According to the US National Library of Medicine the early history of cesarean-section remains shrouded in myth and dubious in accuracy but there seems to be consensus that around the 15th century the first cesarean operations were performed. These operations were initially performed as a last resort to save a baby from an already dead or dying mother. Fast-forward 200 years and the word operation was replaced by the word section and the outcome was no longer only to remove the baby from the mother, but to try and ensure that both mother and baby would survive.
According to the South African Journal of Obstetrics and Genecology the first successful cesarean-sections with proven survival of mother and child took place in the Netherlands in 1792, in South Africa in 1826, in the UK in 1834, in the USA in 1835 and in Germany in 1841. The point to be made is that when one looks at the history of our existence, the cesarean-section is brand new. In fact, it has only been performed successfully for less than 0.2% of our time here on earth.
Being proud ambassadors of Mother Nature’s brilliant design it has baffled us that despite great antenatal education, care and birth support many women wanting to birth their babies naturally end up having ‘emergency’ cesarean-sections due to ‘failure to progress’. To better understand this nights were spent reading articles online, books were ordered and finally flights were booked to attend the Paramana Doula Course offered by Dr. Michel Odent and Liliana Lammers in Highgate London.
Between Odent and Lammers they offered the perfect mix - research based recommendations, countless years of practical experience, and something that is a rare commodity nowadays - good ol’ natural instinct. Dr Michel Odent is an 90-year-old French Obstetrician residing in the UK, who has dedicated his life to not only birthing mothers but to compile a database where correlations are made between the ‘primal period’ (a period including fetal life, the perinatal period and the year following birth), and health, including mental health, later in life. This database is called the Primal Health Research Databank and is an important role player in understanding how every part of the journey into this world affects health and wellbeing in the long-term. Liliana Lammers was born in Argentina and moved to the UK in her 20’s. Her road to becoming a Doula is paved with personal experience and instinct rather than book knowledge. After a difficult and unpleasant hospital birth with her firstborn she wanted a different experience for both her and her baby the second time around. At that time Odent was already tending to women at home. Odent was present at Lammers' third and fourth births too. It is now thirty years later and they have been working together for the last 20+ years. Michel as the Midwife and Liliana as the Doula. Together they offer courses for birth attendants to share what they have come to learn from more than 15 000 births.
What is evident from this pair is that they are still as humble and eager to learn from every birthing mother and baby as they were at the start of their partnership. Liliana affectionately relates how she and Michel sit together after a birth, discussing what they have observed and learnt.
Going through the course notes and reading through the highlighted paragraphs from Odent’s book Do we need midwives, one gets so excited about the topics raised and connections offered that it is difficult to know where to start and how much to say without rewriting the entire book! Here follows a few excerpts with Odent's permission. the excerpts appear in the same order as in the book.
Humans are grouped with other mammals whom are warm blooded, develop a neocortex, grow their young in a placenta, birth their live young, and breastfeed them. Another fascinating similarity between humans and other animals is the presence of the love and bonding hormone called Oxytocin. In The Oxytocin Factor, author Kerstin Uvnäs Moberg explains when researchers first became aware of the hormone. It was in 1906 when the English teacher Sir Henry Dale discovered the substance in the pituitary gland that could speed up the birthing process. He named it Oxytocin, from the Greek words for “quick” and “childbirth labor”. Later, he found that it also promoted the expulsion of breastmilk. Now it appears that Oxytocin plays a much larger physiological role than previously recognized, since under many circumstances it has the ability to produce the effects that we associate with the state of calm and connection. (Moberg, 2011: 3) Moberg goes on to say that oxytocin is found, entirely unchanged chemically, in all species of mammals. (Moberg, 2011: 4).
Although all mammals possess a neocortex, the human brain has a highly developed neocortex. It is this part of the brain that makes our ability to think, reason, talk and analyse possible. But, can our neocortical function, or simply put, our critical thoughts, hinder an instinctive natural birth?
Ina May Gaskin
“…The important point is that when the ‘fetus ejection reflex’ is initiated, women are obviously losing neocortical control – control by the thinking brain, the brain for intellect, the part of the brain that is highly developed only among humans. Women may suddenly talk nonsense. They can behave in a way that usually would be considered inacceptable for a civilised woman, for example screaming, swearing, and biting the midwife… They can find themselves in the most unexpected, bizarre, often mammalian, quadrupedal (on all fours) postures. They seem to be ‘on another planet’. A reduced neocortical control is obviously a prerequisite for an easy birth among humans. In other words, the main reason for human handicap during such a physiological process is the inhibitory effect of an active, powerful neocortex. It is easy to explain why the concept of the fetus ejection reflex is not understood after thousands of years of socialisation of childbirth. It is precisely when birth seems to be imminent that the birth attendant has a tendency to become even more intrusive. If, for example, the labouring woman says ‘Am I going to die?’ ‘Kill me!’ or ‘Let me die…’, instead of keeping a low profile. The well-intentioned birth attendant usually interferes, at least with reassuring, rational words. These rational words can interrupt progress towards the fetus ejection reflex. The reflex does not occur if there is a birth attendant who behaves like a coach, or an observer, or a helper, or a guide, or a support person. And it is exceptionally rare when the baby’s father participates in the birth. The fetus ejection reflex can also be inhibited by eye-to-eye contact or the imposition of a change of environment, as would happen, in our modern world, when a woman is transferred to a delivery room. It is inhibited when the intellect of the labouring woman is stimulated by any rational language, for example if the birth attendant says: ‘Now you are at complete dilation. It’s time to push’. During an authentic reflex, the mother is in a quasi-ecstatic state and does not even realise that the baby is coming. Any interference tends to bring her back ‘down to Earth’, and tends to transform the fetus ejection reflex into a second stage of labour, which involves voluntary movements.” (Odent, 2016:20)
Dr. Melodie de Jager
“… There are inescapable questions to be faced about the probable evolution of the human capacity to give birth, even without referring specifically to the laws of natural selection. Today, with the help of epigenetics, it is understood that when a physiological function is underused it has a tendency to become weaker and weaker from generation to generation. In an age of pharmacological assistance during labour and simplified techniques of cesarean-section, the Oxytocin system is an example of a physiological function that has suddenly become underused: until recently, it was possible to give birth to babies and placentas without an intense activation of this system. From another perspective, practitioners who routinely ask how a pregnant woman was herself born have come to the conclusion that there is a correlation between the way a woman was born and how she gives birth to her own children.” (Odent, 2016:27)
“When the cesarean-section is accepted as a ‘normal’ way to be born, the focus is different. The main questions are about the timing of the operation. When is the best time to perform the operation. From that perspective there are three kinds of cesareans: pre-labour cesarean-section, in-labour non-emergency cesarean-section, and in-labour emergency cesarean-section. We must consider the usual classifications, which confuse the terms ‘pre-labour’ and ‘elective’, and also ‘in-labour’ and ‘emergency’:it is possible to plan an in-labour cesarean-section, and an in-labour operation can be decided on and performed before the birth becomes an emergency.
It is easy to anticipate differences between babies born pre-labour and those born by the other routes. In particular we know that there are increased risks of respiratory difficulties after pre-labour birth, which makes sense since we now understand that the fetal lungs themselves provide a signal to initiate labour: surfactant, a protein within the lungs, serves as a labour hormone that indicates to the mother’s uterus that the fetal lungs are mature enough to withstand the critical transition from life in fluid to air breathing. Furthermore, the well-known role of maternal and fetal stress hormones in the maturation of the baby’s lungs is relevant. Everybody knows that when a premature birth is considered imminent the mother is given analogues of stress hormones (corticosteroids) to mature the baby’s lungs. The stress of labour is associated with the release of endorphins, which induce the release of prolactin. One of the many effects of prolactin is to participate in lung maturation. We must also take into consideration the effect of the fetal stress hormone noradrenaline, which is released during labour. Fetal noradrenaline has multiple roles to play, including protection against lack of oxygen during uterine contractions and lung maturation.
This is an important point: the multiple negative effects of stress deprivation among babies born by pre-labour cesarean-section have been underestimated until recently. For example, it has been demonstrated that, under the effect of noradrenaline, the sense of smell has reached a high degree of maturity at birth among babies born by in-labour cesarean-section. We must emphasise the paramount role of the sense of smell immediately after birth. I mentioned in the 1970’s that the sense of smell is the main guide towards the nipple during the hour following birth. It has been demonstrated that it is mostly through the sense of smell that a newborn baby can identify his mother (and, to a certain extent, that the mother can identify her baby). There has recently been an accumulation of data to support the practice of waiting, whenever possible, for the onset of labour before performing a cesarean.” (Odent, 2016:29)
NEWBORN GUT FLORA AND ADULT OBESITY
“It appears that, apart from the route of birth and exposure to antibiotics, a shortened duration of pregnancy tends to delay the maturation of the gut flora: one week more or less in the duration of pregnancy is associated with highly significant differences. A pre-labour cesarean implies the association of all the known factors that can delay the maturation of the gut flora. This study is all the more important as it also reveals that delayed maturation of the gut flora is a risk factor for increased adiposity at the age of 18 months.” (Odent, 2016:31)
THE STRESS OF LABOUR AND BRAIN DEVELOPMENT
“In spite of possible interspecies differences, we must seriously consider animal experiments suggesting that the stress of labour influences brain development. Studies have demonstrated that the birth process in mice triggers the expression of a protein (uncoupled protein 2) that is important for hippocampus development. In humans, the hippocampus is a major component of the limbic system. It has been compared to the ‘conductor of an orchestra’ directing brain activity. It has also been presented as a kind of GPS system, helping us navigate while also storing memories in space and time.” (Odent, 2016:32)
Sue Carter, Biologist & Behavioural Neurobiologist
Since 1985, the international healthcare community has considered the ideal rate for cesarean-sections to be between 10% and 15%. Since then, cesarean-sections have become increasingly common in both developed and developing countries. When medically justified, a cesarean-section can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of cesarean delivery for women or infants who do not require the procedure. As with any surgery, cesarean sections are associated with short and long-term risk which can extend many years beyond the current delivery and affect the health of the woman, her child, and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care. In recent years, governments and clinicians have expressed concern about the rise in the numbers of cesarean-section births and the potential negative consequences for maternal and infant health.
• In 1846 dentist T.G. Morton experimentally used dietyl ether as anaesthesia. Once anaesthesia, antisepsis, and asepsis were firmly established obstetricians were able to concentrate on improving the techniques employed in cesarean-section.
• In 1928 Alexander Fleming had discovered Penicillin. It was purified as a drug in 1940 and is today known as modern antibiotics.
• In addition to surgical advances, the development of cesarean-section was influenced by the continued growth in number of hospitals, by significant demographic changes, and by numerous other factors, including religion. Religion has affected medicine throughout recorded history and, as noted earlier, both Jewish and Roman law helped shape early medical practice.
• As the rate of urbanization rapidly increased in Britain, throughout Europe, and the United States there arose at the turn of the century an increased need for cesarean-sections. Cut off from agricultural produce and exposed to too little sunlight, city children experienced a sharply elevated rate of the nutritional disease rickets. In women where improper bone growth had resulted, malformed pelvises often prohibited normal delivery. As a result the rate of cesarean-section went up markedly.
• In urban centers large numbers of uprooted working class women gave birth in hospitals because they could not rely on the support of family and friends, as they could in the countryside. Special hospitals for women sprang up throughout the United States.
• Since 1940, the trend toward medically managed pregnancy and childbirth has steadily accelerated. Many new hospitals were built in which women gave birth and in which obstetrical operations were performed. By 1938, approximately half of U.S. births were taking place in hospitals. By 1955, this had risen to ninety-nine percent.
• In the late 1940’s and 1950’s ultrasound made it possible to measure fetal growth and fetal skull width in relation to mother’s pelvic dimension’s and now has become a routine diagnostic advice. While this type of visualization provided medical personnel with valuable information, it also influenced attitude toward the fetus. The fetus then became a patient.
Several factors have contributed to the rise in cesarean-sections. Some of the factors are technological, some cultural, some professional, others legal. The growth in malpractice suites no doubt promoted surgical intervention, but there were many other influences at work.
In Penny Simkin’s ‘The Birth Partner’ she starts off with this important truth: ‘How a woman is cared for and supported during birth is a major influence, not only in how she gives birth but also in how she feels about it. Yet, medical care before and during childbirth focuses almost exclusively on the physical safety of the baby and mother. This medical care places little emphasis on the mother’s emotional well-being, her relationship with her partner, and her readiness to parent.’ (Simkin 2013; 9)
Knowing that an unhindered birth is important is not enough. We need to ask for, and create, a birth environment that will assist a birthing mother to access her primitive state, allowing her natural instincts to work, to labour.
• Feeling safe and secure
• Warm and comfortable room temperature
• Darkness or dimmed lights
• Active birth, moving around and finding the position that feels the most comfortable.
• Feeling threatened
• Feeling observed
• Feeling cold
• Questions and talking (stimulation of the Neocortex) • Bright lights
• Coached birth, instructed to breathe in a certain way, instructed to push, confined to a bed etc.
Dr. Michel Odent