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Note: All names and identifying information have been altered to protect the identity of informants. During the course of my four-month study abroad program in Greece in the fall of 2005, my interest in women’s health and my background in medical anthropology evolved into an ethnographic research project on the medical and non-medical discourses on pregnancy and childbirth in Athens. As women began to share story after story of highly-technological hospital births, I began to wonder how a country known for its strong affinity for tradition could so universally have wiped out any remnants of “natural” homebirth in favor of the Western model of hospital birthing. The transition of birthing practices in Greece from a homebirth culture, in which women deliver at home surrounded by family and under the supervision of a typically female birth attendant, to a biomedical birth model, in which women deliver in a hospital with numerous forms of medical intervention and under the control of a physician, has been unusually rapid. As late as 1960, Greece’s homebirth rate was at sixty percent (Mikkola, 1997, p. 46). Today, the vast majority of women in Greece give birth in technologically-advanced hospitals, with the percentage of homebirths as low as 6 tenths of one percent (Georges, 1996, p. 160). Western medicine not only dominates the health care system in Greece but has an essential hegemony on women’s health care. My research examines whether the pervasive utilization of biomedical environments for birthing can be explained by a lack of alternatives or by women’s satisfaction with the technology and care available in hospitals. I also examine how women retain control over their experience of pregnancy and childbirth within the biomedical context, and I attempt to explain the emerging construction of a “natural” discourse on pregnancy and childbirth in Greece. Over the course of three months, I interviewed eight people in Athens—5 mothers, two midwives, and one Ob/Gyn. All are middle-class, live in Athens, and have spent significant time abroad, mostly in England or the US. One woman is German, two women are American (one of whom is Greek-American), and all the rest are Greek-born and raised. The Ob/Gyn was the only male informant. I conducted one interview in English with each person, and most interviews lasted about an hour. I took hand notes during my interviews and typed up the transcript as soon after the interview as possible. My sampling method was generally a snowball sample, since each woman I was referred to would refer me to her friends and her doctors who would then refer me to their friends and their doctors, etc.
The socially prescribed ways in which human reproduction takes place serve to generate official power and authority over birth (Lazarus, 1994, p. 25). Medical knowledge, like most knowledge, is inseparable from social relationships and social experiences. Because medical knowledge is unequally distributed (with doctors perceived to have more and patients less), it is inherently linked to matters of power and control (Lazarus, 1994, p. 26). Through clinical encounters, during which doctors monitor women’s behavior and provide biomedical lessons, and through such popular sources as magazines, television, videos, childbirth classes, and pregnancy guides, women learn to conceive of pregnancy as a biomedical event (Fox, 1999, p. 331). The dominant model of birth in Greece is medical, founded on the assumption that birth is a potentially pathological condition in which something could go wrong at any time (Lazarus, 1994, p. 27). Katerina, an environmentalist in her late 30s who sells hand-crafted clothes and gifts, said, “In Greece, a pregnant woman is treated like a sick person. When you’re pregnant, it’s acceptable to complain as much as you want, to eat as much as you want…because people think you have a condition or a sickness.” Researchers in a variety of disciplines, including medicine, public health, psychology, sociology, and anthropology, have put forth a strong critique of the medical management of pregnancy, labor, and delivery (Fox, 1999, p. 327). The main argument that emerges from this cannon of research is that the medical management of childbirth decreases the control of the birthing woman, fails to improve the physical and emotional outcome of the birth, and alienates women from a potentially empowering experience (Fox, 1999, p. 327). Throughout Greece, pregnancy, birth, and abortion have been fully medicalized for at least a generation, and in urban areas, even longer (Georges, 1996, p. 160). Furthermore, the technological discourse of biomedicine is continually displacing old explanations and practices, including local knowledges of the pregnant body (Georges, 1996, p. 160). Today, births in Greek hospitals include routine use of pubic shaving, enemas, IV drips, pitocin to augment labor, electronic fetal monitors, episiotomies, the lithotomy position with arms and legs strapped to the delivery table, and cesarean section for a growing number of women (Georges, 1996, p. 160). Birthing at home has become unthinkable (Georges, 1996, p. 160). Eleni, a Greek midwife, said, “I just met a young woman who said that she will lose status when people on her island find out she had a homebirth—the more expensive the birth, the more status one has. If she has a homebirth, people will assume she couldn’t afford a hospital birth.” Dr. Makriyianni, an Ob/Gyn in his thirties who works at a private maternity hospital in Athens, reported, “Home childbirth is almost unacceptable. It’s considered [socially irresponsible] and risky… Truthfully, people would think you were a hippie if you wanted a homebirth.”
In response to the rapidly growing dominance of medical childbirth, a discourse on “natural” childbirth emerged. “Natural childbirth” can not be easily defined by women, and medical professionals alike have differing perspectives on what defines “natural.” For the purposes of this paper, “natural childbirth” is interchangeable with “non-medical approach to birth” and refers to a birthing experience in which the mother’s desire for limited intervention, often in the form of the prohibition of an epidural, episiotomy, labor induction, and cesarean section, is respected by the birthing attendants. Influenced by the consumer and feminist movements, proponents of “natural” childbirth argue that women gain power through access to information and control over personal choices. At one end of the discourse on natural childbirth are advocates of homebirth who seek to achieve a “natural” experience by delivering in the comfort of their home, able to move about as they wish, and without the interference of technological machinery. At the other end of the spectrum of “natural childbirth” are women who deliver in a hospital under the direction of a doctor, but still seek to limit medical intervention. An interest in non-medicalized approaches to birth has become apparent in Athens only in the last decade. A number of vocal, yet limited, groups have emerged to offer information and services to women who seek alternative or complementary perspectives on birth. The groups’ sphere of influence is mainly in and around Athens, but a breastfeeding advocacy and support group had established chapters in Thessaloniki and throughout northern Greece. Moreover, there seems to be an increasing number of Ob/Gyn’s, largely foreign-born, who are known to be more open to “natural birth.” Critics argue that the flaw in much of the literature on natural childbirth is its uncritical acceptance that unmedicated birthing and hands-on mothering is superior to other forms of birthing and mothering (Browner, 1982, p. 8). Moreover, critics suggest the literature implies that women should assume control over their labors and deliveries and ignores what women may gain from medical intervention (Fox, 1999, p. 330). Evidence is mounting that, although some women are alienated by their experience of medicalized birth, many women across social classes welcome medical intervention and are quite satisfied with hospital deliveries (Fox, 1999, p. 328).
As the biomedical model of birth has gained dominance, the definition of natural childbirth by medical professionals has broadened to “include any birth in which the mother is awake and delivers vaginally” (Brozan, 1988, p.14). The changing conception of what defines “natural” can lead to misunderstandings between women and their doctors. For example, Gabby said, “I told [my doctor] that I wanted natural childbirth, and he agreed. But, at the time of the birth, it became clear that his conception of ‘natural’ meant not a C-section; whereas, my conception of ‘natural’ meant no medicines and less intervention.” Like Gabby, many of the women I interviewed were motivated to seek a more “natural” childbirth after first having had a negative experience during a hospital birth. Contrary to my expectations, these women often did not seek a midwife but stayed within the biomedical setting and sought, sometimes relentlessly, a physician who they could trust to respect their wishes. A woman’s interest in natural childbirth was not of itself a predictor of whether she would seek a doctor or a midwife to assist in her delivery. Instead, the women I interviewed seemed to be highly influenced by their pre-existing attitudes towards hospitals, their body, and pregnancy. Katerina, who had a homebirth, remarks, “I was never fearful. I was very convinced since I was young that I wanted to have a homebirth. I helped out with two homebirths that were beautiful. And, I never felt safe in hospitals.” The women who sought midwife-assisted births believed that they could have more trust in a midwife than a doctor to use as little intervention as possible. These women talked about retaining the responsibility of birthing, rather than passing off this responsibility to a physician. Katerina says, “It’s easier to lay responsibility in the hands of a doctor…The family prefers to put the responsibility on a doctor. Homebirth acknowledges that a lot of birth is your own work.” A recurrent theme that emerged from the interviews was the importance women placed on their choice of birth attendant. Lazarus (1994, p. 27) finds that women’s interest in maintaining control over the course of their pregnancies and over childbirth influences their choice of physician, and that choosing a doctor agreeable to their views increased women’s control over their pregnancy and delivery. Women’s definition of control varied. To some women, control was a general notion of being involved in decision-making and exercising some power over what happened during birth. For other women, their definition of control was more particular, relating to their views on specific technologies, such as anesthesia or episiotomy. For all of the women, choosing the right caregiver was essential to maintaining control. Women’s interest in maintaining control over their pregnancy related to a more general control over their lives. Their resistance to submit to doctors’ authority, or at least to retain some power in the decision-making process, related to a larger refusal to submit to dominant authorities. Regardless of whether she chose a midwife or an obstetrician, all of the women recognized the life-saving capacity of medical intervention and were willing to accept birth as a biomedical event, although to varying degrees. The women with the strongest feelings on natural childbirth were willing to accept medical intervention as a last resort, while women with less strong views on natural childbirth were willing to resort to medical intervention at an earlier point. For all of the women, in the case of a medical emergency, saving the life of their baby was their primary concern. However, women who sought a natural childbirth viewed a positive emotional experience of birth as a primary factor in the future health of their baby and in the formation of the mother-child relationship. A common theme of the interviews was that mothering in the urban environment of Athens was individualizing and alienating. Numerous women suggested that Athenian society offered little emotional support to mothers and that the experiences of motherhood were no longer shared collectively among women, as it had been in the villages. (Rapid urbanization has resulted in over one third of Greece’s population living in Athens. Therefore, people commonly refer to village life as symbolic of the past.) Eleni said:
The women in this study all discussed the lack of power they felt in the medical setting and emphasized how little support existed for women interested in non-medical approaches to childbirth. Dr. Makriyianni points out, “There’s no infrastructure to support women for homebirths… In rural areas, maybe there might be an old midwife who might be able to assist, but, generally, people go to cities.” Within the hospital, women who challenge hospital policy or doctor’s judgment are often deemed crazy and irresponsible by hospital staff. Sarah relates the following story of the birth of her second baby, who was born with jaundice:
In response to women’s apparent feeling of disempowerment within the medical setting of birthing, the primary breastfeeding advocacy group in Athens encourages women to trust their instinct and question medical authority. Sarah said, “Through our group, you realize warning signs [that your doctor doesn’t share your point of view or won’t accommodate your wishes] and you get the courage to change doctors. We’ve had women who change doctors at 9 months pregnant!…We encourage women to trust themselves [because] friends will say, ‘you’re crazy!’” Lazarus (1994, p. 37) suggests that knowledge alone does not give women power within the medical system. Issues of consent proved to be a major reason why women who felt prepared prior to labor to refuse what they deemed “unnecessary” medical interventions never had the chance to express their wishes during labor. Katerina had more resolve and preparation than perhaps any of the other women I interviewed, and, yet, a number of medical interventions were used in her homebirth without her consent. Katerina recounts:
Irini, a German-born woman in her early 40s, had discussed her interest in a natural childbirth with her doctor, but describes the many medical interventions that were used on her either without her consent or as the doctor’s override of her refusal:
Because women have unequal access to knowledge and differing degrees of desire for such knowledge (Lazarus, 1994, p. 36), it seems essential for multiple discourses on birth to coexist. Demand for natural childbirth services remains limited in Greece, but the voice of the women seeking non-medical approaches to birth is becoming more audible. Although women involved in the natural childbirth movement have made little headway in diminishing doctors’ skepticism of natural birthing, they have succeeded in creating a more organized support network for women interested in non-medical approaches to childbirth and have established a number of practical resources, including a natural birthing center and an educational center. While it is clear that natural childbirth is not the desired model for all, or even most, women, the wishes of women interested in natural childbirth have yet to be met with respect from medical professionals or support from within the birthing infrastructure. Whether women can affect fundamental changes in childbirth practices within the physician-dominated health care system or must seek non-medical alternatives is a subject of considerable debate. Because the amount of institutional and societal support given to the medical perspective is far greater than that given to individual women seeking non-mainstream childbirth, it is unclear whether individual coping strategies will be sufficient or if broader social reforms are necessary for the varying beliefs of women to be respected during pregnancy and delivery. Eleni describes the lack of support felt by some mothers in Athens:
In light of women’s apparent interest in improving women’s experience of pregnancy and childbirth in Athens, it is essential that researchers more thoroughly examine the interaction of medical and non-medical discourses on childbirth within Greek society.
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