History of Birthing Positions
Most of what we understand of the most ancient birthing methods are through images of birth itself. Giving birth was at the center of many religious and cultural beliefs, and many cultures had unique methods to protect both the baby and the parents. However, one thing was pretty consistent cross-culturally: Most people squatted or sat while giving birth.
Throughout time, variety of equipment was often used to support the labor. For example, the earliest depiction of a birthing chair was from 1450 BC in a birth house in Luxor. Birthing chairs are low, slightly reclined chairs, that provided support during birth, and an opening at the seat to allow for the infant to pass through. They were a standard-of-care in middle-ages Europe, but also in use across the world.
When forgoing equipment, positions were often supported by people themselves. Whether midwives, birthing assistants, family members, or the spouse, people present for the birth would assist in positioning the prospective mother. Historian Jen-Der Lee focuses on delivery in imperial China. She states: “During delivery, women clung to ropes, leaned in a vertical position, or were supported by others around the waist.”
Often times, cross-culturally, the midwife would observe the exit of the baby, being present to assist the baby’s exit position. In any time, childbirth is a community process, with prospective parents, supportive family members, and experienced helpers assisting in the process.
History of Supine Birthing
Squat-birthing and birthing chairs were common globally in antiquity and later cultures. Late 17th century European medical practitioners began to advocate for childbirth to occur on the back. This arises from the medicalization of birthing, with the burgeoning role of surgeons in the birthing process.
Prior, cross-culturally midwives were the go-to for birth, with both their personal experiences and longstanding practices informing their methods. Surgeons began to be a part of the process in the late 16th century with French surgeon Ambroise Paré taking on high-risk and high-mortality births. This new position allowed the practitioner to observe the process easier, especially if it was a long labor.
A common myth of the change to supine birthing position is rooted in French King Louis XIV.
“Since Louis XIV reportedly enjoyed watching women giving birth, he became frustrated by the obscured view of birth when it occurred on birthing stool, and promoted the new reclining position,” Lauren Dundes, sociologist, wrote for the American Journal of Public Health. However, the effects of Louis XIV’s preference are mostly overstated. The role of physicians and surgeons prioritized the position for ease of tracking the process of birthing.
The real progenitor of change was French physician François Mariceau. In his groundbreaking 1668 book, The Diseases of Women with Child and in Child-Bed, he wrote:
“…the best and surest [posture] is to be delivered in their Bed, to shun
the inconvenience and trouble of being carried thither after-
wards;
The Bed must be so made, that the Woman being ready to
be delivered, should lie on her Back upon it, having her Body
in a convenient Figure, that is, her Head and Breast a little
raised so that she be neither lying nor sitting…”
Mariceau enacted the most prominent changes through his view of pregnancy as an illness or a tumor — “inherently pathologic and abnormal.” The medicalization of the birthing process has immense benefits — with both infant and maternal mortality rates decreased since the middle ages. Most of this decline is because of standardized hygiene practice, clean water, and better nutrition. Much of this decline, as well, is due to understanding pre-birth high-risk issues such as pre-eclampsia and gestational diabetes.
When anesthesia began being used for pain relief in birthing, most prominently with Queen Victoria in 1853, the supine position became solidified as standard practice in several European countries and in the United States. Patients now were unable to move or change positions while under anesthesia.
Supine birthing has only recently become the standard norm cross-culturally. In 1961, a survey by Naroll (et al.) of 76 cultures found that only 18% of cultures chose a flatter position like supine.
Now, non-American cultures tend to also adopt supine positions. A 2012 survey found that 95% of Nigerians giving birth did so in the supine position. Only 18.9% were open to trying different positions in the future.
So what spurred the change in African countries? One 2020 study in Tanzania surveyed both mothers post-birth and midwives about their preferences and experiences with alternative positions. The study found a general lack of knowledge of positions alternative to supine, especially among midwives. Notable quotes from midwives the study:
“I only know the supine position…it is the only birthing position taught in schools.”
“…Even if she has her preferred position, we convince her to change her mind and use supine.”
Basically, the conclusions of multiple studies seem to be that the supine position is common, even for uncomplicated births, because it’s what’s taught to both prospective parents and midwives.
Case for Positional Birthing
A variety of studies have found that upright and vertical positions decrease the second stage of labor by 6.6 minutes to 36 minutes. This might be due to the help of gravity, but also that contractions are more effective in more upright conditions. Lastly, the pelvis becomes around 20% more open in upright positions vs in horizontal positions.
There are theories that upright positions might have detriments — such as increased blood loss (due to gravity) or increased perineal tearing. However, a 2016 study of nearly 3,000 women giving birth with a variety of positions had lower incidence of severe perineal trauma compared to horizontal positions. The cases of increased blood loss are almost always associated with cases which have perineal tearing present. Unfortunately, regardless of position, 85% of birthing women experience perineal tears of some kind.
There are some medical detriments to horizontal positions as well. In fact, there is a condition directly related to laying flat in late pregnancy, called “supine hypotension syndrome.” The pregnant uterus compresses the vena cava and prevents flow of blood back into the heart. This decreases cardiac output and causes a drop in blood pressure.
“You should follow your body and do what feels right, and not be limited by expectations,” says Dr. Charlotte Elder, New Zealand obstetrician. In the face of high risk births and complications, someone can always change their position into supine when necessary.
Modern childbirth often relies less on community experience and more on medical experience. Many newly expecting parents only have the reference of mothers and grandmothers who also had medically-oriented births.
One 2013 study of women in Brazil had one group be educated on positions, options, and pain relief options. The other group did not receive this education. Those who did receive the education felt more in control of their birthing process and expressed more satisfaction with their birthing experience than the control group. Those who received the education were more likely to use a variety of birthing positions and non-pharmacological pain relief methods.
So What’s Best?
So what is better? Supine or non-supine positions? There is no correct answer. Each birth is unique. In medical emergency, supine position is necessary for anesthesia, c-sections, or other procedures. However, as most births are non-emergent, one can make the case to allow for instinctual changes in positions, employing non-supine positions as well. As research unfolds and expands on the topic, remaining educated and open to change is necessary for both the birther and the healthcare providers.
