to slow it down or speed it up. To take the challenge and the pain out of it. But in so doing, we may also be making pain less powerful and profound. And none of us knows what the long-term consequences of that will be.

In history and in literature, heroism involves facing a challenge—facing a challenge and knowing that the place you're going to will be difficult and the way will be hard.

Giving birth is hero's work. I dare say, what the world needs now (perhaps more than ever) is a few more heroes.