Childbirth and Trauma, 1940s–1980s

Childbirth and Trauma, 1940s–1980s Abstract This article analyzes trauma in mid-twentieth century hospital births, focusing on the United States, but with additional evidence drawn from Great Britain and France. As many as half of women today experience childbirth as traumatic and no evidence suggests that the figure was lower a half-century ago. Drawing on women’s birth narratives and psychiatric literature, this article highlights the striking consistency over time in how women describe their experiences of traumatic birth. By the 1970s, however, women proved less ready to accept their trauma as the product of their own psychological shortcomings. Under the sway of second-wave feminism, they pushed back against care they defined as inhumane in both conventional maternity care and in natural childbirth. Psychiatry too demonstrates change over time. Hegemonic at midcentury, Freudian thinking began to yield to critiques that questioned gender norms and the preeminence of the subconscious. Based on private letters to maternity caregivers and between physicians, as well as a wide array of medical journal articles, popular magazines, and newsletters from childbirth education and birth advocacy organizations, this article argues that, despite different approaches to trauma in birth and clarity about how best to minimize it, contemporary maternity care has to date proven unable to heed the lessons of history. Childbirth and Trauma, 1940s–1980s Writing in 1950, Salt Lake City psychiatrist Fred Kartchner recounts the story of an unnamed patient visited by frequent nightmares after the birth of her first child. Upon waking in the middle of the night, she did not recall their content, only the lingering feeling of terror. Amid this recurring nocturnal distress, she greeted her second pregnancy with anxiety. During the birth, through a fog of anesthesia “she screamed, ‘There they are! The lights! The people! They said they didn’t hurt me but they did! They did! I just didn’t remember!’”1 She later learned that during her first labor she had been given the amnesic scopolamine and while under its influence had experienced severe labor pain and a forceps delivery, about which she had no conscious memory and had never been informed. Her nightmares appear to have been a subconscious re-experiencing of that trauma, which her second labor brought to the surface. According to the current edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), “recurrent, distressing dreams” related to a prior traumatic event are symptomatic of Post-Traumatic Stress Disorder (PTSD).2 This article analyzes the historical experience of and theories about psychological trauma in childbirth. I focus on the United States in the mid-twentieth century, when, amid a baby boom, mothers, their partners and their caregivers engaged in a national dialogue about how best to have a safe, satisfying birth experience. The US was also the epicenter of psychiatric thinking that circulated globally. Supplementary evidence from Great Britain and France points to commonalities across national boundaries despite differences in the delivery of care. I understand the mid-twentieth century to be the temporal locus of a transnational “knot of resistance” to the status quo in maternity care.3 Women’s experiences of birth trauma led directly to the movement for natural childbirth, which pressed for a less interventionist approach than conventional maternity care offered at the time. In particular, advocates eschewed the use of pharmacological pain relief that was widespread for middle class, white American women and, to a lesser extent, their British and French counterparts. American women typically gave birth in hospital under the heavy sedation of “twilight sleep.” Combining scopolamine with morphine, twilight sleep left many women disappointed with their experience, of which, like Kartchner’s patient, they had no clear memory. They feared having comported themselves in undignified ways, crying and thrashing about through the drug-induced haze. For other women, not only in the US, but also in the UK and France, unmanaged pain or gruff treatment left them feeling distressed and disempowered by conventional hospital maternity care. Among other forces, the rise in the late 1960s and early 1970s of the women’s movement nurtured the fight for a different way of giving birth. Resisting resort to pharmacological pain relief became a signifier of women’s power and strength. But the unchecked pain that sometimes accompanied that effort proved, as in interventionist obstetric practices, to be psychologically damaging. From the US, UK, and France come strikingly similar attestations to suffering in both conventional, medicalized births and natural births. Perhaps significantly, this testimony emanates from hospital-based maternity care and is less audible in stories of births at home or in alternative birth centers. Because natural childbirth and the reforms in conventional maternity care that it sparked in the US and Western Europe sprang in part from women’s experiences of traumatic birth, sources from this movement provide rich testimonial evidence. Magazine articles, letters, and newsletters from childbirth education organizations and birth activist groups offer moving stories. Psychiatrists, obstetricians, midwives, and childbirth educators also described and debated traumatic birth’s sources and treatment. Medical and paramedical professionals were in a shared conversation with patients and birth activists, drawing from a common vocabulary and often subscribing to a shared set of values and beliefs. In her classic study of childbirth in the United States, Judith Walzer Leavitt highlights this dialogue between maternity patients and their caregivers, emphasizing women’s role as active collaborators in the generation of meaning and practices in childbirth even when they curbed women’s own authority and autonomy.4 Leavitt’s stance informs my accent on shared agency in constructing norms of behaviour and theories of female psychology in childbirth. Though patient and caregiver narratives at times converge, for the sake of clarity and organization for the most part I deal with each in turn. I begin with a brief sketch of the broader maternity care context in which experiences of and theories about birth trauma unfolded. Second, I use women’s narratives of their birth experiences to access what they understood to be traumatic birth. The third section reconstructs the psychiatric profession’s evolving understanding of trauma and birth. I focus heavily on the mid-century Freudian thinking generated in the US, but dominant in Western Europe as well. Of course, neither women’s own words nor medical professionals’ evaluations can be taken at face value. Borrowing from subaltern studies, I attempt to analyze case histories and birth narratives against the grain to uncover alternate readings of women’s experiences. As for defining whose experiences can be understood as meeting the ever-changing definition of trauma, I do not limit the discussion to cases that conform to today’s PTSD diagnosis. Such a standard would set a high, quite specific, and anachronistic threshold to which the historical evidence does not often clearly rise. I embrace instead the notion that “trauma is in the eye of the beholder.”5 Women’s own reflections on their births as traumatic deserves sustained, though not uncritical, attention as do their medical caregivers’ assessments. British anthropologist, midwife, and birth activist Sheila Kitzinger captures the broad significance of birth trauma when, at a 1983 conference on pre- and post-natal psychology, she remarked that “how the woman is treated, how the baby is treated, all help to define what birth is, the meaning of birth in that society.”6 With as many as half of women worldwide experiencing childbirth as traumatic, the question is both significant and urgent.7 Women’s traumatic experiences in the 1940s and 1950s contributed to the push for reform in the 1960s and 1970s. Out of this struggle came a slew of changes, though how deep and wide they ran remains debatable. In the name of mother-centered and family-centered care, midwifery made a comeback in the US after having been driven to the brink of extinction. Both there and in Europe, hospitals began to allow fathers in the labor and delivery room. Maternity wards were redesigned to provide homey birthing suites and rooming in. These trends in hospital-based maternity care speak, among other things, to women’s ongoing quest to minimize or eliminate trauma in birth for mother and baby.8 Yet we must ask ourselves about the impact of these reforms when so many women continue today to reflect on their experience of birth as traumatic. Women’s experiences then and now demonstrate considerable continuity over time. Strides have been made, but the aspiration to achieve in equal measure both safety and satisfaction in birth remains for too many women elusive. A Brief History of the “Birth Wars”9 Arguments about what constitutes safe, humane maternity care have their roots in the mid-nineteenth century, when changes in the medical profession and in medical knowledge began to reshape women’s birth experiences. Greater attention to antiseptic practices spurred a reduction in postpartum infection. The advent of antibiotics in the 1940s further drove down maternal and infant mortality rates, while modern anesthetics helped many women to give birth in greater comfort. Celebratory scholarship rightly lauds improvements in birth outcomes for women and their babies since the mid-nineteenth century, but these advances came bundled with practices that worked to take control of birth out of the home and out of the hands of women.10 Originally the site of birth for only the poorest women, hospitals came to mean safety and comfort for the white middle class as sanitary measures improved and anesthesia became available there. With promises of expert, skilled care, predominantly male physicians asserted a more common role in childbirth during the late nineteenth and early twentieth centuries. These changes came slower to Great Britain and France than to the United States, but were underway there as well in the first half of the twentieth century. On a continuum that spanned from midwife-led home birth to pathologized, obstetrician-led hospital birth, the American model sat at the most medicalized and pathologized end, with less reliance on anesthesia and a greater presence of midwives in the UK and, to a lesser extent, France. Feminist birth activists and historians have argued that what emerged from these transformations were practices that left women isolated from their families and disempowered in the face of medical authority.11 The movement for natural childbirth emerged in response not just to changes in medical practices, but also to shifting ideas about marriage and women’s roles. In 1933, British physician Grantly Dick-Read coined the term “natural childbirth” to describe his approach to maternity care, which emphasized prenatal education to alleviate the fears that he saw at the root of women’s pain in labor. A raft of similar approaches sprang up, including perhaps most famously the Lamaze method, also known as psychoprophylaxis. After witnessing this technique in the USSR, French obstetrician Fernand Lamaze began to promote a combination of patterned breathing and conscious relaxation at a Paris hospital popularly known as Les Bluets. Doctors from all over the world came there to study with Lamaze and this approach gained a global following.12 What advocates of the Read, Lamaze, and other methods initially shared was the belief that pain in labor had a psychological origin. Their explanations for this ranged from the sociological to the Freudian, but there was broad consensus among natural childbirth advocates from the movement’s inception through the 1970s that women’s minds were the sole or primary source of pain and constituted the front line of battle against their suffering. Psychology unquestionably plays a role in labor pain, but it is important to remember that for several decades in the mid-twentieth century a large and vocal group of medical professionals and their patients asserted that labor pain was largely or completely psychogenic, a belief that framed debates about birth trauma. Gaining currency in the 1940s and 1950s and expanding its reach in the 1960s and 1970s, natural childbirth rode the waves of interlocking postwar social trends.13 Touting a partnership of equals, albeit with strictly defined gender roles, companionate marriage and togetherness became the domestic ideal.14 Couples sought to extend this partnership in the labor room. Togetherness in labor and birth could only be meaningful if women said no to twilight sleep and other anesthetic cocktails that might offer relief from pain, but also robbed them of consciousness. The United States escaped the worst ravages of the thalidomide scare, but it contributed to women’s reluctance to take drugs during pregnancy, up to and including pain medication in labor and birth. In the 1970s, as countercultural values spread to the middle class, “nature” and “natural” began to be valued over the earlier “better living through science” ethos. Simultaneously, the women’s movement embraced natural childbirth as a path to empowerment in the face of patriarchal obstetric authority. In the 1980s and beyond, medical innovations and shifting values eroded the appeal of natural childbirth. Crucial in this transition was the popularization of epidural anesthesia, which allowed most women to give birth painlessly while still “awake and aware,” the very thing they had sought in natural childbirth.15 Natural childbirth is no longer a popular choice in maternity care, but it continues to have vocal partisans.16 Two polarized camps face off in today’s birth wars. On one hand, advocates for natural childbirth emphasize the satisfaction and gentleness of their approach. They generally support midwife-led, family-centered maternity care, or what historians dub “social birth.”17 They argue that the hospital’s regimented routines—characterized by its detractors as “technocratic birth”—disempower women, exacerbate pain, and incite trauma.18 Advocates for in-hospital, anesthetized birth emphasize the damage that long labors can inflict on mothers and babies. The medical establishment typically attends more to the physical outcome of birth for mother and child, with only a distant and distinctly secondary concern for the quality of birth as an affective experience. These priorities are evident in the fact that less than one percent of recent articles on birth trauma address the topic from the psychological perspective.19 But despite this inattention, supporters of the medicalized model make their case in part by underscoring that severe, untreated pain in childbirth can lead to psychological trauma.20 In short, the psychological argument features on both sides of the birth wars. Central to these debates is the line between pain and suffering. As leading American midwifery researcher Penny Simkin observes, the “definition of trauma comes very close to the definition of suffering.”21 Pain differs from suffering in that the latter captures the affective quality that sometimes, though not always accompanies pain. We suffer when pain becomes unbearable, not by the body, but by the mind. Childbirth proves to be a uniquely vexed context for distinguishing between pain and suffering. Physician Eric Cassell points out that the relationship between pain and suffering is generally understood to be a direct one: the greater the pain, the greater the suffering. But childbirth is a special case, as pain “can be extremely severe, and yet be considered uplifting…. the perceived meaning of pain influences the amount of medication required to control it.”22 We imbue the pain of childbirth with important meaning that for some mitigates suffering and even has the potential to transform it into an emotion of a wholly different timbre. Advocates for natural childbirth find meaning of the kind Cassell highlights in the pain of labor and birth; detractors see only senseless suffering that could be readily alleviated through the tools of modern medicine. They liken natural childbirth to a root canal undertaken without anesthesia. No one would call “natural dentistry” a good idea, they jest.23 Women’s Narratives of Traumatic Hospital Births Women had, of course, always told birth stories, but amid the postwar baby boom these narratives began to make their way into the American popular press in growing numbers. Behind the scenes, in private letters to medical practitioners and childbirth educators, women wrote poignantly about traumatic birth experiences. Their stories of the inhumanity and indignity of conventional hospital birth helped make the case for attentiveness to more than just the physical health of mother and baby. American women’s hospital birth stories echoed similar ones told by their European sisters, even as birth practices differed substantially between the US and Europe. From the late 1940s through the 1980s, alongside joyful narratives of deeply satisfying and empowering birth experiences, one finds across national borders a remarkably cohesive body of stories that convey the pain and disappointment of women who felt unsupported and uncared for in their moment of greatest vulnerability. Women’s narratives of trauma in birth coalesce around three intertwined themes: abandonment, cruelty, and fear. Mothers felt abandoned in hospitals, where, before fathers were routinely at their partners’ sides, it was common for women to labor in solitude or perhaps in the company (or within earshot) of other laboring women. In one extreme case, a war bride in 1950s' England, whom I will call Mrs. C, recalls that she “was shown into a very bare and unfriendly room where I had the shave, enema, and bath. After that I was left alone in that room on a stretcher with not even a blanket to cover myself.”24 She had undergone preparation for natural childbirth but, without someone by her side to support her efforts, her sense of control faltered. The nursing staff “did nothing to help me, but just left me alone.”25 After her baby was delivered, with tears in her eyes, Mrs. C asked a nurse to just sit with her for a few moments. In response, the undoubtedly overworked, exhausted nurse left the new mother alone in her room. Other mothers offer similar stories that suggest Mrs. C’s case was not unique. “Misunderstanding and loneliness” during her four hospital births inspired Heda Borton to join Great Britain’s natural childbirth movement during this same era.26 Twenty years later, Madame [Mme] R, who gave birth using psychoprophylaxis, wrote to the administration at Les Bluets that the nurses and midwives had been nice, but she nonetheless experienced “a feeling of abandonment while in the labor room.”27 Other new mothers had less generous words to say about the care they received at Les Bluets. As Mme O writes, “I think that I could have endured transition better if the midwife had been with me more and relieved my partner, who was becoming upset by my cries and beginning to be impatient with my lack of bravery.”28 Mme O’s words remind us that birth can be traumatic not only for the mother, but for the partner bearing witness to a loved one’s suffering.29 Another Les Bluets mother’s testimony gives insight into Mme R’s and Mme O’s experiences in a clinic with a longstanding reputation for gentle, supportive care. Mme P gave birth twice at Les Bluets using the psychoprophylactic technique: For my first birth, the midwives were overwhelmed—and I felt abandoned, despite my husband being there. I managed to control myself only with the presence of the midwives and I panicked knowing she was busy with other women. My delivery was not very successful: panic, anxiety, fear, etc. For the second, I was the only woman to give birth that night. I felt totally reassured. I knew the midwife was at the ready to respond to my call.30 Faced with staff shortages, midwives scurried to attend to multiple laboring women and, in the process, the quality of patient interactions declined. Overwork contributed to women’s sense of abandonment, as caregivers donned a “veneer of callousness” in an effort to cope with the workload.31 “The nurses were so pressed for time that if you wanted anything you were just a nuisance,” Mrs. C had decried in London in 1956.32 Twenty years and 200 miles separated her from Mmes R, O, and P, but their despair at the absence of supportive, constant professional care through labor was the same. Overwork alone fails to explain the gruff, inhumane treatment women at times faced in both conventional maternity care and in clinics supportive of natural childbirth. Some experienced outright cruelty at the hands of nurses, midwives, and doctors who seemed unmoved by their pain. In 1957, one nurse famously denounced conventional maternity care in the US as “sadism.”33 In a representative example, an unnamed American mother who gave birth in the late 1940s reflected on her experience as one of “terror and humiliation,” and the notion that “childbirth is meant to be the most satisfying experience in a woman’s life” was simply “poppycock.” Her pain was searing, leading the nurse to stuff a towel in her mouth to muffle her cries. “Finally, when I felt sure I was about to split apart at the bottom, the ugly grey mask pressed against my face” and she gave birth under general anesthesia. This new mother woke to find a healthy baby girl waiting for her, but “all I remember thinking was that I never wanted another baby.”34 From France, too, one finds similar attestations of caregiver indifference. Mme N shared her traumatic story of giving birth in 1949. Without any explanation from her doctor beforehand about what to expect, she went into labor late at night. She became terrified when, after her husband was sent home, the nurse ordered her to get into bed and, after a few sharp words, left the room. When the midwife finally appeared in the early morning, Mme N lamented that “I had been alone during my whole labor and I had suffered a lot.”35 Unsurprisingly, she turned to natural childbirth in her quest for a more humane experience when she became pregnant the next time, but maternity wards that promoted natural childbirth were not immune from charges that ranged from indifference to torture. One French woman who gave birth in 1976 in Les Bluets bemoaned her encounter with a midwife who was obstinately opposed to the use of anesthetics and analgesics. Mme S complained in a letter to the hospital that “despite the midwife’s compliments about my ‘good cooperation’ and ‘good preparation,’ I would have preferred an epidural because I did not choose to become a masochist.”36 The reasons for denying women pain relief varied over time and place. For Mme S and other French women, public financing of epidural anesthesia for childbirth became routine only in 1994, when patient request, rather than doctor’s orders, became standard maternity care practice.37 Beyond financial considerations, there were common beliefs—not just in France, but in the UK, US, and elsewhere—that tamped down the use of anesthetics and analgesics. Pain in childbirth was alternately natural, normal, universal, useful, or exaggerated. Irrespective of the truth of these claims, they served to justify a reluctance to provide pharmacological pain relief. Women often found their complaints dismissed as a nuisance, such as in one typical example in 1956 where a UK mother was told by a nurse, “don’t make such a noise, you frighten all the girls.”38 Others heard that childbirth was the time to pay for the fun they had had earlier, or that the pain would deepen their bond to their child, beliefs distantly rooted in the biblical injunction that Eve “bring forth children in suffering” (Genesis 3:16). Until the late 1970s and early 1980s, most midwives and nurses active in the promotion of natural childbirth believed that pain in childbirth was wholly or largely psychogenic. Mme S’s midwife likely thought that her supportive words and encouragement to relax and breathe should have been enough to manage her pain. When they were not, she futilely persisted down the same, ineffective path through either dogmatism or a lack of other tools at her disposal. Those mothers who experienced acute, unbearable pain felt that the “enchanted fairy tale version of childbirth,” which natural childbirth advocates touted, was “just another shuck.”39 Midcentury, medical professionals quite routinely dismissed not just pain, but also women’s fears. Doctors conceded that they should “certainly pay more heed to the emotional aspects of childbirth,” but that typically meant explaining to women why their concerns were irrational.40 One can imagine that it was a dubious comfort to be told by your physician that It’s true women have died having babies, but almost always as a result of their own carelessness in not seeing a doctor soon enough or not following his orders. People also die in traffic accidents—yet you are not afraid to cross the street or ride in an automobile. Think in the same way of the possibility of your baby being abnormal. The chance is only one in a thousand or less, and even if it happens it’s no longer the tragedy it once was, now that we can correct conditions that used to be lifetime handicaps.41 Anthropologist Margaret Mead found it unsurprising that postwar hospital-based birth proved frightening. “For months [the expectant woman] has been preparing to leave her home and her husband for a strange segregated spot where she and many other women unknown to her will lie together giving birth among strangers.”42 A quarter-century later, fear continued to define conventional hospital birth as, in the description of one California midwife in the 1970s, women lay “spread-eagled on an operating room table, drugged, confused, frightened and at the mercy of a manipulating man.”43 Under the influence of the feminist critique of medicalized maternity care, in the 1980s Kitzinger took this argument further when she asserted that the routines and practices of hospital-based birth were, in fact, intended to spark fear in order to induce compliance with obstetric authority.44 The natural childbirth approach championed by Kitzinger and others was, as already observed, no guarantee for humane care, but many women turned to this approach after a negative experience with their first child’s birth. A traumatic first birth propelled their search for something different. With her husband recently demobilized after World War II, Peggy Studwell was happy to find herself pregnant, but feared the pain. She gave birth to daughter Cherie under heavy anesthesia, but she “could not fully enjoy her small daughter” because she was so traumatized by her birth experience. She was unable to shake the fear of pain that had gripped her before the birth of her first child and that she had sought to escape through anesthesia, a choice that she regretted.45 For the birth of her second child Peggy sought training in natural childbirth. She undertook prenatal classes at the Yale Obstetrical Clinic at Grace-New Haven Hospital, which, under the guidance of Herbert Thoms, was one of the first clinics in the US to offer preparation in the Read method.46 The birth was not painless or without the use of drugs, but for Peggy it was a much more satisfying experience and one that was accompanied by far less anxiety. Another mother who gave birth at Thoms’s clinic in the late 1940s reported a similarly positive natural childbirth experience after a traumatic conventional first birth. “This time I felt no unbearable pain. I felt no panic. Nor was I given drugs to deaden my feelings. This time I lay there, wide awake—and watched my son born.”47 Positive birth experiences had therapeutic value for the resolution of lingering trauma from earlier births. For Peggy and others, there was an “almost complete elimination of the postpartum ‘blues’ which so many women dread.”48 The psychological benefits were not just enjoyed by the mother, but were believed to benefit the entire family. “Children who are naturally born are less likely to show emotional upsets traceable to birth trauma. Husbands, knowing the birth process as a normal function without danger or unbearable pain, lose their fears—and any unconscious guilt feelings they may harbor as the person responsible for their wives’ danger.”49 Domestic harmony allegedly emerged from the psychologically healthy and balanced interpersonal dynamic that ensues as each member accepts his or her rightful role, especially when “the mother has no hidden resentments against her unborn child for fears and pain she must endure.”50 In the decades after these glowing claims about natural childbirth appeared, tens of thousands of other mothers followed in their footsteps with mixed results. By 1985, when Yorkshire (UK) television aired a panel discussion on the topic, the popularity of natural childbirth was already on the wane for a variety of reasons, including patient disappointment with pain management. The show’s guests included natural childbirth promoter and obstetrician Michel Odent and writer Polly Toynbee, “who had tried natural childbirth and didn’t find it at all natural.”51 In the audience sat mothers for and against the use of pain medication during labor and birth. One audience member described having had epidural anesthesia, which had worn off when it was time to push: “so I could have a natural birth. I was in a supported squat and actually felt her coming out. And I remember for days afterwards I harked back to that moment. I wanted to relive that moment and that pain of actually having her.” The show’s host, Miriam Stoppard, then asked, “and is that partly to do with suffering pain? That you’d overcome it?” “I think so, yes, yes,” she responded.52 This young mother had the powerful relief of epidural anesthesia during labor and transition, which for most women is the most painful stage. She found value in what pain she did experience, but perhaps it would have been more accurate for Stoppard to suggest that this mother “had” pain rather than “suffered” it. Her pain does not appear to have passed into the realm of suffering. Toynbee took her to task, challenging what she saw as a sanctification of pain. “There's nothing particularly special about suffering a great deal of pain. There is nothing moral about pain. I think some people have been rather puritanical about saying you don't deserve the baby unless you've suffered for it. Something like the curse of Eve in the Bible. You know, we were made to suffer that pain, so suffer it.”53 Toynbee rejected the meaning that these women inscribed on their pain. For her, the pain had transformed into suffering and there was nothing romantic or redemptive in it. The Psychiatric View Toynbee never used the word “trauma” in either a clinical or colloquial sense to describe her birth experience, but we can hear in her testimony something akin to it. Trauma as a psychological category has a long and convoluted history that has inched gradually toward our present understanding and is evident in the language we use. Locating in the historical record what we identify today as trauma in birth is complex and problematic. Only with its entry into the 1980 edition of the DSM did PTSD become an official psychiatric diagnosis.54 Prior to this, the medical establishment employed a variety of fluid terms to describe what we understand as its symptoms, such as Kartchner’s description of his patient’s recurring nightmares. A partisan of the dominant midcentury viewpoint, Kartchner deploys the Freudian terminology of “traumatic neurosis” to describe her condition. One also at times encounters “hysteria” as a descriptor of the cluster of symptoms that resemble today’s PTSD. There was a certain shared vocabulary of trauma, but psychiatrists and physicians varied the emphases and inflections. In the era of PTSD, too, there is ongoing refinement of the condition’s definition. With each iteration of the DSM, debates ensue about the pros and cons of these emendations.55 It took twenty years for PTSD to be recognized as potentially relevant to the experience of birth. The view of birth as normal, natural, safe, and routine for most women perhaps contributed to the medical community’s failure to hear some women’s attestations of profound suffering. Only in the early twenty-first century did maternity care researchers apply this diagnostic lens to birth experiences. Today’s PTSD has roots in the mid-nineteenth century, when the budding science of the mind began modern inquiry into the relationship between memory and psychological disorder. Jean-Martin Charcot led the way in understanding traumatic memories of prior events as having an impact later in life, as manifested in the condition of hysteria. He shifted emphasis from what was believed to be a physical causality best treated by the removal of the uterus and proposed, alternatively, that maladjustment resulted from prior, psychologically traumatizing experience. Charcot was unequivocal that the womb played no role in hysteria and that men were equally susceptible to it.56 Pierre Janet, Joseph Breuer, and Sigmund Freud subsequently built on this line of inquiry. Freud eventually veered away from the emphasis on a concrete, precipitating event and instead stressed suppressed memories of early psychosexual development that resided in the subconscious.57 Among Freud’s colleagues and disciples who explored this theme, Sándor Ferenczi was almost unique in his continued emphasis on prior traumatic events as the root cause of psychological disturbance—a view that would in later years, after the heyday of Freudianism had passed, come to dominate trauma theory. Ferenczi adhered to Freud’s belief in the significance of the child’s unresolved sexual desire for one’s parent, but he also saw a range of other potential sources of trauma, including real or perceived physical danger.58 Writing in the early twentieth century, Freudian psychoanalyst Otto Rank understood the trauma of birth from the perspective of the newborn. Ultimately disavowed by Freud, Rank argued that neurosis was a universal human condition that was best explained by origins even deeper than those of early childhood. He saw in parturition itself the root cause of psychological suffering with the act of literal separation from the mother. Rank regarded expulsion of the baby as “a vaguely remembered primal trauma,” over which later traumas, such as a girl’s unrequited sexual desire for her father, were layered.59 For Rank, war neurosis—a precursor to today’s PTSD—found explanation in his theory that “the primal anxiety is directly mobilized through shock, the otherwise unconsciously reproduced birth situation being affectively materialized through the outer danger of death.”60 In other words, the existential threat of war triggers a re-experiencing of the trauma of being born. In the 1940s, the psychoanalyst Nandor Fodor, who was an analysand of Rank, elaborated on the relationship between the trauma of being born and of giving birth. He wrote: “No sexual injury is more likely to raise the ghost of our own arrival into this world than that of bearing a child; and it cannot be disputed that bearing a child is a sexual injury.”61 Childbearing unleashes a primal, existential anxiety, a fear of death inscribed on our psyche from our own journey through the birth canal. Childbirth passes that trauma on to the next generation, while simultaneously rekindling in the mother her original trauma of being born. He observes that some women feel “panic-stricken at the prospect of bearing a child” and, though “they are not likely to die,” they nonetheless “feel as if they were confronting death.”62 While most today would dismiss Fodor’s claim that women have these feelings because giving birth reopens the psychic wound of their own birth, Fodor’s affective description captures well the emotions that mid-century women expressed—and their physicians deemed irrational—while gesturing toward the symptoms of today’s PTSD. Though I have no direct evidence of their influence, Rankian thinkers appear to have left their mark on the writings of maternity care professionals. Contemporaneous to Fodor, natural childbirth advocates at New York City’s Maternity Center Association (MCA) lamented the emotional sterility that accompanied hospital birth and potentially exacerbated the trauma of being born. “Nobody holds [the baby] close to cuddle it and makes it feel secure… . A ritual of anxious concern rather than of pleasure” surrounds the newborn, in contrast to the experience of babies “in primitive societies, [where] the baby emerges from the warm darkness of his mother’s uterus and is gently introduced to life by being nestled and cuddled close to her soft skin.”63 Two decades later, French obstetrician Frédérik Leboyer’s advocacy of “childbirth without violence” similarly echoes of Rank’s and Fodor’s concern with the trauma of birth. Leboyer argues for as calm and quiet an entrance into life as possible. He promotes the use of dim lighting and the maintenance of a serene environment, despite the inconvenience posed to medical staff. Some challenged Leboyer’s emphasis on the baby’s gentle passage, arguing that he had all but forgotten the woman and her comfort. They claimed that he rendered her invisible, relegated to a mere vessel.64 He was taken to task for going so far as depicting the mother as a “monster” who is the source of the baby’s torture during labor and birth.65 His partisans dismissed this criticism as reflective of a “lack of understanding of his techniques and philosophy,” with Leboyer gaining a following in France and abroad, including in the US and UK, in the 1970s and 1980s.66 With respect to the psychological experience of the mother, Helene Deutsch articulated the fullest and most influential Freudian interpretation.67 A contemporary of Fodor, Deutsch undergirds her ideas with biological determinism and emphasizes early psychosexual experiences in the development of female sexuality and the expression of sex roles, most notably in mothering. Deutsch asserts that the awakening of the vagina to full sexual functioning is entirely dependent upon the male’s activity; and this absence of spontaneous vaginal activity constitutes the physiologic background of feminine passivity. The competition of the clitoris, which intercepts the excitations unable to reach the vagina, and the genital trauma then create the dispositional basis of a permanent sexual inhibition, i.e. frigidity.68 Female passivity could manifest itself in the act of childbirth, as women “blindly follow other people’s instruction and, like children, are interested only in getting rid of their fear and being subjected to as little pain as possible.”69 This strategy of avoidance interfered with experiencing childbirth as a satisfying, even therapeutic lifecycle event; it could, instead, be a source of trauma, as could a woman’s futile desires to control childbirth, an unconditional, involuntary neuromuscular process. Only by achieving a balance between activity and passivity could a woman not risk childbirth reigniting the trauma of her inherent inadequacy as a female, a notion captured in Freud’s theory of penis envy.70 Advocates for natural childbirth invoked Deutsch to justify their views on how women could give birth with the greatest satisfaction and the least trauma. A midcentury American obstetrics textbook, for example, endorses natural childbirth and cites Deutsch as the source for understanding childbirth as an expression of masochism that weaves “pain together with the ecstasy of the act of parturition…. [T]he alleviation of all pain with medication deprives the woman of an important part of her obstetric experience.”71 Dick-Read himself describes Deutsch as “the great American expert” on female neurosis and he agreed with “so much” of her writings.72 He attributed to her his appreciation of the role “incidents of unhappy sex and birth” play in a woman’s psychological makeup.73 Her mark on his thinking comes through when he writes of the woman “overconfident” in her ability to strike the right note between what Deutsch would characterize as passivity and activity.74 However, Dick-Read rejected the idea that pain in childbirth offered a masochistic pleasure. He argued vehemently that pain in normal birth was purely a manifestation of fear. The idea that there was something common, possibly useful, and maybe even pleasurable in labor pain was utter anathema to his thinking.75 He also took umbrage at her critique of his work as denying the physical sources of pain in labor in favor of a wholly psychological theory of its origins.76 Along with Deutsch, Karen Horney contributed to defining feminine psychology in the Freudian tradition. Most famously and controversially, she asserted that penis envy was not simply a feminine desire to heal the wound of her inadequacy for having been born female, but a longing for what today we would call male privilege—the collective social, cultural, political, and economic benefits accrued to all men simply by virtue of being male. The desire was not for a physical penis, as Freud and Deutsch would have it, but for the freedoms and entitlements that accompanied possession of that organ. Moreover, this envy was in Horney’s estimation mutual, as women’s capacity to bring life into the world and to experience the empowerment that went with that inspired in men “womb envy.”77 Horney left her mark on the natural childbirth movement once secondwave feminists drew fresh attention to her writings from a half-century earlier. It is evident in Kitzinger’s 1983 critique of Leboyer, whom she believes evinces “cringing terror” of female power, which stimulates “the envy of woman’s ability to give birth, envy of female sexuality, and dread of it.”78 The psychology of birth was of a piece with Freudian thinking on a raft of female maladies. Psychoanalysts and physicians alike were quick to attribute disturbance in female sexuality, reproduction, and wellbeing broadly to the power of women’s minds over their bodies. Pre-menstrual syndrome (PMS) spoke to a woman’s unfulfilled desire for motherhood. Infertility, frigidity, and painful intercourse evidenced ambivalence toward motherhood and a rejection of femininity.79 Dick-Read, for example, asserted that one of his patient’s “psychological attitude was probably the major factor” in her inability to conceive.80 For those who fell pregnant, morning sickness, miscarriage, uterine inertia, preterm labor, and overdue labor all attested to a continuing negativity toward imminent maternity.81 Fodor claims that a powerful subconscious desire to avoid pregnancy could induce a miscarriage, but the depths of a woman’s conscious desire for a child or the fetus’s own “amazing tenacity” could, on occasion, conquer these forces.82 Arguing for the mother’s “mental processes” as the source of her problems, Dick-Read shared these views on the power of female psychology to enable or subvert pregnancy. He dismissed one woman’s “so-called miscarriages” as induced by her own negative thinking.83 For the woman who carried a pregnancy to term, her psychological stance toward her experience of pregnancy, birth, and new motherhood continued to drive bodily malfunction. Fodor argues that heavy bleeding, difficulty breastfeeding, and other physical ailments following childbirth attested to “the psychic storm through which the mother had passed and of which, in her unconscious, she is still in the throes.”84 For some psychiatrists, a concern with the role of social conditions tempered the preeminence Freudians gave to women’s subconscious desires. New York psychiatrist Henrietta Klein emphasized how material circumstances, such as unemployment and overcrowding, contributed to alcohol abuse and domestic violence, with obvious implications for women’s psychological preparedness for motherhood. “One cannot ignore the part played by reality factors,” she stressed.85 Postwar housing shortages made the prospect of bringing a baby into the family a challenge. Many young couples lived with relatives in cramped quarters, or had otherwise marginal or unstable living arrangements. That these women were ambivalent about their pregnancies, Klein argued, made perfect sense; their attitude was a rational response to adverse material conditions, and not a sign of maladjustment.86 She cautioned against those psychiatrists who prescribed pregnancy as treatment for an unhappy married life and insisted that motherhood would exacerbate a deteriorating domestic situation. Women pushed into pregnancy and childbirth might experience it as traumatic, resulting in difficulty bonding with their babies and living harmoniously with their husbands.87 Most mid-century psychiatrists believed that, whatever women’s material circumstances, they came into pregnancy and childbirth predisposed either to weathering the experience well or not. They adhered to the belief that adult experiences, including labor and birth, were not the sources of trauma, but merely triggered a pre-existing psychological propensity.88 For all her emphasis on material conditions, Klein nonetheless argued that women already predisposed toward anxiety before pregnancy would find that inclination persistent or even strengthened during pregnancy and childbirth.89 Among the 500 maternity cases examined in Kartchner’s 1949 study of fear and anxiety during and after pregnancy, sixty women allegedly demonstrated significant or “complete lack of control” in labor and birth in their physician’s estimation; afterwards these women experienced feelings that sound much like post-traumatic stress or postpartum depression.90 Kartchner asserts that for about two-thirds of these women little could have been done to avoid their traumatic experience because they came into pregnancy with subconscious “severe emotional conflicts.”91 Prenatal preparation, relaxation techniques, and soothing support from a caregiver or loved one were unlikely to prove effective interventions for these women in his estimation. Dick-Read shared this belief that a woman’s psychological makeup played a prominent, though not necessarily determinative role in the question of trauma in birth. The case of Mrs. B serves to illustrate his views and what they meant for the clinical encounter between doctor and patient. In correspondence with his colleague, Dr. Z, regarding their mutual patient, Mrs. B, in Johannesburg, Dick-Read describes how she “had a bad 20 hours [of labor] during which she gained little relief by the usual sedative methods. I became fully aware then that she was suffering far more from psychological labor than from any physical effort of parturition. … I did not enquire into her obsessions, inhibitions or frustrations… but the fact of their presence was clearly established.”92 Dr. Z shared Dick-Read’s assessment of Mrs. B more than a month postpartum: [she] still has a lot of obsessions or frustrations. …All [she] could talk about was how difficult her confinement had been. Usually a woman forgets those things as soon as the baby has been born, but to [Mrs. B] it seems to be far to [sic] much of a reality still. I have always felt that she had some sort of inhibition or frustration but could not actually lay my finger on it. She tries hard but something is wrong. In my own mind I have a strong suspicion that it is related to sex in some way.93 Dick-Read and Dr. Z do not here reference the writings of Deutsch or other Freudians explicitly, but the terminology they use clearly signals adherence to this perspective. Whether Dr. Z’s belief that “something is wrong” “related to sex” is correct or not is of less interest than their consensus and its implications. Impugning Mrs. B’s mental fitness delegitimizes her complaints. They appear never to consider seriously any physiological cause for her suffering. Dick-Read certainly fails to entertain the possibility, here or elsewhere, that his method might have been ineffective for some of his patients. She may have truly been experiencing exceptionally acute pain if, for example, the baby was in a posterior position. Perhaps the dose of the opiate pethidine that Dick-Read administered had been insufficient, as she had complained at the time. Like many of the women who attested to traumatic birth experiences in this era, her pain and exhaustion may have been exacerbated by fear and perhaps even a sense of her physician’s lack of compassion. Mrs. B’s continued suffering postpartum induces little sympathy from these men. They absolve themselves of responsibility for her care and for any need to heed her complaints. From her correspondence with Dick-Read, we learn that Mrs. B herself readily accepts these medical men’s proffered interpretation of her distress, as no doubt many patients did in similar circumstances. “I have said that [your natural childbirth method] did not [work] because of the reasons you gave me: that I had various inhibitions including a resentment of pregnancy.”94 In her estimation as well as theirs, her marred mind generated or exaggerated her pain. In a sense, she created her own suffering, albeit subconsciously. Mrs. B was perhaps seen (and saw herself) as responsible for it in a way that she would not have been if her pain had been understood as of physiological origin. Whether Mrs. B’s trauma originated in her mind or body, the consequences for mother and baby were grim. Dick-Read reported to Dr. Z that upon delivery her psychological condition was demonstrated by the fact that she refused to take any interest in the child when it was born and turned her away with an expression more of disgust than anything else. That … is a moment when one sees the promptings of motherhood most clearly exhibited. Before the cord was cut, however, I insisted that she should look at her child, and told her to take it in her arms, realising that it was hers and that it was not the child's fault that it was born or words to that effect. Her description of it was not complimentary, although in reality it was a lovely baby, and after a few minutes she very sternly demanded that it be removed.95 Dick-Read clearly saw Mrs. B’s initial postpartum reaction as evidence of maladjustment. Alternatively, her demeanor perhaps signaled the physical and emotional toll of the birth. Her chilly, flat affect might have been evidence of the psychic numbing and difficulty connecting with others that is characteristic of trauma. Conclusion One of several factors, second-wave feminism contributed mightily to reshaping the field of psychiatry and rethinking the roots of trauma for both men and women.96 Birth activists and feminist psychiatrists questioned the roles to which women were supposed to adjust; the social system into which those roles fit; and the ways that doctor-patient dynamics and maternity care practices conspired to coopt, silence, delegitimize, and disempower women. Kitzinger put her finger on the issue when in 1983 she said that “we have been taught time and time again, in sex generally, as in childbirth, to ask ‘What did I do wrong?’ Now all this doesn’t happen just by chance. We live in a society which molds women into compliant housekeepers, mothers and patients…. A hospital turns a woman into a maternity patient through a series of rites” intended to strip her of power, yet the woman is left asking herself how she succumbed to fear and pain, or was railroaded into an intervention she had sought to avoid.97 Feminism contested the notion that women experienced birth as traumatic because there was something already wrong with them; it led women, instead, to challenge as inadequate the care they received. As was evident in their testimonies from the 1970s and 1980s, women pushed back against the kind of professional judgments that patients like Mrs. B had readily accepted from men like Dick-Read in the 1940s and 1950s. But as Kitzinger and others show, medical ideas about gender and trauma were changing, too, through professional debates enmeshed with and informed by popular discussions. It is perhaps impossible to unravel who influenced whom in the evolution of these ideas. Patients and their physicians carried on simultaneous and overlapping conversations. A new chapter in the history of trauma began with the codification of PTSD in 1980. In contrast to the dominant theories of trauma that gained currency earlier in the twentieth century, PTSD located the source of trauma outside the imaginings of the sufferer’s own mind. In rejecting the Freudian emphasis on the subconscious, PTSD perhaps validated suffering in a way that was not possible when it was rooted so wholly in the psyche. Blame, in a sense, became externalized with the new emphasis on real-world events. War, rape, and severe car accidents were all considered possible “stressors”—extraordinary events capable of inducing the cluster of symptoms that define PTSD. Psychiatrists accepted adult experiences as causative in and of themselves, rather than as mere triggers of a pre-existing disorder.98 Only in the last decade has there been an efflorescence of medical research on PTSD and childbirth. In a departure from the earlier medical literature, prior trauma and depression constitute only two possible risk factors for developing postpartum PTSD.99 Other considerations include “unexpected medical interventions, pain beyond the coping ability of the woman, care from providers that was uncaring, unsafe, and inhumane, and the possibility of injury or death for herself or infant.”100 We see in recent thinking about birth trauma a range of causality far beyond the Freudian focus on the subconscious, though it is conspicuous how very long it took for maternity caregivers and mental health professionals to recognize the relevance of PTSD to birth. Although ideas about the origins of trauma have changed radically in recent decades, how best to avoid it in childbirth has not proven a mystery. The role of caregivers has been and remains absolutely essential to minimizing or averting trauma, irrespective of how its origins are explained. In the 1940s, Kartchner found that “sympathetic, constant care with repeated explanations was most frequently mentioned” as the reason for satisfactory experiences, free of “unpleasant emotional upheaval.”101 More than a half-century later, in the most comprehensive US study todate on nonpharmacological pain management measures in maternity care, researchers identified constant companionship and support as the most effective approach.102 A 2016 literature review by midwifery researchers Simpson and Catling finds consensus that high quality care that meets “the patient’s stated and implied needs, as perceived by the patient” plays a significant role in curbing women’s experience of trauma in childbirth.103 From past and present the answer seems equally clear. The enduring question appears to be why, despite all that we know and have known for a long time, is the hospital maternity ward still a site of suffering for so many women? Footnotes 1 F. D. Kartchner, “A Study of the Emotional Reactions during Labor,” American Journal of Obstetrics and Gynecology 60, no. 1 (July 1950): 20. 2 “Trauma- and Stressor-Related Disorders,” in Diagnostic and Statistical Manual of Mental Disorders, 5th ed., DSM Library (n.p.: American Psychiatric Association, 2013), doi:10.1176/appi.books.9780890425596.dsm07. 3 Michel Foucault, The History of Sexuality, trans. Robert Hurley (New York: Pantheon, 1978), 96. 4 Judith Walzer Leavitt, Brought to Bed: Childbearing in America, 1750 to 1950 (New York: Oxford University Press, 1986). 5 Cheryl Tatano Beck, “Birth Trauma: In the Eye of the Beholder,” Nursing Research 53, no. 1 (February 2004): 28–35. 6 Sheila Kitzinger, “Nurturing Mothers,” Healthsharing, Winter 1983, 15. 7 Madeleine Simpson and Christine Catling, “Understanding Psychological Traumatic Birth Experiences: A Literature Review,” Women and Birth 29, no. 3 (2016): 203–04, doi:10.1016/j.wombi.2015.10.009. 8 On the history of twentieth-century childbirth in the US, see, Wendy Kline, Bodies of Knowledge: Sexuality, Reproduction, and Women’s Health in the Second Wave (Chicago: University of Chicago Press, 2010); Judith Walzer Leavitt, Make Room for Daddy: The Journey from Waiting Room to Birthing Room (Chapel Hill: The University of North Carolina Press, 2009); Paula A. Michaels, Lamaze: An International History (New York: Oxford University Press, 2014); Margarete Sandelowski, Pain, Pleasure, and American Childbirth: From the Twilight Sleep to the Read Method, 1914-1960 (Westport, CT: Greenwood Press, 1984); Jacqueline H Wolf, Deliver Me from Pain: Anesthesia and Birth in America (Baltimore: Johns Hopkins University Press, 2009). On Great Britain, see Angela Davis, Modern Motherhood: Women and Family in England, c.1945-2000 (Manchester: University of Manchester, 2014). On France, see Marianne Caron-Leulliez and Jocelyne George, L’accouchement sans douleur histoire d’une révolution oubliée (Paris: Les éd. de l’atelier/Les éd. ouvrières, 2004); Yvonne Knibiehler, La révolution maternelle: femmes, maternité, citoyenneté depuis 1945 (Paris: Perrin, 1997); Yvonne Knibiehler, Accoucher: femmes, sages-femmes et médecins depuis le milieu du XXe siècle (Rennes: Ecole nationale de la santé publique, 2007). 9 I borrow this moniker from Mary-Rose MacColl, The Birth Wars (St Lucia, Qld.: University of Queensland Press, 2009). 10 Donald Caton, What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth from 1800 to the Present (New Haven, CT: Yale University Press, 1999). 11 E.g., Barbara Ehrenreich and Deirdre English, Complaints and Disorders: The Sexual Politics of Sickness (Old Westbury, NY: The Feminist Press, 1975). 12 Michaels, Lamaze. 13 Though difficult to measure, abundant anecdotal evidence points to its popularity. In 1962, at least a decade before interest peaked, it was described as “the most-dropped phrase among America’s pregnant women today.” Waldo Lewis Fielding and Lois Benjamin, The Childbirth Challenge: Commonsense Versus “Natural” Methods, (New York: Viking Press, 1962), 9. 14 Rebecca Jo Plant, Mom: The Transformation of Motherhood in Modern America (Chicago: University of Chicago Press, 2012); Jessica Weiss, To Have and to Hold: Marriage, the Baby Boom, and Social Change (Chicago: University of Chicago Press, 2000). 15 Irwin Chabon, Awake and Aware: Participating in Childbirth through Psychoprophylaxis (New York: Delacorte Press, 1966). 16 E.g., Abby Epstein, The Business of Being Born (Burbank, CA: New Line Home Entertainment, 2008). 17 Richard W. Wertz and Dorothy C. Wertz, Lying-in: A History of Childbirth in America (New York: Free Press, 1977). 18 Robbie E. Davis-Floyd, “The Technocratic Model of Birth,” in Feminist Theory in the Study of Folklore, eds. Susan Tower Hollis, Linda Pershing, and M. Jane Young (Urbana-Champaign: University of Illinois Press, 1993), 297–326. 19 Simpson and Catling, “Understanding Psychological Traumatic Birth Experiences,” 204. 20 E.g., Fielding and Benjamin, The Childbirth Challenge; Amy Tuteur, Push Back: Guilt in the Age of Natural Parenting (New York: Dey Street Books, 2016). 21 Penny Simkin, “Pain, Suffering, and Trauma in Labor and Prevention of Subsequent Posttraumatic Stress Disorder,” The Journal of Perinatal Education 20, no. 3 (2011): 167, doi:10.1891/1058-1243.20.3.166. 22 Eric J. Cassell, The Nature of Suffering: And the Goals of Medicine (New York: Oxford University Press, 1994), 34. 23 Gregory K. Moffatt, The Parenting Journey: From Conception Through the Teen Years (Westport, CT: Praeger, 2004), 55. 24 “Natural Childbirth,” Parents Group Bulletin, Summer 1956, 45. I use pseudonyms in two situations. In some cases, I draw on archival documents held in repositories that require the use of pseudonyms in order to protect patient identity. For the sake of consistency and out of an abundance of caution, I have chosen to use pseudonyms even when I was not explicitly required to do so by the archive. In other cases, published sources describe anonymous cases; to ease narrative flow, I have assigned pseudonyms in some instances, which I note as in the next above. The initials do not correspond to women’s given names or surnames. 25 Ibid., 47. 26 Letter from Heda Borton to Ian Donald and A.C. Turnbull, 30 January 1975, National Childbirth Trust Archive, Box 2, unnumbered folder, London (hereafter NCT). Borton was active in the Natural Childbirth Trust, founded by mother-activists to promote the ideas of Grantly Dick-Read. Known today as the National Childbirth Trust, this is the largest prenatal education organization in the UK. On its history, see Valerie Allen, The Legacy of Grantly Dick-Read (London: National Childbirth Trust, 1991). 27 Letter from Mme R to Les Bluets, 18 October 1976, Box X-1, Collection l’Accouchement sans Douleur, Archives de l’Union fraternelle de la métallurgie, L’Institut d’HIstoire Sociale CGT de la Métallurgie, Paris (hereafter ASD). 28 Letter from Mme O to Les Bluets, [1980], Box X-2, ASD. Transition describes the final stage of labor, when a woman reaches full dilation. For many women, this is the most painful period. 29 Simkin, “Pain, Suffering, and Trauma in Labor and Prevention of Subsequent Posttraumatic Stress Disorder,” 167. 30 Response from Mme P to Les Bluets Exit Questionnaire, [1980], Box X-2, ASD. Emphasis in original. 31 MacColl, The Birth Wars, 192. 32 “Natural Childbirth,” 47. 33 Registered Nurse, “Sadism in Delivery Rooms?,” Ladies Home Journal, November 1957, 4. 34 [As Told To] Amy Selwyn, “I Watched My Baby Born,” Pageant, January 1949, 5. 35 Quoted in Alain Noirez, “L’Accouchement sans douleur: De la présence du conjoint à l’accouchemnt de son épouse. Le vécu de la paternité, le rôle du mari au cours de la gestation. La crise modern de la paternité” (PhD diss, Université Pierre et Marie Curie, Paris-VI, 1976), 122. 36 Letter from Mme S to Les Bluets, 17 October 1976, Box X-1, ASD. 37 Michaels, Lamaze, 130–32. 38 “Natural Childbirth,” 47. 39 Glenda Adams, “Natural Childbirth: Just Another Shuck,” Village Voice, 30 September 1971, 18. 40 “Natural Childbirth without Pain,” New Haven Register, 2 March 1947, 3. 41 Morton Sontheimer, “Miracle in the Delivery Room,” Women’s Home Companion, December 1948, 4. 42 Quoted in “What Can We Learn from New Guinea? The 1949 Annual Report of the Maternity Center Association, New York,” 1949, Herbert Thoms Collection, MS 14, Scrapbooks, Yale University, Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT (hereafter HCJHW). 43 Offprint, “Mister Midwife of San Diego, Prevention,” June 1972, Midwifery Collection, MS 454, Box 6, Folder 7, Sophia Smith Collection, Northampton, MA. 44 Kitzinger, “Nurturing Mothers,” 16. 45 Toni Taylor, “Natural Childbirth,” Today’s Woman, December 1949, 47. 46 Herbert Thoms, “Natural Childbirth in a Teaching Clinic,” Journal of Obstetrics and Gynecology of the British Empire 56, no. 1 (1949): 18–21. 47 Selwyn, “I Watched My Baby Born,” 5. Emphasis in original. 48 Taylor, “Natural Childbirth,” 52. 49 Ibid. Emphasis in original. 50 Ibid. 51 Nick Abson, “Where There’s Life” (Yorkshire Television, 28 August 1985), British Film Institute. 52 Ibid. Natural childbirth activists might well have challenged this woman’s characterization of her birth as “natural” given that she labored with the benefit of epidural anesthesia. Her understanding may in part reflect national differences, as the US natural childbirth movement was the most dogmatic in its rejection of pharmacological pain relief. 53 Ibid. 54 On the history of the DSM, see Hannah Decker, The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (New York: Oxford University Press, 2013); Gary Greenberg, The Book of Woe: The DSM and the Unmaking of Psychiatry (New York: Blue Rider Press, 2014); Allan Young, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (Princeton, N.J.: Princeton University Press, 1997). 55 For example, on the debate surrounding adding Complex Post-Traumatic Stress Disorder to the DSM, see Patricia A. Resick et al., “A Critical Evaluation of the Complex PTSD Literature: Implications for DSM-5,” Journal of Traumatic Stress 25, no. 3 (2012): 241–51, doi:10.1002/jts.21699. 56 Mark S. Micale, Hysterical Men: The Hidden History of Male Nervous Illness (Harvard University Press, 2009). 57 Shoshana Ringel and Jerrold R. Brandell, eds., Trauma: Contemporary Directions in Theory, Practice, and Research (Thousand Oaks, CA: Sage Publications, 2011), 1-2. 58 Miguel Gutiérrez Peláez, “Trauma Theory in Sándor Ferenczi’s Writings of 1931 and 1932,” International Journal of Psychoanalysis 90, no. 6 (2009): 1218. See also Didier Fassin and Richard Rechman, The Empire of Trauma: An Inquiry into the Condition of Victimhood (Princeton, NJ: Princeton University Press, 2009), 62-63. 59 Otto Rank, The Trauma of Birth (New York: Dover Publications, 1993), 21. 60 Ibid., 47. War neurosis has its own long, complicated genealogy and well-developed historiography. See, for example, Paul Frederick Lerner, Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890-1930 (Ithaca: Cornell University Press, 2003); Ruth Leys, Trauma: A Genealogy (Chicago: University of Chicago Press, 2010); Young, The Harmony of Illusions. 61 Nandor Fodor, “The Trauma of Bearing,” Psychiatric Quarterly 23, no. 1 (1949): 59; M. Straker, “Psychological Factors During Pregnancy and Childbirth,” Canadian Medical Association Journal 70, no. 5 (1954): 510–14. 62 Fodor, “The Trauma of Bearing,” 59. 63 “What Can We Learn from New Guinea? The 1949 Annual Report of the Maternity Center Association, New York.” 64 Michaels, Lamaze, 133–34. 65 Sandra Schildroth, “Book Review: A Deeper Look at Leboyer. Birth without Violence by Frederick Leboyer,” News from H.O.M.E. 1, no. 1 (1976): 2; also Kitzinger, “Nurturing Mothers,” 18. 66 “Leboyer and Consciousness of the Baby,” Birth Notes 1, no. 3 & 4 (1977): 1. 67 Deutsch is cited widely and described by Straker as “extremely influential.” Straker, “Psychological Factors During Pregnancy and Childbirth,” 511. 68 Helene Deutsch, The Psychology of Women: A Psychoanalytic Interpretation, vol. 2 (New York: Grune & Stratton, 1944), 233. In later years, research by Masters and Johnson challenged these notions of female sexuality as passive, as did feminist psychiatry. Thomas Maier, Masters of Sex: The Life and Times of William Masters and Virginia Johnson, the Couple Who Taught America How to Love (New York: Basic Books, 2009); Kate Millet, Sexual Politics (New York: Ballantine Books, 1970). 69 Deutsch, The Psychology of Women, 2: 234. 70 Sigmund Freud, “The Sexual Enlightenment of Children,” in The Standard Edition of the Complete Psychological Works of Sigmund Freud, trans. James Strachey and Anna Freud, vol. 9: Jensen’s “Gradiva” and other works, 1906-1908, 24 vols. (London: Vintage: Hogart Press: The Institute of Psycho-Analysis, 2001), 129–40. 71 Clarence D. Davis, “Section II: Prepared Childbirth,” undated supplement to Davis’ Gynecology and Obstetrics, vol. 1 (Hagerstown, MD: W. F. Prior, 1949), 88. 72 The phrase “the great American expert” comes from Grantly Dick-Read, Typescript, Unpublished Autobiography, n.d., 33, Personal Papers, Grantly Dick Read, A.92, Wellcome Library, London (hereafter PP/GDR/A.92/WL). “So much” is found in Letter from Grantly Dick-Read to Herbert Thoms, 1 March 1949, Herbert Thoms Collection, MS14, Box 1, Fol 1, HCJHW. 73 Dick-Read, Typescript, Unpublished Autobiography, 33, PP/GDR/A.92/WL. 74 Ibid., 10. 75 Letter from Grantly Dick-Read to Herbert Thoms. 76 Quoted in Kartchner, “A Study of the Emotional Reactions during Labor,” 24. 77 Karen Horney, Feminine Psychology, Revised ed. edition (New York; London: W. W. Norton & Company, 1993). 78 Kitzinger, “Nurturing Mothers,” 18. 79 Horney, Feminine Psychology, 99–106; Straker, “Psychological Factors During Pregnancy and Childbirth,” 512. 80 Letter from Grantly Dick-Read to Dr. Y, 30 March 1950, PP/GDR/D.180, WL. 81 Ibid; Fodor, “The Trauma of Bearing,” 59, 62, 63; “Mrs. Sheila Kitzinger’s Talk on the Relationship between Instinct and Training in Childbirth,” National Childbirth Trust Newsletter, September 1963, 9. 82 Fodor, “The Trauma of Bearing,” 60. 83 Letter from Grantly Dick-Read to Dr. Z, 27 September 1950, PP/GDR/D.183, WL. 84 Fodor, “The Trauma of Bearing,” 60; Nandor Fodor, “The Search for the Beloved,” Psychiatric Quarterly 20, no. 4 (1945): 549–602. 85 Henriette R. Klein, Anxiety in Pregnancy and Childbirth (New York: P.B. Hoeber, 1950), 13. 86 Ibid., 15, 17, 18. 87 Klein, Anxiety in Pregnancy and Childbirth; Straker, “Psychological Factors During Pregnancy and Childbirth”; Kartchner, “A Study of the Emotional Reactions during Labor.” 88 Fassin and Rechtman, Empire of Trauma, 5-8. 89 Klein, Anxiety in Pregnancy and Childbirth, 21, 25. 90 Kartchner, “A Study of the Emotional Reactions during Labor,” 21. 91 Ibid., 27. 92 Letter from Grantly Dick-Read to Dr. Z, 30August 1950, PP/GDR/D.183/WL. 93 Letter from Dr. Z to Grantly Dick-Read, 21 September 1950, PP/GDR/D.183/WL. 94 Letter from Mrs. B to Grantly Dick Read, 24 August 1951, PP/GDR/D.79/WL. 95 Letter from Grantly Dick-Read to Dr. Z, 30 August 1950. 96 The role of Vietnam and the psychiatric encounter with veterans is, of course, widely seen as central in revising the understanding of trauma, but other factors played a part as well, including Holocaust traumatology and the psychology of nuclear war. The influential work of Robert Jay Lifton exemplifies the convergence of several social movements and political events to redefine trauma after World War II. See, for example, his Death in Life: Survivors of Hiroshima (New York: Random House, 1968) and Home from the War: Vietnam Veterans, Neither Victims nor Executioners (New York: Simon and Schuster, 1973). The influence of feminism on his thinking about the trauma of the Vietnam War is evident when he writes, for example, that the “super-masculine ethos fits in with war-making and the war-like ethos,” the psychological costs of which are borne by veterans. Untitled typeset manuscript, [1971 or 1972?], Robert Jay Lifton Papers, box 116, folder 1, Manuscripts and Archives Division, New York Public Library, New York. 97 Kitzinger, “Nurturing Mothers,” 16. 98 Ringel and Brandell, Trauma; Fassin and Rechtman, Empire of Trauma, esp. 77-93. 99 E.g., Jenny Gamble and Debra Creedy, “Psychological Trauma Symptoms of Operative Birth,” British Journal of Midwifery 13, no. 4 (2005): 218–224, doi:10.12968/bjom.2005.13.4.17981; J. Söderquist et al., “Risk Factors in Pregnancy for Post‐traumatic Stress and Depression after Childbirth,” BJOG: An International Journal of Obstetrics & Gynaecology 116, no. 5 (2009): 672–680, doi:10.1111/j.1471-0528.2008.02083.x. 100 Grace Zimmerman, “Birth Trauma: Posttraumatic Stress Disorder After Childbirth,” International Journal of Childbirth Education 28, no. 3 (2013): 62. 101 Kartchner, “A Study of the Emotional Reactions during Labor,” 25. 102 Penny P. Simkin and MaryAnn O’Hara, “Nonpharmacologic Relief of Pain during Labor: Systematic Reviews of Five Methods,” American Journal of Obstetrics and Gynecology 186, no. 5 Suppl Nature (2002): S131-159. 103 Simpson and Catling, “Understanding Psychological Traumatic Birth Experiences,” 204. © The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the History of Medicine and Allied Sciences Oxford University Press

Childbirth and Trauma, 1940s–1980s

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Oxford University Press
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© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com
ISSN
0022-5045
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1468-4373
D.O.I.
10.1093/jhmas/jrx054
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Abstract

Abstract This article analyzes trauma in mid-twentieth century hospital births, focusing on the United States, but with additional evidence drawn from Great Britain and France. As many as half of women today experience childbirth as traumatic and no evidence suggests that the figure was lower a half-century ago. Drawing on women’s birth narratives and psychiatric literature, this article highlights the striking consistency over time in how women describe their experiences of traumatic birth. By the 1970s, however, women proved less ready to accept their trauma as the product of their own psychological shortcomings. Under the sway of second-wave feminism, they pushed back against care they defined as inhumane in both conventional maternity care and in natural childbirth. Psychiatry too demonstrates change over time. Hegemonic at midcentury, Freudian thinking began to yield to critiques that questioned gender norms and the preeminence of the subconscious. Based on private letters to maternity caregivers and between physicians, as well as a wide array of medical journal articles, popular magazines, and newsletters from childbirth education and birth advocacy organizations, this article argues that, despite different approaches to trauma in birth and clarity about how best to minimize it, contemporary maternity care has to date proven unable to heed the lessons of history. Childbirth and Trauma, 1940s–1980s Writing in 1950, Salt Lake City psychiatrist Fred Kartchner recounts the story of an unnamed patient visited by frequent nightmares after the birth of her first child. Upon waking in the middle of the night, she did not recall their content, only the lingering feeling of terror. Amid this recurring nocturnal distress, she greeted her second pregnancy with anxiety. During the birth, through a fog of anesthesia “she screamed, ‘There they are! The lights! The people! They said they didn’t hurt me but they did! They did! I just didn’t remember!’”1 She later learned that during her first labor she had been given the amnesic scopolamine and while under its influence had experienced severe labor pain and a forceps delivery, about which she had no conscious memory and had never been informed. Her nightmares appear to have been a subconscious re-experiencing of that trauma, which her second labor brought to the surface. According to the current edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), “recurrent, distressing dreams” related to a prior traumatic event are symptomatic of Post-Traumatic Stress Disorder (PTSD).2 This article analyzes the historical experience of and theories about psychological trauma in childbirth. I focus on the United States in the mid-twentieth century, when, amid a baby boom, mothers, their partners and their caregivers engaged in a national dialogue about how best to have a safe, satisfying birth experience. The US was also the epicenter of psychiatric thinking that circulated globally. Supplementary evidence from Great Britain and France points to commonalities across national boundaries despite differences in the delivery of care. I understand the mid-twentieth century to be the temporal locus of a transnational “knot of resistance” to the status quo in maternity care.3 Women’s experiences of birth trauma led directly to the movement for natural childbirth, which pressed for a less interventionist approach than conventional maternity care offered at the time. In particular, advocates eschewed the use of pharmacological pain relief that was widespread for middle class, white American women and, to a lesser extent, their British and French counterparts. American women typically gave birth in hospital under the heavy sedation of “twilight sleep.” Combining scopolamine with morphine, twilight sleep left many women disappointed with their experience, of which, like Kartchner’s patient, they had no clear memory. They feared having comported themselves in undignified ways, crying and thrashing about through the drug-induced haze. For other women, not only in the US, but also in the UK and France, unmanaged pain or gruff treatment left them feeling distressed and disempowered by conventional hospital maternity care. Among other forces, the rise in the late 1960s and early 1970s of the women’s movement nurtured the fight for a different way of giving birth. Resisting resort to pharmacological pain relief became a signifier of women’s power and strength. But the unchecked pain that sometimes accompanied that effort proved, as in interventionist obstetric practices, to be psychologically damaging. From the US, UK, and France come strikingly similar attestations to suffering in both conventional, medicalized births and natural births. Perhaps significantly, this testimony emanates from hospital-based maternity care and is less audible in stories of births at home or in alternative birth centers. Because natural childbirth and the reforms in conventional maternity care that it sparked in the US and Western Europe sprang in part from women’s experiences of traumatic birth, sources from this movement provide rich testimonial evidence. Magazine articles, letters, and newsletters from childbirth education organizations and birth activist groups offer moving stories. Psychiatrists, obstetricians, midwives, and childbirth educators also described and debated traumatic birth’s sources and treatment. Medical and paramedical professionals were in a shared conversation with patients and birth activists, drawing from a common vocabulary and often subscribing to a shared set of values and beliefs. In her classic study of childbirth in the United States, Judith Walzer Leavitt highlights this dialogue between maternity patients and their caregivers, emphasizing women’s role as active collaborators in the generation of meaning and practices in childbirth even when they curbed women’s own authority and autonomy.4 Leavitt’s stance informs my accent on shared agency in constructing norms of behaviour and theories of female psychology in childbirth. Though patient and caregiver narratives at times converge, for the sake of clarity and organization for the most part I deal with each in turn. I begin with a brief sketch of the broader maternity care context in which experiences of and theories about birth trauma unfolded. Second, I use women’s narratives of their birth experiences to access what they understood to be traumatic birth. The third section reconstructs the psychiatric profession’s evolving understanding of trauma and birth. I focus heavily on the mid-century Freudian thinking generated in the US, but dominant in Western Europe as well. Of course, neither women’s own words nor medical professionals’ evaluations can be taken at face value. Borrowing from subaltern studies, I attempt to analyze case histories and birth narratives against the grain to uncover alternate readings of women’s experiences. As for defining whose experiences can be understood as meeting the ever-changing definition of trauma, I do not limit the discussion to cases that conform to today’s PTSD diagnosis. Such a standard would set a high, quite specific, and anachronistic threshold to which the historical evidence does not often clearly rise. I embrace instead the notion that “trauma is in the eye of the beholder.”5 Women’s own reflections on their births as traumatic deserves sustained, though not uncritical, attention as do their medical caregivers’ assessments. British anthropologist, midwife, and birth activist Sheila Kitzinger captures the broad significance of birth trauma when, at a 1983 conference on pre- and post-natal psychology, she remarked that “how the woman is treated, how the baby is treated, all help to define what birth is, the meaning of birth in that society.”6 With as many as half of women worldwide experiencing childbirth as traumatic, the question is both significant and urgent.7 Women’s traumatic experiences in the 1940s and 1950s contributed to the push for reform in the 1960s and 1970s. Out of this struggle came a slew of changes, though how deep and wide they ran remains debatable. In the name of mother-centered and family-centered care, midwifery made a comeback in the US after having been driven to the brink of extinction. Both there and in Europe, hospitals began to allow fathers in the labor and delivery room. Maternity wards were redesigned to provide homey birthing suites and rooming in. These trends in hospital-based maternity care speak, among other things, to women’s ongoing quest to minimize or eliminate trauma in birth for mother and baby.8 Yet we must ask ourselves about the impact of these reforms when so many women continue today to reflect on their experience of birth as traumatic. Women’s experiences then and now demonstrate considerable continuity over time. Strides have been made, but the aspiration to achieve in equal measure both safety and satisfaction in birth remains for too many women elusive. A Brief History of the “Birth Wars”9 Arguments about what constitutes safe, humane maternity care have their roots in the mid-nineteenth century, when changes in the medical profession and in medical knowledge began to reshape women’s birth experiences. Greater attention to antiseptic practices spurred a reduction in postpartum infection. The advent of antibiotics in the 1940s further drove down maternal and infant mortality rates, while modern anesthetics helped many women to give birth in greater comfort. Celebratory scholarship rightly lauds improvements in birth outcomes for women and their babies since the mid-nineteenth century, but these advances came bundled with practices that worked to take control of birth out of the home and out of the hands of women.10 Originally the site of birth for only the poorest women, hospitals came to mean safety and comfort for the white middle class as sanitary measures improved and anesthesia became available there. With promises of expert, skilled care, predominantly male physicians asserted a more common role in childbirth during the late nineteenth and early twentieth centuries. These changes came slower to Great Britain and France than to the United States, but were underway there as well in the first half of the twentieth century. On a continuum that spanned from midwife-led home birth to pathologized, obstetrician-led hospital birth, the American model sat at the most medicalized and pathologized end, with less reliance on anesthesia and a greater presence of midwives in the UK and, to a lesser extent, France. Feminist birth activists and historians have argued that what emerged from these transformations were practices that left women isolated from their families and disempowered in the face of medical authority.11 The movement for natural childbirth emerged in response not just to changes in medical practices, but also to shifting ideas about marriage and women’s roles. In 1933, British physician Grantly Dick-Read coined the term “natural childbirth” to describe his approach to maternity care, which emphasized prenatal education to alleviate the fears that he saw at the root of women’s pain in labor. A raft of similar approaches sprang up, including perhaps most famously the Lamaze method, also known as psychoprophylaxis. After witnessing this technique in the USSR, French obstetrician Fernand Lamaze began to promote a combination of patterned breathing and conscious relaxation at a Paris hospital popularly known as Les Bluets. Doctors from all over the world came there to study with Lamaze and this approach gained a global following.12 What advocates of the Read, Lamaze, and other methods initially shared was the belief that pain in labor had a psychological origin. Their explanations for this ranged from the sociological to the Freudian, but there was broad consensus among natural childbirth advocates from the movement’s inception through the 1970s that women’s minds were the sole or primary source of pain and constituted the front line of battle against their suffering. Psychology unquestionably plays a role in labor pain, but it is important to remember that for several decades in the mid-twentieth century a large and vocal group of medical professionals and their patients asserted that labor pain was largely or completely psychogenic, a belief that framed debates about birth trauma. Gaining currency in the 1940s and 1950s and expanding its reach in the 1960s and 1970s, natural childbirth rode the waves of interlocking postwar social trends.13 Touting a partnership of equals, albeit with strictly defined gender roles, companionate marriage and togetherness became the domestic ideal.14 Couples sought to extend this partnership in the labor room. Togetherness in labor and birth could only be meaningful if women said no to twilight sleep and other anesthetic cocktails that might offer relief from pain, but also robbed them of consciousness. The United States escaped the worst ravages of the thalidomide scare, but it contributed to women’s reluctance to take drugs during pregnancy, up to and including pain medication in labor and birth. In the 1970s, as countercultural values spread to the middle class, “nature” and “natural” began to be valued over the earlier “better living through science” ethos. Simultaneously, the women’s movement embraced natural childbirth as a path to empowerment in the face of patriarchal obstetric authority. In the 1980s and beyond, medical innovations and shifting values eroded the appeal of natural childbirth. Crucial in this transition was the popularization of epidural anesthesia, which allowed most women to give birth painlessly while still “awake and aware,” the very thing they had sought in natural childbirth.15 Natural childbirth is no longer a popular choice in maternity care, but it continues to have vocal partisans.16 Two polarized camps face off in today’s birth wars. On one hand, advocates for natural childbirth emphasize the satisfaction and gentleness of their approach. They generally support midwife-led, family-centered maternity care, or what historians dub “social birth.”17 They argue that the hospital’s regimented routines—characterized by its detractors as “technocratic birth”—disempower women, exacerbate pain, and incite trauma.18 Advocates for in-hospital, anesthetized birth emphasize the damage that long labors can inflict on mothers and babies. The medical establishment typically attends more to the physical outcome of birth for mother and child, with only a distant and distinctly secondary concern for the quality of birth as an affective experience. These priorities are evident in the fact that less than one percent of recent articles on birth trauma address the topic from the psychological perspective.19 But despite this inattention, supporters of the medicalized model make their case in part by underscoring that severe, untreated pain in childbirth can lead to psychological trauma.20 In short, the psychological argument features on both sides of the birth wars. Central to these debates is the line between pain and suffering. As leading American midwifery researcher Penny Simkin observes, the “definition of trauma comes very close to the definition of suffering.”21 Pain differs from suffering in that the latter captures the affective quality that sometimes, though not always accompanies pain. We suffer when pain becomes unbearable, not by the body, but by the mind. Childbirth proves to be a uniquely vexed context for distinguishing between pain and suffering. Physician Eric Cassell points out that the relationship between pain and suffering is generally understood to be a direct one: the greater the pain, the greater the suffering. But childbirth is a special case, as pain “can be extremely severe, and yet be considered uplifting…. the perceived meaning of pain influences the amount of medication required to control it.”22 We imbue the pain of childbirth with important meaning that for some mitigates suffering and even has the potential to transform it into an emotion of a wholly different timbre. Advocates for natural childbirth find meaning of the kind Cassell highlights in the pain of labor and birth; detractors see only senseless suffering that could be readily alleviated through the tools of modern medicine. They liken natural childbirth to a root canal undertaken without anesthesia. No one would call “natural dentistry” a good idea, they jest.23 Women’s Narratives of Traumatic Hospital Births Women had, of course, always told birth stories, but amid the postwar baby boom these narratives began to make their way into the American popular press in growing numbers. Behind the scenes, in private letters to medical practitioners and childbirth educators, women wrote poignantly about traumatic birth experiences. Their stories of the inhumanity and indignity of conventional hospital birth helped make the case for attentiveness to more than just the physical health of mother and baby. American women’s hospital birth stories echoed similar ones told by their European sisters, even as birth practices differed substantially between the US and Europe. From the late 1940s through the 1980s, alongside joyful narratives of deeply satisfying and empowering birth experiences, one finds across national borders a remarkably cohesive body of stories that convey the pain and disappointment of women who felt unsupported and uncared for in their moment of greatest vulnerability. Women’s narratives of trauma in birth coalesce around three intertwined themes: abandonment, cruelty, and fear. Mothers felt abandoned in hospitals, where, before fathers were routinely at their partners’ sides, it was common for women to labor in solitude or perhaps in the company (or within earshot) of other laboring women. In one extreme case, a war bride in 1950s' England, whom I will call Mrs. C, recalls that she “was shown into a very bare and unfriendly room where I had the shave, enema, and bath. After that I was left alone in that room on a stretcher with not even a blanket to cover myself.”24 She had undergone preparation for natural childbirth but, without someone by her side to support her efforts, her sense of control faltered. The nursing staff “did nothing to help me, but just left me alone.”25 After her baby was delivered, with tears in her eyes, Mrs. C asked a nurse to just sit with her for a few moments. In response, the undoubtedly overworked, exhausted nurse left the new mother alone in her room. Other mothers offer similar stories that suggest Mrs. C’s case was not unique. “Misunderstanding and loneliness” during her four hospital births inspired Heda Borton to join Great Britain’s natural childbirth movement during this same era.26 Twenty years later, Madame [Mme] R, who gave birth using psychoprophylaxis, wrote to the administration at Les Bluets that the nurses and midwives had been nice, but she nonetheless experienced “a feeling of abandonment while in the labor room.”27 Other new mothers had less generous words to say about the care they received at Les Bluets. As Mme O writes, “I think that I could have endured transition better if the midwife had been with me more and relieved my partner, who was becoming upset by my cries and beginning to be impatient with my lack of bravery.”28 Mme O’s words remind us that birth can be traumatic not only for the mother, but for the partner bearing witness to a loved one’s suffering.29 Another Les Bluets mother’s testimony gives insight into Mme R’s and Mme O’s experiences in a clinic with a longstanding reputation for gentle, supportive care. Mme P gave birth twice at Les Bluets using the psychoprophylactic technique: For my first birth, the midwives were overwhelmed—and I felt abandoned, despite my husband being there. I managed to control myself only with the presence of the midwives and I panicked knowing she was busy with other women. My delivery was not very successful: panic, anxiety, fear, etc. For the second, I was the only woman to give birth that night. I felt totally reassured. I knew the midwife was at the ready to respond to my call.30 Faced with staff shortages, midwives scurried to attend to multiple laboring women and, in the process, the quality of patient interactions declined. Overwork contributed to women’s sense of abandonment, as caregivers donned a “veneer of callousness” in an effort to cope with the workload.31 “The nurses were so pressed for time that if you wanted anything you were just a nuisance,” Mrs. C had decried in London in 1956.32 Twenty years and 200 miles separated her from Mmes R, O, and P, but their despair at the absence of supportive, constant professional care through labor was the same. Overwork alone fails to explain the gruff, inhumane treatment women at times faced in both conventional maternity care and in clinics supportive of natural childbirth. Some experienced outright cruelty at the hands of nurses, midwives, and doctors who seemed unmoved by their pain. In 1957, one nurse famously denounced conventional maternity care in the US as “sadism.”33 In a representative example, an unnamed American mother who gave birth in the late 1940s reflected on her experience as one of “terror and humiliation,” and the notion that “childbirth is meant to be the most satisfying experience in a woman’s life” was simply “poppycock.” Her pain was searing, leading the nurse to stuff a towel in her mouth to muffle her cries. “Finally, when I felt sure I was about to split apart at the bottom, the ugly grey mask pressed against my face” and she gave birth under general anesthesia. This new mother woke to find a healthy baby girl waiting for her, but “all I remember thinking was that I never wanted another baby.”34 From France, too, one finds similar attestations of caregiver indifference. Mme N shared her traumatic story of giving birth in 1949. Without any explanation from her doctor beforehand about what to expect, she went into labor late at night. She became terrified when, after her husband was sent home, the nurse ordered her to get into bed and, after a few sharp words, left the room. When the midwife finally appeared in the early morning, Mme N lamented that “I had been alone during my whole labor and I had suffered a lot.”35 Unsurprisingly, she turned to natural childbirth in her quest for a more humane experience when she became pregnant the next time, but maternity wards that promoted natural childbirth were not immune from charges that ranged from indifference to torture. One French woman who gave birth in 1976 in Les Bluets bemoaned her encounter with a midwife who was obstinately opposed to the use of anesthetics and analgesics. Mme S complained in a letter to the hospital that “despite the midwife’s compliments about my ‘good cooperation’ and ‘good preparation,’ I would have preferred an epidural because I did not choose to become a masochist.”36 The reasons for denying women pain relief varied over time and place. For Mme S and other French women, public financing of epidural anesthesia for childbirth became routine only in 1994, when patient request, rather than doctor’s orders, became standard maternity care practice.37 Beyond financial considerations, there were common beliefs—not just in France, but in the UK, US, and elsewhere—that tamped down the use of anesthetics and analgesics. Pain in childbirth was alternately natural, normal, universal, useful, or exaggerated. Irrespective of the truth of these claims, they served to justify a reluctance to provide pharmacological pain relief. Women often found their complaints dismissed as a nuisance, such as in one typical example in 1956 where a UK mother was told by a nurse, “don’t make such a noise, you frighten all the girls.”38 Others heard that childbirth was the time to pay for the fun they had had earlier, or that the pain would deepen their bond to their child, beliefs distantly rooted in the biblical injunction that Eve “bring forth children in suffering” (Genesis 3:16). Until the late 1970s and early 1980s, most midwives and nurses active in the promotion of natural childbirth believed that pain in childbirth was wholly or largely psychogenic. Mme S’s midwife likely thought that her supportive words and encouragement to relax and breathe should have been enough to manage her pain. When they were not, she futilely persisted down the same, ineffective path through either dogmatism or a lack of other tools at her disposal. Those mothers who experienced acute, unbearable pain felt that the “enchanted fairy tale version of childbirth,” which natural childbirth advocates touted, was “just another shuck.”39 Midcentury, medical professionals quite routinely dismissed not just pain, but also women’s fears. Doctors conceded that they should “certainly pay more heed to the emotional aspects of childbirth,” but that typically meant explaining to women why their concerns were irrational.40 One can imagine that it was a dubious comfort to be told by your physician that It’s true women have died having babies, but almost always as a result of their own carelessness in not seeing a doctor soon enough or not following his orders. People also die in traffic accidents—yet you are not afraid to cross the street or ride in an automobile. Think in the same way of the possibility of your baby being abnormal. The chance is only one in a thousand or less, and even if it happens it’s no longer the tragedy it once was, now that we can correct conditions that used to be lifetime handicaps.41 Anthropologist Margaret Mead found it unsurprising that postwar hospital-based birth proved frightening. “For months [the expectant woman] has been preparing to leave her home and her husband for a strange segregated spot where she and many other women unknown to her will lie together giving birth among strangers.”42 A quarter-century later, fear continued to define conventional hospital birth as, in the description of one California midwife in the 1970s, women lay “spread-eagled on an operating room table, drugged, confused, frightened and at the mercy of a manipulating man.”43 Under the influence of the feminist critique of medicalized maternity care, in the 1980s Kitzinger took this argument further when she asserted that the routines and practices of hospital-based birth were, in fact, intended to spark fear in order to induce compliance with obstetric authority.44 The natural childbirth approach championed by Kitzinger and others was, as already observed, no guarantee for humane care, but many women turned to this approach after a negative experience with their first child’s birth. A traumatic first birth propelled their search for something different. With her husband recently demobilized after World War II, Peggy Studwell was happy to find herself pregnant, but feared the pain. She gave birth to daughter Cherie under heavy anesthesia, but she “could not fully enjoy her small daughter” because she was so traumatized by her birth experience. She was unable to shake the fear of pain that had gripped her before the birth of her first child and that she had sought to escape through anesthesia, a choice that she regretted.45 For the birth of her second child Peggy sought training in natural childbirth. She undertook prenatal classes at the Yale Obstetrical Clinic at Grace-New Haven Hospital, which, under the guidance of Herbert Thoms, was one of the first clinics in the US to offer preparation in the Read method.46 The birth was not painless or without the use of drugs, but for Peggy it was a much more satisfying experience and one that was accompanied by far less anxiety. Another mother who gave birth at Thoms’s clinic in the late 1940s reported a similarly positive natural childbirth experience after a traumatic conventional first birth. “This time I felt no unbearable pain. I felt no panic. Nor was I given drugs to deaden my feelings. This time I lay there, wide awake—and watched my son born.”47 Positive birth experiences had therapeutic value for the resolution of lingering trauma from earlier births. For Peggy and others, there was an “almost complete elimination of the postpartum ‘blues’ which so many women dread.”48 The psychological benefits were not just enjoyed by the mother, but were believed to benefit the entire family. “Children who are naturally born are less likely to show emotional upsets traceable to birth trauma. Husbands, knowing the birth process as a normal function without danger or unbearable pain, lose their fears—and any unconscious guilt feelings they may harbor as the person responsible for their wives’ danger.”49 Domestic harmony allegedly emerged from the psychologically healthy and balanced interpersonal dynamic that ensues as each member accepts his or her rightful role, especially when “the mother has no hidden resentments against her unborn child for fears and pain she must endure.”50 In the decades after these glowing claims about natural childbirth appeared, tens of thousands of other mothers followed in their footsteps with mixed results. By 1985, when Yorkshire (UK) television aired a panel discussion on the topic, the popularity of natural childbirth was already on the wane for a variety of reasons, including patient disappointment with pain management. The show’s guests included natural childbirth promoter and obstetrician Michel Odent and writer Polly Toynbee, “who had tried natural childbirth and didn’t find it at all natural.”51 In the audience sat mothers for and against the use of pain medication during labor and birth. One audience member described having had epidural anesthesia, which had worn off when it was time to push: “so I could have a natural birth. I was in a supported squat and actually felt her coming out. And I remember for days afterwards I harked back to that moment. I wanted to relive that moment and that pain of actually having her.” The show’s host, Miriam Stoppard, then asked, “and is that partly to do with suffering pain? That you’d overcome it?” “I think so, yes, yes,” she responded.52 This young mother had the powerful relief of epidural anesthesia during labor and transition, which for most women is the most painful stage. She found value in what pain she did experience, but perhaps it would have been more accurate for Stoppard to suggest that this mother “had” pain rather than “suffered” it. Her pain does not appear to have passed into the realm of suffering. Toynbee took her to task, challenging what she saw as a sanctification of pain. “There's nothing particularly special about suffering a great deal of pain. There is nothing moral about pain. I think some people have been rather puritanical about saying you don't deserve the baby unless you've suffered for it. Something like the curse of Eve in the Bible. You know, we were made to suffer that pain, so suffer it.”53 Toynbee rejected the meaning that these women inscribed on their pain. For her, the pain had transformed into suffering and there was nothing romantic or redemptive in it. The Psychiatric View Toynbee never used the word “trauma” in either a clinical or colloquial sense to describe her birth experience, but we can hear in her testimony something akin to it. Trauma as a psychological category has a long and convoluted history that has inched gradually toward our present understanding and is evident in the language we use. Locating in the historical record what we identify today as trauma in birth is complex and problematic. Only with its entry into the 1980 edition of the DSM did PTSD become an official psychiatric diagnosis.54 Prior to this, the medical establishment employed a variety of fluid terms to describe what we understand as its symptoms, such as Kartchner’s description of his patient’s recurring nightmares. A partisan of the dominant midcentury viewpoint, Kartchner deploys the Freudian terminology of “traumatic neurosis” to describe her condition. One also at times encounters “hysteria” as a descriptor of the cluster of symptoms that resemble today’s PTSD. There was a certain shared vocabulary of trauma, but psychiatrists and physicians varied the emphases and inflections. In the era of PTSD, too, there is ongoing refinement of the condition’s definition. With each iteration of the DSM, debates ensue about the pros and cons of these emendations.55 It took twenty years for PTSD to be recognized as potentially relevant to the experience of birth. The view of birth as normal, natural, safe, and routine for most women perhaps contributed to the medical community’s failure to hear some women’s attestations of profound suffering. Only in the early twenty-first century did maternity care researchers apply this diagnostic lens to birth experiences. Today’s PTSD has roots in the mid-nineteenth century, when the budding science of the mind began modern inquiry into the relationship between memory and psychological disorder. Jean-Martin Charcot led the way in understanding traumatic memories of prior events as having an impact later in life, as manifested in the condition of hysteria. He shifted emphasis from what was believed to be a physical causality best treated by the removal of the uterus and proposed, alternatively, that maladjustment resulted from prior, psychologically traumatizing experience. Charcot was unequivocal that the womb played no role in hysteria and that men were equally susceptible to it.56 Pierre Janet, Joseph Breuer, and Sigmund Freud subsequently built on this line of inquiry. Freud eventually veered away from the emphasis on a concrete, precipitating event and instead stressed suppressed memories of early psychosexual development that resided in the subconscious.57 Among Freud’s colleagues and disciples who explored this theme, Sándor Ferenczi was almost unique in his continued emphasis on prior traumatic events as the root cause of psychological disturbance—a view that would in later years, after the heyday of Freudianism had passed, come to dominate trauma theory. Ferenczi adhered to Freud’s belief in the significance of the child’s unresolved sexual desire for one’s parent, but he also saw a range of other potential sources of trauma, including real or perceived physical danger.58 Writing in the early twentieth century, Freudian psychoanalyst Otto Rank understood the trauma of birth from the perspective of the newborn. Ultimately disavowed by Freud, Rank argued that neurosis was a universal human condition that was best explained by origins even deeper than those of early childhood. He saw in parturition itself the root cause of psychological suffering with the act of literal separation from the mother. Rank regarded expulsion of the baby as “a vaguely remembered primal trauma,” over which later traumas, such as a girl’s unrequited sexual desire for her father, were layered.59 For Rank, war neurosis—a precursor to today’s PTSD—found explanation in his theory that “the primal anxiety is directly mobilized through shock, the otherwise unconsciously reproduced birth situation being affectively materialized through the outer danger of death.”60 In other words, the existential threat of war triggers a re-experiencing of the trauma of being born. In the 1940s, the psychoanalyst Nandor Fodor, who was an analysand of Rank, elaborated on the relationship between the trauma of being born and of giving birth. He wrote: “No sexual injury is more likely to raise the ghost of our own arrival into this world than that of bearing a child; and it cannot be disputed that bearing a child is a sexual injury.”61 Childbearing unleashes a primal, existential anxiety, a fear of death inscribed on our psyche from our own journey through the birth canal. Childbirth passes that trauma on to the next generation, while simultaneously rekindling in the mother her original trauma of being born. He observes that some women feel “panic-stricken at the prospect of bearing a child” and, though “they are not likely to die,” they nonetheless “feel as if they were confronting death.”62 While most today would dismiss Fodor’s claim that women have these feelings because giving birth reopens the psychic wound of their own birth, Fodor’s affective description captures well the emotions that mid-century women expressed—and their physicians deemed irrational—while gesturing toward the symptoms of today’s PTSD. Though I have no direct evidence of their influence, Rankian thinkers appear to have left their mark on the writings of maternity care professionals. Contemporaneous to Fodor, natural childbirth advocates at New York City’s Maternity Center Association (MCA) lamented the emotional sterility that accompanied hospital birth and potentially exacerbated the trauma of being born. “Nobody holds [the baby] close to cuddle it and makes it feel secure… . A ritual of anxious concern rather than of pleasure” surrounds the newborn, in contrast to the experience of babies “in primitive societies, [where] the baby emerges from the warm darkness of his mother’s uterus and is gently introduced to life by being nestled and cuddled close to her soft skin.”63 Two decades later, French obstetrician Frédérik Leboyer’s advocacy of “childbirth without violence” similarly echoes of Rank’s and Fodor’s concern with the trauma of birth. Leboyer argues for as calm and quiet an entrance into life as possible. He promotes the use of dim lighting and the maintenance of a serene environment, despite the inconvenience posed to medical staff. Some challenged Leboyer’s emphasis on the baby’s gentle passage, arguing that he had all but forgotten the woman and her comfort. They claimed that he rendered her invisible, relegated to a mere vessel.64 He was taken to task for going so far as depicting the mother as a “monster” who is the source of the baby’s torture during labor and birth.65 His partisans dismissed this criticism as reflective of a “lack of understanding of his techniques and philosophy,” with Leboyer gaining a following in France and abroad, including in the US and UK, in the 1970s and 1980s.66 With respect to the psychological experience of the mother, Helene Deutsch articulated the fullest and most influential Freudian interpretation.67 A contemporary of Fodor, Deutsch undergirds her ideas with biological determinism and emphasizes early psychosexual experiences in the development of female sexuality and the expression of sex roles, most notably in mothering. Deutsch asserts that the awakening of the vagina to full sexual functioning is entirely dependent upon the male’s activity; and this absence of spontaneous vaginal activity constitutes the physiologic background of feminine passivity. The competition of the clitoris, which intercepts the excitations unable to reach the vagina, and the genital trauma then create the dispositional basis of a permanent sexual inhibition, i.e. frigidity.68 Female passivity could manifest itself in the act of childbirth, as women “blindly follow other people’s instruction and, like children, are interested only in getting rid of their fear and being subjected to as little pain as possible.”69 This strategy of avoidance interfered with experiencing childbirth as a satisfying, even therapeutic lifecycle event; it could, instead, be a source of trauma, as could a woman’s futile desires to control childbirth, an unconditional, involuntary neuromuscular process. Only by achieving a balance between activity and passivity could a woman not risk childbirth reigniting the trauma of her inherent inadequacy as a female, a notion captured in Freud’s theory of penis envy.70 Advocates for natural childbirth invoked Deutsch to justify their views on how women could give birth with the greatest satisfaction and the least trauma. A midcentury American obstetrics textbook, for example, endorses natural childbirth and cites Deutsch as the source for understanding childbirth as an expression of masochism that weaves “pain together with the ecstasy of the act of parturition…. [T]he alleviation of all pain with medication deprives the woman of an important part of her obstetric experience.”71 Dick-Read himself describes Deutsch as “the great American expert” on female neurosis and he agreed with “so much” of her writings.72 He attributed to her his appreciation of the role “incidents of unhappy sex and birth” play in a woman’s psychological makeup.73 Her mark on his thinking comes through when he writes of the woman “overconfident” in her ability to strike the right note between what Deutsch would characterize as passivity and activity.74 However, Dick-Read rejected the idea that pain in childbirth offered a masochistic pleasure. He argued vehemently that pain in normal birth was purely a manifestation of fear. The idea that there was something common, possibly useful, and maybe even pleasurable in labor pain was utter anathema to his thinking.75 He also took umbrage at her critique of his work as denying the physical sources of pain in labor in favor of a wholly psychological theory of its origins.76 Along with Deutsch, Karen Horney contributed to defining feminine psychology in the Freudian tradition. Most famously and controversially, she asserted that penis envy was not simply a feminine desire to heal the wound of her inadequacy for having been born female, but a longing for what today we would call male privilege—the collective social, cultural, political, and economic benefits accrued to all men simply by virtue of being male. The desire was not for a physical penis, as Freud and Deutsch would have it, but for the freedoms and entitlements that accompanied possession of that organ. Moreover, this envy was in Horney’s estimation mutual, as women’s capacity to bring life into the world and to experience the empowerment that went with that inspired in men “womb envy.”77 Horney left her mark on the natural childbirth movement once secondwave feminists drew fresh attention to her writings from a half-century earlier. It is evident in Kitzinger’s 1983 critique of Leboyer, whom she believes evinces “cringing terror” of female power, which stimulates “the envy of woman’s ability to give birth, envy of female sexuality, and dread of it.”78 The psychology of birth was of a piece with Freudian thinking on a raft of female maladies. Psychoanalysts and physicians alike were quick to attribute disturbance in female sexuality, reproduction, and wellbeing broadly to the power of women’s minds over their bodies. Pre-menstrual syndrome (PMS) spoke to a woman’s unfulfilled desire for motherhood. Infertility, frigidity, and painful intercourse evidenced ambivalence toward motherhood and a rejection of femininity.79 Dick-Read, for example, asserted that one of his patient’s “psychological attitude was probably the major factor” in her inability to conceive.80 For those who fell pregnant, morning sickness, miscarriage, uterine inertia, preterm labor, and overdue labor all attested to a continuing negativity toward imminent maternity.81 Fodor claims that a powerful subconscious desire to avoid pregnancy could induce a miscarriage, but the depths of a woman’s conscious desire for a child or the fetus’s own “amazing tenacity” could, on occasion, conquer these forces.82 Arguing for the mother’s “mental processes” as the source of her problems, Dick-Read shared these views on the power of female psychology to enable or subvert pregnancy. He dismissed one woman’s “so-called miscarriages” as induced by her own negative thinking.83 For the woman who carried a pregnancy to term, her psychological stance toward her experience of pregnancy, birth, and new motherhood continued to drive bodily malfunction. Fodor argues that heavy bleeding, difficulty breastfeeding, and other physical ailments following childbirth attested to “the psychic storm through which the mother had passed and of which, in her unconscious, she is still in the throes.”84 For some psychiatrists, a concern with the role of social conditions tempered the preeminence Freudians gave to women’s subconscious desires. New York psychiatrist Henrietta Klein emphasized how material circumstances, such as unemployment and overcrowding, contributed to alcohol abuse and domestic violence, with obvious implications for women’s psychological preparedness for motherhood. “One cannot ignore the part played by reality factors,” she stressed.85 Postwar housing shortages made the prospect of bringing a baby into the family a challenge. Many young couples lived with relatives in cramped quarters, or had otherwise marginal or unstable living arrangements. That these women were ambivalent about their pregnancies, Klein argued, made perfect sense; their attitude was a rational response to adverse material conditions, and not a sign of maladjustment.86 She cautioned against those psychiatrists who prescribed pregnancy as treatment for an unhappy married life and insisted that motherhood would exacerbate a deteriorating domestic situation. Women pushed into pregnancy and childbirth might experience it as traumatic, resulting in difficulty bonding with their babies and living harmoniously with their husbands.87 Most mid-century psychiatrists believed that, whatever women’s material circumstances, they came into pregnancy and childbirth predisposed either to weathering the experience well or not. They adhered to the belief that adult experiences, including labor and birth, were not the sources of trauma, but merely triggered a pre-existing psychological propensity.88 For all her emphasis on material conditions, Klein nonetheless argued that women already predisposed toward anxiety before pregnancy would find that inclination persistent or even strengthened during pregnancy and childbirth.89 Among the 500 maternity cases examined in Kartchner’s 1949 study of fear and anxiety during and after pregnancy, sixty women allegedly demonstrated significant or “complete lack of control” in labor and birth in their physician’s estimation; afterwards these women experienced feelings that sound much like post-traumatic stress or postpartum depression.90 Kartchner asserts that for about two-thirds of these women little could have been done to avoid their traumatic experience because they came into pregnancy with subconscious “severe emotional conflicts.”91 Prenatal preparation, relaxation techniques, and soothing support from a caregiver or loved one were unlikely to prove effective interventions for these women in his estimation. Dick-Read shared this belief that a woman’s psychological makeup played a prominent, though not necessarily determinative role in the question of trauma in birth. The case of Mrs. B serves to illustrate his views and what they meant for the clinical encounter between doctor and patient. In correspondence with his colleague, Dr. Z, regarding their mutual patient, Mrs. B, in Johannesburg, Dick-Read describes how she “had a bad 20 hours [of labor] during which she gained little relief by the usual sedative methods. I became fully aware then that she was suffering far more from psychological labor than from any physical effort of parturition. … I did not enquire into her obsessions, inhibitions or frustrations… but the fact of their presence was clearly established.”92 Dr. Z shared Dick-Read’s assessment of Mrs. B more than a month postpartum: [she] still has a lot of obsessions or frustrations. …All [she] could talk about was how difficult her confinement had been. Usually a woman forgets those things as soon as the baby has been born, but to [Mrs. B] it seems to be far to [sic] much of a reality still. I have always felt that she had some sort of inhibition or frustration but could not actually lay my finger on it. She tries hard but something is wrong. In my own mind I have a strong suspicion that it is related to sex in some way.93 Dick-Read and Dr. Z do not here reference the writings of Deutsch or other Freudians explicitly, but the terminology they use clearly signals adherence to this perspective. Whether Dr. Z’s belief that “something is wrong” “related to sex” is correct or not is of less interest than their consensus and its implications. Impugning Mrs. B’s mental fitness delegitimizes her complaints. They appear never to consider seriously any physiological cause for her suffering. Dick-Read certainly fails to entertain the possibility, here or elsewhere, that his method might have been ineffective for some of his patients. She may have truly been experiencing exceptionally acute pain if, for example, the baby was in a posterior position. Perhaps the dose of the opiate pethidine that Dick-Read administered had been insufficient, as she had complained at the time. Like many of the women who attested to traumatic birth experiences in this era, her pain and exhaustion may have been exacerbated by fear and perhaps even a sense of her physician’s lack of compassion. Mrs. B’s continued suffering postpartum induces little sympathy from these men. They absolve themselves of responsibility for her care and for any need to heed her complaints. From her correspondence with Dick-Read, we learn that Mrs. B herself readily accepts these medical men’s proffered interpretation of her distress, as no doubt many patients did in similar circumstances. “I have said that [your natural childbirth method] did not [work] because of the reasons you gave me: that I had various inhibitions including a resentment of pregnancy.”94 In her estimation as well as theirs, her marred mind generated or exaggerated her pain. In a sense, she created her own suffering, albeit subconsciously. Mrs. B was perhaps seen (and saw herself) as responsible for it in a way that she would not have been if her pain had been understood as of physiological origin. Whether Mrs. B’s trauma originated in her mind or body, the consequences for mother and baby were grim. Dick-Read reported to Dr. Z that upon delivery her psychological condition was demonstrated by the fact that she refused to take any interest in the child when it was born and turned her away with an expression more of disgust than anything else. That … is a moment when one sees the promptings of motherhood most clearly exhibited. Before the cord was cut, however, I insisted that she should look at her child, and told her to take it in her arms, realising that it was hers and that it was not the child's fault that it was born or words to that effect. Her description of it was not complimentary, although in reality it was a lovely baby, and after a few minutes she very sternly demanded that it be removed.95 Dick-Read clearly saw Mrs. B’s initial postpartum reaction as evidence of maladjustment. Alternatively, her demeanor perhaps signaled the physical and emotional toll of the birth. Her chilly, flat affect might have been evidence of the psychic numbing and difficulty connecting with others that is characteristic of trauma. Conclusion One of several factors, second-wave feminism contributed mightily to reshaping the field of psychiatry and rethinking the roots of trauma for both men and women.96 Birth activists and feminist psychiatrists questioned the roles to which women were supposed to adjust; the social system into which those roles fit; and the ways that doctor-patient dynamics and maternity care practices conspired to coopt, silence, delegitimize, and disempower women. Kitzinger put her finger on the issue when in 1983 she said that “we have been taught time and time again, in sex generally, as in childbirth, to ask ‘What did I do wrong?’ Now all this doesn’t happen just by chance. We live in a society which molds women into compliant housekeepers, mothers and patients…. A hospital turns a woman into a maternity patient through a series of rites” intended to strip her of power, yet the woman is left asking herself how she succumbed to fear and pain, or was railroaded into an intervention she had sought to avoid.97 Feminism contested the notion that women experienced birth as traumatic because there was something already wrong with them; it led women, instead, to challenge as inadequate the care they received. As was evident in their testimonies from the 1970s and 1980s, women pushed back against the kind of professional judgments that patients like Mrs. B had readily accepted from men like Dick-Read in the 1940s and 1950s. But as Kitzinger and others show, medical ideas about gender and trauma were changing, too, through professional debates enmeshed with and informed by popular discussions. It is perhaps impossible to unravel who influenced whom in the evolution of these ideas. Patients and their physicians carried on simultaneous and overlapping conversations. A new chapter in the history of trauma began with the codification of PTSD in 1980. In contrast to the dominant theories of trauma that gained currency earlier in the twentieth century, PTSD located the source of trauma outside the imaginings of the sufferer’s own mind. In rejecting the Freudian emphasis on the subconscious, PTSD perhaps validated suffering in a way that was not possible when it was rooted so wholly in the psyche. Blame, in a sense, became externalized with the new emphasis on real-world events. War, rape, and severe car accidents were all considered possible “stressors”—extraordinary events capable of inducing the cluster of symptoms that define PTSD. Psychiatrists accepted adult experiences as causative in and of themselves, rather than as mere triggers of a pre-existing disorder.98 Only in the last decade has there been an efflorescence of medical research on PTSD and childbirth. In a departure from the earlier medical literature, prior trauma and depression constitute only two possible risk factors for developing postpartum PTSD.99 Other considerations include “unexpected medical interventions, pain beyond the coping ability of the woman, care from providers that was uncaring, unsafe, and inhumane, and the possibility of injury or death for herself or infant.”100 We see in recent thinking about birth trauma a range of causality far beyond the Freudian focus on the subconscious, though it is conspicuous how very long it took for maternity caregivers and mental health professionals to recognize the relevance of PTSD to birth. Although ideas about the origins of trauma have changed radically in recent decades, how best to avoid it in childbirth has not proven a mystery. The role of caregivers has been and remains absolutely essential to minimizing or averting trauma, irrespective of how its origins are explained. In the 1940s, Kartchner found that “sympathetic, constant care with repeated explanations was most frequently mentioned” as the reason for satisfactory experiences, free of “unpleasant emotional upheaval.”101 More than a half-century later, in the most comprehensive US study todate on nonpharmacological pain management measures in maternity care, researchers identified constant companionship and support as the most effective approach.102 A 2016 literature review by midwifery researchers Simpson and Catling finds consensus that high quality care that meets “the patient’s stated and implied needs, as perceived by the patient” plays a significant role in curbing women’s experience of trauma in childbirth.103 From past and present the answer seems equally clear. The enduring question appears to be why, despite all that we know and have known for a long time, is the hospital maternity ward still a site of suffering for so many women? Footnotes 1 F. D. Kartchner, “A Study of the Emotional Reactions during Labor,” American Journal of Obstetrics and Gynecology 60, no. 1 (July 1950): 20. 2 “Trauma- and Stressor-Related Disorders,” in Diagnostic and Statistical Manual of Mental Disorders, 5th ed., DSM Library (n.p.: American Psychiatric Association, 2013), doi:10.1176/appi.books.9780890425596.dsm07. 3 Michel Foucault, The History of Sexuality, trans. Robert Hurley (New York: Pantheon, 1978), 96. 4 Judith Walzer Leavitt, Brought to Bed: Childbearing in America, 1750 to 1950 (New York: Oxford University Press, 1986). 5 Cheryl Tatano Beck, “Birth Trauma: In the Eye of the Beholder,” Nursing Research 53, no. 1 (February 2004): 28–35. 6 Sheila Kitzinger, “Nurturing Mothers,” Healthsharing, Winter 1983, 15. 7 Madeleine Simpson and Christine Catling, “Understanding Psychological Traumatic Birth Experiences: A Literature Review,” Women and Birth 29, no. 3 (2016): 203–04, doi:10.1016/j.wombi.2015.10.009. 8 On the history of twentieth-century childbirth in the US, see, Wendy Kline, Bodies of Knowledge: Sexuality, Reproduction, and Women’s Health in the Second Wave (Chicago: University of Chicago Press, 2010); Judith Walzer Leavitt, Make Room for Daddy: The Journey from Waiting Room to Birthing Room (Chapel Hill: The University of North Carolina Press, 2009); Paula A. Michaels, Lamaze: An International History (New York: Oxford University Press, 2014); Margarete Sandelowski, Pain, Pleasure, and American Childbirth: From the Twilight Sleep to the Read Method, 1914-1960 (Westport, CT: Greenwood Press, 1984); Jacqueline H Wolf, Deliver Me from Pain: Anesthesia and Birth in America (Baltimore: Johns Hopkins University Press, 2009). On Great Britain, see Angela Davis, Modern Motherhood: Women and Family in England, c.1945-2000 (Manchester: University of Manchester, 2014). On France, see Marianne Caron-Leulliez and Jocelyne George, L’accouchement sans douleur histoire d’une révolution oubliée (Paris: Les éd. de l’atelier/Les éd. ouvrières, 2004); Yvonne Knibiehler, La révolution maternelle: femmes, maternité, citoyenneté depuis 1945 (Paris: Perrin, 1997); Yvonne Knibiehler, Accoucher: femmes, sages-femmes et médecins depuis le milieu du XXe siècle (Rennes: Ecole nationale de la santé publique, 2007). 9 I borrow this moniker from Mary-Rose MacColl, The Birth Wars (St Lucia, Qld.: University of Queensland Press, 2009). 10 Donald Caton, What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth from 1800 to the Present (New Haven, CT: Yale University Press, 1999). 11 E.g., Barbara Ehrenreich and Deirdre English, Complaints and Disorders: The Sexual Politics of Sickness (Old Westbury, NY: The Feminist Press, 1975). 12 Michaels, Lamaze. 13 Though difficult to measure, abundant anecdotal evidence points to its popularity. In 1962, at least a decade before interest peaked, it was described as “the most-dropped phrase among America’s pregnant women today.” Waldo Lewis Fielding and Lois Benjamin, The Childbirth Challenge: Commonsense Versus “Natural” Methods, (New York: Viking Press, 1962), 9. 14 Rebecca Jo Plant, Mom: The Transformation of Motherhood in Modern America (Chicago: University of Chicago Press, 2012); Jessica Weiss, To Have and to Hold: Marriage, the Baby Boom, and Social Change (Chicago: University of Chicago Press, 2000). 15 Irwin Chabon, Awake and Aware: Participating in Childbirth through Psychoprophylaxis (New York: Delacorte Press, 1966). 16 E.g., Abby Epstein, The Business of Being Born (Burbank, CA: New Line Home Entertainment, 2008). 17 Richard W. Wertz and Dorothy C. Wertz, Lying-in: A History of Childbirth in America (New York: Free Press, 1977). 18 Robbie E. Davis-Floyd, “The Technocratic Model of Birth,” in Feminist Theory in the Study of Folklore, eds. Susan Tower Hollis, Linda Pershing, and M. Jane Young (Urbana-Champaign: University of Illinois Press, 1993), 297–326. 19 Simpson and Catling, “Understanding Psychological Traumatic Birth Experiences,” 204. 20 E.g., Fielding and Benjamin, The Childbirth Challenge; Amy Tuteur, Push Back: Guilt in the Age of Natural Parenting (New York: Dey Street Books, 2016). 21 Penny Simkin, “Pain, Suffering, and Trauma in Labor and Prevention of Subsequent Posttraumatic Stress Disorder,” The Journal of Perinatal Education 20, no. 3 (2011): 167, doi:10.1891/1058-1243.20.3.166. 22 Eric J. Cassell, The Nature of Suffering: And the Goals of Medicine (New York: Oxford University Press, 1994), 34. 23 Gregory K. Moffatt, The Parenting Journey: From Conception Through the Teen Years (Westport, CT: Praeger, 2004), 55. 24 “Natural Childbirth,” Parents Group Bulletin, Summer 1956, 45. I use pseudonyms in two situations. In some cases, I draw on archival documents held in repositories that require the use of pseudonyms in order to protect patient identity. For the sake of consistency and out of an abundance of caution, I have chosen to use pseudonyms even when I was not explicitly required to do so by the archive. In other cases, published sources describe anonymous cases; to ease narrative flow, I have assigned pseudonyms in some instances, which I note as in the next above. The initials do not correspond to women’s given names or surnames. 25 Ibid., 47. 26 Letter from Heda Borton to Ian Donald and A.C. Turnbull, 30 January 1975, National Childbirth Trust Archive, Box 2, unnumbered folder, London (hereafter NCT). Borton was active in the Natural Childbirth Trust, founded by mother-activists to promote the ideas of Grantly Dick-Read. Known today as the National Childbirth Trust, this is the largest prenatal education organization in the UK. On its history, see Valerie Allen, The Legacy of Grantly Dick-Read (London: National Childbirth Trust, 1991). 27 Letter from Mme R to Les Bluets, 18 October 1976, Box X-1, Collection l’Accouchement sans Douleur, Archives de l’Union fraternelle de la métallurgie, L’Institut d’HIstoire Sociale CGT de la Métallurgie, Paris (hereafter ASD). 28 Letter from Mme O to Les Bluets, [1980], Box X-2, ASD. Transition describes the final stage of labor, when a woman reaches full dilation. For many women, this is the most painful period. 29 Simkin, “Pain, Suffering, and Trauma in Labor and Prevention of Subsequent Posttraumatic Stress Disorder,” 167. 30 Response from Mme P to Les Bluets Exit Questionnaire, [1980], Box X-2, ASD. Emphasis in original. 31 MacColl, The Birth Wars, 192. 32 “Natural Childbirth,” 47. 33 Registered Nurse, “Sadism in Delivery Rooms?,” Ladies Home Journal, November 1957, 4. 34 [As Told To] Amy Selwyn, “I Watched My Baby Born,” Pageant, January 1949, 5. 35 Quoted in Alain Noirez, “L’Accouchement sans douleur: De la présence du conjoint à l’accouchemnt de son épouse. Le vécu de la paternité, le rôle du mari au cours de la gestation. La crise modern de la paternité” (PhD diss, Université Pierre et Marie Curie, Paris-VI, 1976), 122. 36 Letter from Mme S to Les Bluets, 17 October 1976, Box X-1, ASD. 37 Michaels, Lamaze, 130–32. 38 “Natural Childbirth,” 47. 39 Glenda Adams, “Natural Childbirth: Just Another Shuck,” Village Voice, 30 September 1971, 18. 40 “Natural Childbirth without Pain,” New Haven Register, 2 March 1947, 3. 41 Morton Sontheimer, “Miracle in the Delivery Room,” Women’s Home Companion, December 1948, 4. 42 Quoted in “What Can We Learn from New Guinea? The 1949 Annual Report of the Maternity Center Association, New York,” 1949, Herbert Thoms Collection, MS 14, Scrapbooks, Yale University, Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT (hereafter HCJHW). 43 Offprint, “Mister Midwife of San Diego, Prevention,” June 1972, Midwifery Collection, MS 454, Box 6, Folder 7, Sophia Smith Collection, Northampton, MA. 44 Kitzinger, “Nurturing Mothers,” 16. 45 Toni Taylor, “Natural Childbirth,” Today’s Woman, December 1949, 47. 46 Herbert Thoms, “Natural Childbirth in a Teaching Clinic,” Journal of Obstetrics and Gynecology of the British Empire 56, no. 1 (1949): 18–21. 47 Selwyn, “I Watched My Baby Born,” 5. Emphasis in original. 48 Taylor, “Natural Childbirth,” 52. 49 Ibid. Emphasis in original. 50 Ibid. 51 Nick Abson, “Where There’s Life” (Yorkshire Television, 28 August 1985), British Film Institute. 52 Ibid. Natural childbirth activists might well have challenged this woman’s characterization of her birth as “natural” given that she labored with the benefit of epidural anesthesia. Her understanding may in part reflect national differences, as the US natural childbirth movement was the most dogmatic in its rejection of pharmacological pain relief. 53 Ibid. 54 On the history of the DSM, see Hannah Decker, The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (New York: Oxford University Press, 2013); Gary Greenberg, The Book of Woe: The DSM and the Unmaking of Psychiatry (New York: Blue Rider Press, 2014); Allan Young, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (Princeton, N.J.: Princeton University Press, 1997). 55 For example, on the debate surrounding adding Complex Post-Traumatic Stress Disorder to the DSM, see Patricia A. Resick et al., “A Critical Evaluation of the Complex PTSD Literature: Implications for DSM-5,” Journal of Traumatic Stress 25, no. 3 (2012): 241–51, doi:10.1002/jts.21699. 56 Mark S. Micale, Hysterical Men: The Hidden History of Male Nervous Illness (Harvard University Press, 2009). 57 Shoshana Ringel and Jerrold R. Brandell, eds., Trauma: Contemporary Directions in Theory, Practice, and Research (Thousand Oaks, CA: Sage Publications, 2011), 1-2. 58 Miguel Gutiérrez Peláez, “Trauma Theory in Sándor Ferenczi’s Writings of 1931 and 1932,” International Journal of Psychoanalysis 90, no. 6 (2009): 1218. See also Didier Fassin and Richard Rechman, The Empire of Trauma: An Inquiry into the Condition of Victimhood (Princeton, NJ: Princeton University Press, 2009), 62-63. 59 Otto Rank, The Trauma of Birth (New York: Dover Publications, 1993), 21. 60 Ibid., 47. War neurosis has its own long, complicated genealogy and well-developed historiography. See, for example, Paul Frederick Lerner, Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890-1930 (Ithaca: Cornell University Press, 2003); Ruth Leys, Trauma: A Genealogy (Chicago: University of Chicago Press, 2010); Young, The Harmony of Illusions. 61 Nandor Fodor, “The Trauma of Bearing,” Psychiatric Quarterly 23, no. 1 (1949): 59; M. Straker, “Psychological Factors During Pregnancy and Childbirth,” Canadian Medical Association Journal 70, no. 5 (1954): 510–14. 62 Fodor, “The Trauma of Bearing,” 59. 63 “What Can We Learn from New Guinea? The 1949 Annual Report of the Maternity Center Association, New York.” 64 Michaels, Lamaze, 133–34. 65 Sandra Schildroth, “Book Review: A Deeper Look at Leboyer. Birth without Violence by Frederick Leboyer,” News from H.O.M.E. 1, no. 1 (1976): 2; also Kitzinger, “Nurturing Mothers,” 18. 66 “Leboyer and Consciousness of the Baby,” Birth Notes 1, no. 3 & 4 (1977): 1. 67 Deutsch is cited widely and described by Straker as “extremely influential.” Straker, “Psychological Factors During Pregnancy and Childbirth,” 511. 68 Helene Deutsch, The Psychology of Women: A Psychoanalytic Interpretation, vol. 2 (New York: Grune & Stratton, 1944), 233. In later years, research by Masters and Johnson challenged these notions of female sexuality as passive, as did feminist psychiatry. Thomas Maier, Masters of Sex: The Life and Times of William Masters and Virginia Johnson, the Couple Who Taught America How to Love (New York: Basic Books, 2009); Kate Millet, Sexual Politics (New York: Ballantine Books, 1970). 69 Deutsch, The Psychology of Women, 2: 234. 70 Sigmund Freud, “The Sexual Enlightenment of Children,” in The Standard Edition of the Complete Psychological Works of Sigmund Freud, trans. James Strachey and Anna Freud, vol. 9: Jensen’s “Gradiva” and other works, 1906-1908, 24 vols. (London: Vintage: Hogart Press: The Institute of Psycho-Analysis, 2001), 129–40. 71 Clarence D. Davis, “Section II: Prepared Childbirth,” undated supplement to Davis’ Gynecology and Obstetrics, vol. 1 (Hagerstown, MD: W. F. Prior, 1949), 88. 72 The phrase “the great American expert” comes from Grantly Dick-Read, Typescript, Unpublished Autobiography, n.d., 33, Personal Papers, Grantly Dick Read, A.92, Wellcome Library, London (hereafter PP/GDR/A.92/WL). “So much” is found in Letter from Grantly Dick-Read to Herbert Thoms, 1 March 1949, Herbert Thoms Collection, MS14, Box 1, Fol 1, HCJHW. 73 Dick-Read, Typescript, Unpublished Autobiography, 33, PP/GDR/A.92/WL. 74 Ibid., 10. 75 Letter from Grantly Dick-Read to Herbert Thoms. 76 Quoted in Kartchner, “A Study of the Emotional Reactions during Labor,” 24. 77 Karen Horney, Feminine Psychology, Revised ed. edition (New York; London: W. W. Norton & Company, 1993). 78 Kitzinger, “Nurturing Mothers,” 18. 79 Horney, Feminine Psychology, 99–106; Straker, “Psychological Factors During Pregnancy and Childbirth,” 512. 80 Letter from Grantly Dick-Read to Dr. Y, 30 March 1950, PP/GDR/D.180, WL. 81 Ibid; Fodor, “The Trauma of Bearing,” 59, 62, 63; “Mrs. Sheila Kitzinger’s Talk on the Relationship between Instinct and Training in Childbirth,” National Childbirth Trust Newsletter, September 1963, 9. 82 Fodor, “The Trauma of Bearing,” 60. 83 Letter from Grantly Dick-Read to Dr. Z, 27 September 1950, PP/GDR/D.183, WL. 84 Fodor, “The Trauma of Bearing,” 60; Nandor Fodor, “The Search for the Beloved,” Psychiatric Quarterly 20, no. 4 (1945): 549–602. 85 Henriette R. Klein, Anxiety in Pregnancy and Childbirth (New York: P.B. Hoeber, 1950), 13. 86 Ibid., 15, 17, 18. 87 Klein, Anxiety in Pregnancy and Childbirth; Straker, “Psychological Factors During Pregnancy and Childbirth”; Kartchner, “A Study of the Emotional Reactions during Labor.” 88 Fassin and Rechtman, Empire of Trauma, 5-8. 89 Klein, Anxiety in Pregnancy and Childbirth, 21, 25. 90 Kartchner, “A Study of the Emotional Reactions during Labor,” 21. 91 Ibid., 27. 92 Letter from Grantly Dick-Read to Dr. Z, 30August 1950, PP/GDR/D.183/WL. 93 Letter from Dr. Z to Grantly Dick-Read, 21 September 1950, PP/GDR/D.183/WL. 94 Letter from Mrs. B to Grantly Dick Read, 24 August 1951, PP/GDR/D.79/WL. 95 Letter from Grantly Dick-Read to Dr. Z, 30 August 1950. 96 The role of Vietnam and the psychiatric encounter with veterans is, of course, widely seen as central in revising the understanding of trauma, but other factors played a part as well, including Holocaust traumatology and the psychology of nuclear war. The influential work of Robert Jay Lifton exemplifies the convergence of several social movements and political events to redefine trauma after World War II. See, for example, his Death in Life: Survivors of Hiroshima (New York: Random House, 1968) and Home from the War: Vietnam Veterans, Neither Victims nor Executioners (New York: Simon and Schuster, 1973). The influence of feminism on his thinking about the trauma of the Vietnam War is evident when he writes, for example, that the “super-masculine ethos fits in with war-making and the war-like ethos,” the psychological costs of which are borne by veterans. Untitled typeset manuscript, [1971 or 1972?], Robert Jay Lifton Papers, box 116, folder 1, Manuscripts and Archives Division, New York Public Library, New York. 97 Kitzinger, “Nurturing Mothers,” 16. 98 Ringel and Brandell, Trauma; Fassin and Rechtman, Empire of Trauma, esp. 77-93. 99 E.g., Jenny Gamble and Debra Creedy, “Psychological Trauma Symptoms of Operative Birth,” British Journal of Midwifery 13, no. 4 (2005): 218–224, doi:10.12968/bjom.2005.13.4.17981; J. Söderquist et al., “Risk Factors in Pregnancy for Post‐traumatic Stress and Depression after Childbirth,” BJOG: An International Journal of Obstetrics & Gynaecology 116, no. 5 (2009): 672–680, doi:10.1111/j.1471-0528.2008.02083.x. 100 Grace Zimmerman, “Birth Trauma: Posttraumatic Stress Disorder After Childbirth,” International Journal of Childbirth Education 28, no. 3 (2013): 62. 101 Kartchner, “A Study of the Emotional Reactions during Labor,” 25. 102 Penny P. Simkin and MaryAnn O’Hara, “Nonpharmacologic Relief of Pain during Labor: Systematic Reviews of Five Methods,” American Journal of Obstetrics and Gynecology 186, no. 5 Suppl Nature (2002): S131-159. 103 Simpson and Catling, “Understanding Psychological Traumatic Birth Experiences,” 204. © The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com

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Journal of the History of Medicine and Allied SciencesOxford University Press

Published: Jan 1, 2018

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