by Christine Wood, BWI Childbirth Educator student
“… all physical functions are affected by what is going on in our minds. Breathing, digestion, elimination of waste, heart rate and blood pressure, and in labour uterine function, are profoundly affected by emotions, beliefs and relationships. It has been known for a long time that stress can make labour slow down or stop altogether, and cause uterine incoordination and excessive pain.” (Kitzinger, 2000)
“It hurts!” she moans.
“Are you ready for your epidural?” the nurse asks.
“I’m not sure.” She clutches her husband’s hand.
“Whatever you want, honey,” he says. “If that’s what you need, it’s okay.”
“I don’t know. It’s not what I wanted.”
Throughout history – across culture, time and place – love and safety have been integral parts of physiological birth. As we have begun to understand more about the intricate interplay of hormones that happens during labour and birth, we have been able to affirm what, historically, women knew more instinctively: there is, as Ina May Gaskin terms it, a ‘powerful mind-body connection’ in labour. Her book, Ina May’s Guide to Childbirth (2019), documents clearly how fear or worry can slow dilation and how love and encouragement can accelerate dilation. For, while love and safety are integral to a physiological birth, the opposite is true as well: fear inhibits (or stops) the natural progression of labour and birth.
In today’s medicalized system of health care, awareness of the effects of both safety and fear on the birth process is more important than ever. Researchers from many fields have studied labour and birth, and their conclusions are the same: feeling safe enhances labour’s progress and the birthing person’s well-being, while fear inhibits labour’s progress and outcomes (see, e.g., Dixon et al. 2013; Haines et al., 2004; Lothian, 2004; Olza et al., 2020; Pascali-Bonaro & Kroeger, 2004; Simkin & O’Hara, 2002; Van der Gucht & Lewis, 2015; Walter et al., 2021). “A birthing woman’s experience is influenced by the woman’s expectations and history,” concludes Flores (2018), “but it is the environment in which she gives birth that will – directly or indirectly – influence labor and delivery.” (p. 224)
This paper will look at the effects that love and fear have on the birth process; the effects that those emotions have on hormonal release – specifically oxytocin and adrenaline – during labour; and will discuss practical solutions that can influence a beneficial hormonal pattern during labour, leading to improved outcomes for both mother and baby.
Feeling Safe in Birth (or Not)
Research into labour and birth – and, by extension, its wider effects on the well-being of women – has continued into the twenty-first century, and encompasses many fields. From psychology to midwifery, researchers have studied birth from varying viewpoints: pain in labour, the hormonal balance of labour, labour and fear, labour and place, etc. Examining a cross-section of these studies, a few recurring conclusions appear – and among them we find one incontrovertible truth: feeling safe during the labour and birth process promotes physiological birth. How does this happen? What is so important about safety in labour?
Where Does it Hurt?
It would be impossible to discuss labour and birth without addressing the topic of pain. While not an exhaustive list, an overall increased experience of pain can result from a variety of factors, including: antenatal anxiety about pain (Haines et al., 2012); encountering strangers during labour (Pascali-Bonaro & Kroeger, 2004); anxiety, tension and fear during labour (Feeley et al., 2021; Flores, 2018); position during labour (e.g. supine vs standing/moving) (Gönenç & Dikmen, 2020; Lowe, 2022); viewing labour pain as suffering rather than as having a purpose (Whitburn et al., 2019); and stress (Olza et al., 2020). Additionally, while pain is almost universally associated with the birth process, its intensity varies widely from woman to woman. Whitburn et al. (2019) state:
Pain is not simply driven by the state of the tissues and nociceptive input into the central nervous system. Rather, it emerges from a complex integration of affective, cognitive and sensory constituents, and only emerges when the brain determines that there is a threat to the self and that the individual should know about it. (p. 30)
Our twenty-first century culture (over)emphasizes the pain associated with labour, and current practices around labour and birth are often contributors themselves to increased labour pain and decreased labour progress (see, e.g., Dixon et al., 2013, Lothian, 2004; Pascali-Bonaro & Kroeger, 2004; Van der Gucht & Lewis, 2015; etc.). Immersed in this ‘birth is pain’ mentality, it is no surprise that many women go into labour seeking one of modern medicine’s interventions (e.g. epidural, narcotics, etc.) which are intended solely to relieve or eliminate labour pain. In fact, fear of their ability to cope with labour can lead women to choose a surgical birth (cesarean) rather than risk the perceived threat (Haines et al., 2012). These women may not understand why, but they do know that they anticipate a painful event – and that they do not want to experience labour without pain relief.
What Are You Afraid Of?
With pain (or the expectation of pain) at the centre of labour and birth for many women, the resulting fear-pain loop becomes somewhat inevitable. Commonly known as the ‘fear-tension-pain’ cycle, Victoria Flores (2018) states the problem clearly:
Tension and fear are foes of labor because they interrupt the neurohormonal pathways between the brain, the circulatory system, and the uterus, thereby restricting blood flow and oxygen. As a result of such restricted blood flow to the uterus, the cervix tightens and closes, causing pain. With each contraction, the woman then braces for more pain, which creates a continuous feedback loop resulting in painful childbirth. (pp. 221, 222)
The prevalence of fear in the labour process has perhaps become even more significant in the current medicalized space in which most births occur. Several influences known to increase fear (and, along with it, stress and anxiety) are commonplace in institutionalized birth. In addition to widespread cultural messages of negative birth stories and anticipation of a painful experience, women may labour in social isolation (Van der Gucht & Lewis, 2015), under the scrutiny of multiple clinical attendants (Pascali-Bonaro, & Kroeger, 2004), or while feeling judged or inadequate (Flores, 2018). Without the knowledge or support they need to break free of the cycle of fear and pain, birth becomes a difficult and dreaded process.
Why is This Happening?
Two significant findings explain why the birth environment, when joined together with women’s preconceived fears and anxieties about labour, can so drastically change the birth experience. First, when looking at the brain’s response to stress, it becomes clear that institutionalized birth environments are not conducive to physiologic birth. Women – especially in cases of stress related to motherhood – may not have the basic ‘fight and flight’ response to stress that we long believed was ubiquitous, say Taylor et al. (2000). Instead, women may have a ‘tend and befriend’ response to stress, in which they look for community. Pascali-Bonaro & Kroeger (2004) agree: “Women respond to stress with a cascade of brain chemicals that facilitate bonding with other women” (pp. 19-20). This bonding would, historically, have resulted in a community of care, a circle of support when it came to labour and birth. That natural support system has been largely broken – first by a medicalized model of birth and subsequently, one can conclude, by the loss of knowledge that has occurred because several generations of women have birthed apart from their natural and instinctive bonding with other women during labour.
Second, researchers continue to gain insight into the intricate hormonal dance that occurs in birth – the interruption of which leads directly to an array of negative consequences. Oxytocin, the hormone most responsible for many of the processes of labour, birth and even the postpartum, is normally released in ever increasing amounts during labour. Among other uses, oxytocin facilitates the dominance of the parasympathetic nervous system (Olza et al., 2020) which in turn allows women to turn inward and find a place where they can cope more easily with labour (Dixon et al., 2013). However, fear, stress and anxiety cause the release of catecholamines – which then block oxytocin’s ability to flourish. As Flores states, “Adrenaline – a catecholamine – is especially effective in halting the progress of labor by disrupting the flow of oxytocin. Many women in labor experience that effect upon arrival at the hospital, when even full-on labor slows or even halts” (p.225). She further adds, “It may take as little as feeling startled, embarrassed, vulnerable, or guarded to interrupt the oxytocin cascade” (p.234).
So… What About Love?
Love steps into this story of pain, fear and interrupted birth physiology as somewhat of a rescuer. Where caring support and a calm environment intersect with birth, they create the safety that is integral to physiological birth; they counteract the fear that is often part of (and created by) birth in the modern age. Women around the world find courage, strength and the ability to give birth without fear due to the powerful effects of love – that helps them feel safe, and in turn helps their bodies progress in labour.
Simple comfort measures – such as one-on-one care, touch or massage, privacy, a reassuring presence, etc. – can help women feel safe during labour and reduce their fear and anxiety (see, e.g., Feeley et al., 2021; Lothian, 2004; Murray-Davis et al., 2014; Walter et al., 2021, etc.). These non-pharmacologic interventions are widely effective in the promotion of physiological birth (see, e.g., Gönenç & Dikmen, 2020; Simkin & O’Hara, 2002; Van der Gucht & Lewis, 2015, etc.). Olza et al. (2020) state: “It is important for maternity care providers to know that the central release of oxytocin, and its positive effect, can be modified by environmental factors. Stress and frightening situations and surroundings increase the activity in the stress system… and decreases the activity of parasympathetic nervous activity and the decrease oxytocin release” (p.10). They conclude:
The physiological importance of social support for reduction of pain and stress during labor prompts a reconsideration of many aspects of modern maternity care. There is sufficient evidence to increase advocacy for improved maternity care and for promotion of… one- to-one support in labour. This information also calls for a more feminist and humanistic attitude regarding labour and birth from public institutions and health professionals worldwide. (p. 12)
Conclusion
Feeling safe is intricately related to the progress of labour. Both historically and currently, those who study birth and birthing women’s experiences find that the results of not feeling safe (i.e. fear, tension and anxiety) lead to a ‘cascade of interventions’ rather than the cascade of oxytocin and other neurochemicals that so positively influence the labour process. Women’s innate ‘tend and befriend’ response instead becomes one of ‘fight and flight’.
Twenty-first century research calls for a return to the circle of care that was historically present for women giving birth, and for the relational support that facilitates physiologic birth. Researchers appeal to caregivers in the medical system to learn from the evidence – and change their approach to birth. This plea is especially poignant in the current North American culture of medicalized births – where the environment in which women give birth is one that often promotes fear (and thereby pain) and rarely provides the support or privacy needed to feel safe.
And what about love? From home birth to cesarean birth, love – the labouring woman being seen, respected, and cared for compassionately in word, touch and surroundings – promotes so much more than just birth. Love sets the stage for baby’s first moments in the world; for the mother-baby dyad’s first hour; for the benefits of that warm, safe birthing space to be part of the mother’s circle of security in parenting; and for the best start possible in baby’s journey in life.
Bio
Christine Wood is a labour and birth doula (The Gentle Doula) in Sudbury, Ontario, Canada. She is passionate about providing informed, relational care to all families and believes deeply in the difference that doula support makes – not just for the birthing person, but also for babies, families and communities. Christine is currently pursuing her certification as a childbirth educator with BirthWorks International and hopes this will open further opportunities to share life-changing and empowering birth knowledge. When she’s not working or busy learning more about birth, Christine can often be found reading, crocheting, baking, or going for a walk with a friend or with her goldendoodle. She lives with her husband and best friend, Jeffrey, and is the proud mother of three grown children. You can find Christine on social media @thegentledoula or at her website www.gentledoulasudbury.com
References
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