A newborn child in the maternity ward of Kaliningrad Maternity Hospital No. 4. Photo (c): Igor Zarembo / RIA Novosti. All rights reserved.
“Returning to nature” is in fashion everywhere. Lovers of this “naturalness” associate it with something authentic and positive; the correct order of things, or the continuity of generations past and their wisdom. Naysayers, on the one hand, see it as a promotional gimmick, remarking ironically that the only difference between an organic beetroot and a non-organic one is its price.
On the other hand, they criticise this trend towards the “natural” as standing in the way of the modernisation of society – when, for example, the celebration of women’s “real nature” turns out to be another way of perpetuating the worst gender stereotypes.
What is a natural birth?
One sign of this “return to nature” is the growing popularity of “natural childbirth”. But such occurrences have long since become a rare exception. The Russian government, anxious about demographics, is putting all its efforts into lowering the infant mortality rate and developing high tech obstetrics. How does “naturalness” fit into this picture – and what does the term mean anyway?
Anthropologists tell us that “naturalness” in fact has a social basis – concepts like “natural” and “untouched by civilisation” develop in parallel to ideas of the “artificial” and “pollution”. Tthe current model of “natural birth” may be based less on physiology than on social factors.
Those who prefer an alternative approach are united by distrust of “official” obstetrics, which they see as a soulless and dysfunctional conveyer belt
It’s difficult to give a clear-cut definition of the term itself. The range of possibilities go from a “hospital” birth without recourse to anaesthetics or C- section, to a planned home birth with a midwife in attendance. But it is, in fact, more of an ideological concept centred on the idea of protecting oneself from the “system”, whatever that may be.
There are several levels of “naturalness” (three, to be exact) currently available to Russian families, depending on their income levels.
If you want something done well, do it yourself!
The first model is the home birth. This practice is not licenced by the state, nor is it recognised by the medical establishment; any midwife involved could be charged with a criminal offence and the family subjected to visits from the child protection agencies. Since the 2000s, however, “domestic” obstetrics has gradually turned from a dissident movement into a business. Centres are opening in all large cities, offering expectant parents ante-natal classes to prepare for a home birth and services to help them through it. Popular science books and articles on the subject are also easily available. “Home” births are becoming the first choice of parents who would like an individual scenario for their baby’s arrival in the world and have the money to pay for it.
The cost of home births varies from region to region and the midwife’s reputation. In a big city, it costs about the same as a “private” birth in a maternity hospital – around 50-60,000 roubles [the average Russian earns around 35,000 a month – ed.] This is a grey market, with no fixed rates for services and no quality standard either. The midwives have no accreditation, and their qualification level varies, from people qualified as doctors to others with no medical education at all. To find a version of home birth that suits them, parents need to call on their social capital – midwives they know personally, or families who have hired them.
Why should young, and usually well-educated and affluent women, who have free access to state medical facilities, choose to take such a risk? Negative experience of the official healthcare system play a big part, as does the knowledge that childbirth doesn’t have to be that way.
These were the reasons why Marina [all names have been changed – ed.], whom I met at a scientific conference, rejected the state system. She is 30, has a PhD, lives outside Moscow and teaches at one of the city’s universities. She has two children: she gave birth to the first in a state maternity hospital and the second at home with her husband, without even a midwife present.
Marina’s first childbirth was, by medical standards, not bad: there were no complications and the child was born healthy. Although she was only insured through the Federal Compulsory Medical Insurance Fund rather than a private insurer, she was able to choose her hospital from two options – the local maternity unit, which had a bad reputation, and a Moscow maternity hospital where her husband could be present at the birth. She took the second option.
In other words, she had the most natural birth available in a “free” health service facility. Yet Marina was disturbed by the lack of individual attention and care for the expectant mother at this difficult moment, feeling that priority was given to hospital rules over her comfort. Marina was left with less than glowing memories of her hospital birth. “It was the end of a shift, and they were trying to speed up my labour”, she tells me. “The doctor broke my waters and called a midwife, but her shift was ending in twenty minutes. She kept telling me to hurry up, but I found it very difficult to go any faster. The second time round, at home, the baby took an hour to emerge, but here I had to do it in 15 minutes. And they whisked it away immediately, to swaddle it, without even showing it to me. I asked, ‘What is it? A boy?’ and they said ‘It’s all over. Goodbye!’”
It’s like home decorating. If you want it done well, you have to do it yourself
Maria had read a lot about childbirth, including all the “natural birth” classics: Michel Odent, Ina May Gaskin and Grantly Dick-Read. Although the Russian media present home- birthers as mere ignoramuses, in fact they are usually members of the educated middle classes – those, in other words, who have enough information to decide they want an alternative obstetric experience.
With her second pregnancy, Marina first thought about going for a home birth with a midwife, and even found one through her university colleagues. But it turned out that this Moscow midwife wouldn’t travel several dozen miles to a birth outside the city. So she and her husband decided to do it themselves.
A couple carries out labour in a pool at home, according to the Charkovsky method. Photo (c): Sergey Titov / RIA Novosti. All rights reserved.
“It’s like home decorating. I could hire someone to do it; I can pay someone to do it”, she says. But my husband, for example, would never hire anyone to do painting and decorating, because we all know how they do it. It’s the same with giving birth. If you want everything to be done exactly right, you have to do it yourself”.
“Solo” births are seen as an extreme measure even among supporters of home births. But Marina and her family were lucky – there were no complications. Nonetheless, a few hours later Marina decided to go to see a hospital obstetrician-gynecologist, to check if everything was OK. He didn’t find any problems, but still suggested she stay in hospital. Not surprisingly a woman who had been determined to give birth at home without any medical intervention felt that spending time in a medical facility would be risky for her newborn.
“They wanted to hospitalise me, so they could check both me and the baby out”, she tells me. “I said, ‘no way – the baby’s not coming here’. Because I don’t know about other maternity hospitals, but in ours there are lots of cases of infections, staphylococci and others. Why do it, we thought? It’s not what we wanted.”
Parents can have other reasons for wanting a home birth. They might see it as a spiritual experience, or believe that a baby born at home will be healthier than one born in a maternity hospital. But they all have one thing in common: a distrust of official obstetrics practice – a system that, as they see it, functions as a soulless and dysfunctional baby conveyer belt.
An exclusive service for expectant mothers
The second model is “natural birth” offered by maternity hospitals or organisations associated with them on a commercial basis. Here “naturalness” is replaced by exclusive service. This consists of medical intervention being reduced to a minimum and individual interaction with every expectant mother. The doctor or midwife gets to know their charge long before the birth, provides her with ante-natal advice and is ready to answer her every question. The cost for this service ranges from 60,000 to 300,000 roubles (£824 - £4118), depending on the region and package offered (a private delivery room, a contract with a specific doctor and/or midwife, etc.).
Both home births and “soft” hospital births are a rarity in Russia. There are no official statistics on home births, but figures from Registries of Births, Marriages and Deaths show that just over 1% of births happen at home (including cases where the mother just didn’t manage to get to a hospital on time).
If you pay, you get more attention
Figures for natural births in specialised centres or maternity hospitals are also unavailable. And although in cities there is a demand for such services, there are few doctors who can integrate both “clinical” and “home” perspectives into their practice – “soft” obstetrics are generally not on the curriculum in Russian medical schools.
My friend Maria gave birth to her first child in one of these specialist maternity centres. There were just four midwives working there at the time, and its “turnover” was a mere 300-400 births a year (by comparison, a large maternity hospital in the same city could have a birth rate of 20 a day). There are very few centres like this and they are usually to be found in the big cities (mainly Moscow and St Petersburg), where there are enough potential clients ready to pay for their services.
Maternity ward births: a conveyor belt for newborns, or the best way to keep childbirth safe for mother and for child? Newborns in Rostov city maternity ward No. 5. Photo (c): Sergey Venyavsky / RIA Novosti. All rights reserved.
“I was too scared to give birth in a state hospital”, she says, “I read all the books, listened to everyone’s experiences, and all the mothers and grandmothers had terrible tales to tell – stories about drunken doctors and so on…Better to pay and get more attention. Free healthcare and private healthcare are, after all, very different things. I decided to go private straight away. I’m not one of these women who can give birth in their bath at home. I need a hospital, and I need one with intensive care facilities.”
The combination – private facilities, personal attention and a “natural” approach – meant just one thing: a natural birth centre. Getting into one was not easy: registration happened at a given time on a given day, when a new group of expectant mothers would be assembled. It took Maria half an hour to get through on the phone, but she managed it.
Behind the idea of “naturalness” lies an issue of trust – whether in the institution of medical care or the individual specialist delivering the baby
Every week for the next three months, Maria obediently went to lectures and special exercise classes, as well as the swimming pool and Turkish bath. The classes were led by the midwife who afterwards delivered Maria’s baby: as she attended the classes, she got to know her midwife well and developed a trusting relationship with her.
“In other hospitals, even private ones, you only check in when you have already gone into labour”, says Maria. “They assign you a midwife – you’ve never seen her before, or maybe once, when you signed the original contract – and that’s that. Whereas here, you know her already, you know how she works and how she talks about giving birth.”
Maria’s birth experience couldn’t be called “natural” in its normal sense: it required induction of her labour, intervention by two doctors and a whole series of medical procedures. All this, of course, is very far from the kind of naturalness expected in home births. But for Maria, it was enough to be able to move during contractions, stand under a shower and bounce on an exercise ball, as well as having “her” midwife close by.
And so, as with home births, behind the idea of “naturalness” lies an issue of trust – whether of the institution of medical care or the individual specialist delivering the baby. As one of the midwives working in the centre where Maria had her baby told me, “many people come here to find someone who will stand between them and the system.”
To be natural, to be free
For the vast majority of Russian women, the only available version of natural birth is in an ordinary state maternity hospital. The term “natural” here is narrowly defined: i.e. giving birth without recourse to a Caesarean Section. Other invasive procedures may take place – an epidural, for example – that strip the birth of its “naturalness” from the mother’s point of view, since it boils down to undergoing labour in a hospital ward.
Another definition of “naturalness” that can be found in state maternity hospitals is a birth package offering skin-to-skin contact between mother and baby immediately after the birth, having them sleep together in the neonatal period and help with breastfeeding. This opportunity reflects Russia’s adoption of international healthcare standards back in the 1990s, including the WHO/Unicef Baby-Friendly Hospital Initiative which promoted breast feeding.
Some maternity wards go to great lengths to create a comfortable and relaxed atmosphere - though sometimes with unintended results. Photo courtesy of the author.
Women who gave before the introduction of this programme see it as a more human approach to obstetrics and an improvement in maternity hospital practice. Some, however, feel that even if support for breastfeeding became a general principle, it wouldn’t take individual mothers’ needs into account. Some women, for example, would rather get some rest after giving birth and not have their newborn in bed with them.
So most women having their babies for free in state maternity hospitals can access a minimal version of “natural childbirth”. This should, ideally, be the most democratic model of care, accessible to any woman without any advance notice, preparation or fee required. Highly educated and affluent women, however, bank on receiving an “expanded” version in the form of either a home birth or personal treatment in a private maternity hospital room.
“Natural childbirth” carries particular connotations in a post-Soviet context. As anthropologist Ekaterina Belousova has pointed out in her work, in the late Soviet period home births were already seen less as a means of challenging the medical model of childbirth, than as a challenge to the unreceptive state “system”. For many women, giving birth in a general delivery ward meant a lack of privacy, an authoritarian attitude (and sometimes plain rudeness) on the part of hospital staff and sometimes emotional trauma.
This situation was exacerbated by lack of trust in the medics’ professionalism: Soviet women had no fear of the over-technification of childbirth that was developing in Europe and the USA – on the contrary, they were faced with an unacceptably low-quality service. The “natural birth” movement was an attempt by parents to take responsibility for their child’s birth and turn it into a private family experience.
Soviet women had no fear of the over-technification of childbirth that was developing in Europe and the USA
In today’s Russia, the reform of maternity services has been one of the focuses of social policy since the middle 2000s. Since then, a number of innovations (such as a birth certificate programme as part of the national health project) have led to improvements in maternity hospitals’ technological facilities and made them more accessible to various population groups. Proof that these reforms are working includes infant mortality figures, which show a fall of 24% between 2012, when new definitions for live births and stillbirths were adopted) and 2015.
Ideally, a state maternity ward should be the kind of place where any woman can receive the treatment she needs. However, in practice this is not often the case. Photo courtesy of the author.
Despite these improvements, some mothers (mostly educated urbanites) still distrust state maternity hospitals. Their criteria for a “good” birth don’t completely coincide with those used by the medical profession, and, consequently, the government. What is important for parents is that their child’s birth shouldn’t just match a set of objective “quantitative” factors, but have a “qualitative” element – the opportunity to give birth in comfortable conditions; the mother’s emotional satisfaction.
At the same time, going “natural” requires considerable resources. Some parents can buy trust in, and personal care from, medical professionals by signing a natural birth contract with a maternity hospital. Another small group choose home births, which are generally cheaper but riskier, and complicated to organise.
The fact that natural, “alternative” births are regulated by the state only in the form of a ban on home births shows the mutual distrust between Russians and their government
The fact that natural, “alternative” births are regulated by the state only in the form of a ban on home births shows the mutual distrust between Russians and their government. In the summer of 2014, for instance, the Ministry of Justice drafted a bill to prohibit the birth registration of children born outside medical facilities. The supposed justification for this measure was that those who gave birth at home were actually swindlers, trying to use underhand methods to access government support services for families.
What the government is actually trying to do, by investing in the modernisation of obstetric-gynaecological services, is to increase its control over childbirth as a means of improving its demographic figures. And although post-Soviet parents are keen to individualise their birth experience, the government is less enthusiastic about offering them a better choice in the matter.
Translated by Liz Barnes