|
| |
by Richard Seel
First published in The Health Visitor June 1986
Vol. 59, pp: 182-184
{To
download a Word version, click here.}
Summary
A review of the rites of passage experienced at various stages of life, with
particular emphasis on those associated with birth, suggests that the incompleteness of
birth rites may be a contributory factor in some cases of post-natal depression and
parental anxiety.
Introduction
It has frequently been observed that modern obstetric practices have a ritual as well
as an instrumental function (Kitzinger 1979). This article will look more closely at these
ritual aspects, and ask whether the nature of such rituals may have a connection with
postnatal depression. The rituals surrounding birth belong to a particular class known as
rites of passage and in western society they are incomplete.
The nature of ritual
Rituals have two main areas of operation: they affect the individuals involved and
they express social values. In turn, the social aspect have consequences for the
individuals involved. Rituals are powerful and can have a significant and usually
beneficial influence on the lives of the participants.
Taken as a whole, modern obstetric procedures have a powerful ritual value. Some
procedures may be of little or no ritual consequence. but may be medically important. e.g.
taking blood pressure. Others may be of little medical value but be ritually important,
e.g. wearing masks in the delivery room. Most will have both ritual and medical
importance, e.g. episiotomy.
It is important to be clear that labelling a procedure as ‘ritual’ is not a
criticism of. that procedure. There seems to be a belief in some parts of our society that
rituals are a bad thing. This is not generally so. Rituals can be very helpful to us all,
especially in situations of uncertainty or change of social role. Having a baby is just
such a situation: not only does a woman give birth, but she takes on a new role; she
becomes a mother . Nearly every culture in the world marks this change ritually. The
details of such rituals vary, but their form is largely constant. They belong to a class
of rituals known to anthropologists as rites of passage (van Gennep 1960).
Rites of passage are found whenever a person changes his or her social states;
initiation ceremonies marking the transition from child to adult; wedding ceremonies
marking the transition from single to married; funeral ceremonies marking the transition
from living to dead; and many others. Birth rituals mark the transition to parenthood. A
rite of passage has three main parts, each of which may last for quite a long time and
consist of a number of ritual actions. The rite of passage is only completed when all
three parts have been performed.
Rite of separation
In the first part of the rite of passage, the person undergoing the social change
(becoming a mother, in this case) is separated from her old environment. This is often
achieved by removal to a special place, set apart from normal life: a sacred initiation
ground or building. Rites of cleansing and purifying often take place and new clothing is
adopted.
There are many elements in the preparation for labour and birth which parallel this
description. There is normally a journey to a place set apart (the hospital) where the
parents will be separated from normal society and from each other. Rites of cleansing and
purifying may take place: the woman may be bathed, shaved, or given an enema. New clothing
is given to her. Many parents remark on their feelings of confusion and alienation on
admission to hospital.
The liminal period
The middle stage of a rite of passage is called the liminal period (from the Latin limen,
a threshold). It is the period when those undergoing the rite have no status of any kind.
They have left their old roles behind (indeed, they are often spoken of as having died,
especially in initiation rites), but have not yet adopted their new roles. During the
liminal period, they may be subjected to humiliation and strict discipline. In some
initiation ceremonies, pain may be inflicted on those being initiated, and the liminal
period may be climaxed by some bodily mutilation (circumcision, knocking out of a tooth,
scarification, etc.) Most important of all, there is instruction, often in a symbolic
form, about the nature of society and what is expected of the new role into which the
person is transferred. A period of waiting before the end of the liminal period is also
common.
Again, the parallels are clear .The woman in labour has little status in the hospital.
She may well feel humiliated by her treatment: by the way that her natural functions are
taken over by strangers, by the way she is unable to move because of monitors and drips,
by the way her questions may not be answered to her satisfaction. Pain is, of course,
commonplace during labour , though not inflicted by those in charge of the woman. At the
climax of the labour there may well be that ‘unkindest cut’, the episiotomy (not
to mention the ever more common Caesarean section). After the birth there is a further
period of waiting, of ten days, before the liminal period is over. There is also
instruction, in both plain and symbolic form, and I will return to this later.
Rite of incorporation
The final part of the rite pf passage moves the subject back into the world, but now
in his or her new stats: as adult; husband or wife; or as parent. The new status will be
publicly announced and celebrated, Special clothing may be worn, and there may be feasting
and general rejoicing. Often those who have undergone the ritual will be granted
privileges because of their new status, and will be accorded a new respect by society at
large.
The parallel breaks down here. Although the first two stages of the rite are highly
elaborated in western obstetrics, there is little or no rite of incorporation. We leave
the rite of passage unfinished; the new mother and father are left in limbo, having to
fend for themselves as best they can. The consequences of this incompleteness may be quite
serious for some parents.
The mechanism of the rite of passage
Much of the ritual works to subjugate and humiliate the subject. To many people it
seems pointless, even gratuitously cruel. Feminist writers tend to identify obstetric
ritual with male dominance and a desire to control female fertility. There is much truth
in this view, yet there is also evidence to suggest that the mechanism of the rite has a
purpose, and that ultimately the rite could be beneficial and life-enhancing.
At the level of individual psychology some suggestions made by William Sargant (1957)
may be relevant. Drawing on the work of Pavlov, Sargant argues that in initiation rites,
“an overwhelming emotional stimulus carries the subject to the point of emotional
collapse and increased suggestibility.” In this state of heightened suggestibility,
the person being initiated can be more quickly and effectively conditioned to his or her
new, adult place in society. Sargant sees this process as similar to that which occurs in
brainwashing and ecstatic religious conversion.
The anthropologist Paul Spencer (1965) noted the distress of young girls going through
a marriage ceremony (itself a rite of passage) in Kenya, but was surprised by how quickly
they adapted to a strange home, strange husband and strange mother-in-law. Spencer has
suggested that Sargant’s work can give an insight into all rites of passage; that the
intense anxiety provoked by the rituals and ordeals can help the individual involved to
adapt more quickly and completely to his or her new social identity.
Western birth ritual separates a woman from her normal environment and subjects her to
humiliation and disorientation in a strange setting, where she is powerless and in pain.
As a result of this she is more susceptible to the teaching she receives during the
liminal period, which extends until approximately ten days after the birth. At the end of
this time she should be welcomed back into society, honoured as a mother and nurtured and
supported in her new status.
In this way the obstetric procedures necessary to bring about successful childbirth
and the ritual procedures necessary to bring about a successful transition to parenthood
should run parallel. In theory, this: mix of science and ritual should produce physically
healthy babies and socially well-adjusted parents. In practice, it does not seem to work
so well.
Post-natal depression
Various explanations have been offered for post-natal depression. The term itself is
ill-defined. Yet it is undeniable that many women (and perhaps many men) suffer from some
symptoms associated with depression in the early days and weeks of parenthood. Hormonal
deficiencies (Dalton 1980) and birth experiences (Oakley 1980, Welburn 1980) have been
suggested as contributory factors. I want to look more closely at the possible influence
of birth experience and suggest how such experiences might contribute to depression. In
particular, there are three aspects which are worth looking at in closer detail.
The message of the rite
Instruction and teaching play an important part in many rites of passage. Any
heightened sensitivity engendered by the privations of the rite will tend to make such
instruction very significant for the future attitudes of the person undergoing the ritual.
The effect of staff attitudes and practices in this period on the long-term maintenance of
breastfeeding is well known (Baer & Baer 1980, Wright et al 1983). What other
instruction is given during our birth rite?
In fact, there is not much explicit teaching: how to bath the baby, fix him or her on
the breast, clean the umbilical stem, etc. It should all be fairly straightforward, but
somehow it often gets incredibly complicated, Many mothers find that the advice they get
in hospital in those first ten days is confusing and conflicting. This is true to a lesser
extent when the woman comes home before the ten day liminal period is completed, but any
gain in this direction may be offset by confusion brought about by returning to society
before the liminal period is over.
The problem of conflicting advice is a complex one, involving both variation in advice
given and changes in need and perception by the new mother. This advice is not given and
received in a neutral or value-free way, but rather in the context of an emotional and
ritually charged episode in the mother’s life. This means that what in other
circumstances might be dealt with rationally and calmly may here become a trigger for
anger, frustration or depression (‘baby blues’).
The symbolism of the rite
The explicit postnatal tuition is not the only, or the most important, teaching given
during the birth rite. There are many hidden assumptions and symbolic statements which can
assume highly significant status for the new mother .Symbols used in rituals tend to
express societal values. Sometimes they are of general relevance, e.g. in reaffirming the
current social structure. Sometimes they are more specifically relevant to the experience
of the participants in the rite.
Obstetric intervention and active management of labour are controversial subjects,
whose importance goes beyond the purely functional. Ann Oakley (1980) has found a positive
correlation between what she describes as medium/high technology birth and postnatal
depression. It is not the technology as such which underlies the depression. Rather it is
the way it is used, the reasons for its use, and the implications of its use which may
have consequences for parents’ reactions to their new babies.
I have looked at some aspects of the wider implications of ‘natural’ versus
‘managed’ birth elsewhere, (Seel 1983) but briefly, there is reason to suppose
that the values of managed childbirth are male values and the values of natural childbirth
are female values. This does not mean that all men are in favour of intervention simply
because they are male, or all women in favour of natural birth. However, it does mean that
the ethos of our birth ritual, expressed as it is in terms of the symbolism of technology
and control, may be profoundly upsetting to some parents.
This is not a matter of rational assessment, or scientific argument. In a highly
charged context such as childbirth, symbols are apprehended intuitively. The common mode
of childbirth today expresses certain ideas about the world and society. Some parents
(those who see nature as threatening and find comfort in a clearly defined power
structure) will find these congenial and will have their own values confirmed and
strengthened. Others (those who view technology with distaste and believe in shared
decision making) will find a conflict with their own values. For them the symbolism of
birth may not be life-affirming, but rather perceived as sterile and mechanistic.
The questions of control and male/female values are general: they have more to say
about the way we structure our society than the right way to be a mother. But there are
other aspects of the medical approach to birth which have profound implications for
attitudes to motherhood. For instance, modern obstetrics is child-centred. It is
considered appropriate for the mother to suffer discomfort, alienation and even surgery in
order that the supposed needs of the baby may be satisfied. If a mother questions an
obstetric procedure she is likely to be controlled with a reference to possible harm to
her baby.
The potential problem with this approach is its lack of balance, and its future
repercussions. By denying the importance of the mother’s feelings during labour, the
ritual is saying that if she wants to be a ‘good’ mother, she must subordinate
her own needs and desires to those of the baby. This is almost bound to lead to feelings
of resentment or guilt by the mother, as she is faced with the demanding reality of a new
baby. If she acquiesces in the message of the rite and denies herself entirely for the
sake of the baby she is likely to feel resentful. If she does the opposite she is likely
to feel guilty.
Of course, the baby’s needs are very important, and to this extent the symbolism
of the rite is both correct and vital, but where or when do we ritually celebrate and
support the importance of the new mother? How do we convince her of her own worth and help
her to trust her own judgements and feelings? If this does not happen in the liminal stag
of the rite, then perhaps this celebration should come when she is reincorporated into
society and starts her new career as a mother. Unfortunately, this rarely happens.
The incompleteness of the rite
Rites of passage appear in almost every known culture. The content and the symbols
involved may change, but the form is constant. It is unlikely that such a rite would be so
widespread if it did not fulfil a basic human social need. Regardless of any psychological
mechanisms at work, the rite has its own logic and its own pattern. If that pattern is
disrupted or left incomplete, serious distress could result. In order for any heightened
suggestibility to have positive consequences, there must be a nurturing and welcoming
climax to the rite of passage. Otherwise the participant is left high and dry, with
feelings of alienation and distress.
The rite of incorporation should come at the end of the ten day period, when the
mother is discharged from hospital or receives the last visit from the midwife. It is at
such a time that many parents feel utterly lost and alone; cast adrift on an unwelcoming
and uncharted sea of troubles. Now is the time when they need to be welcomed back and made
to feel part of society again. This re-integration is crucial: if a new mother feels that
her new status is valued by society and that she is part of a network of potential friends
and helpers, any problems become much easier to solve.
The NHS sponsors the first two parts of our rite of passage for birth (even though it
might do so unwittingly), but declines to be involved in any third part. The only possible
NHS continuity is provided by the health visitor. Could s/he do more? Some countries give
a new mother a medal—perhaps the health visitor could present her with a bouquet of
flowers and a congratulations card! Health authorities might gibe at the outlay, but
compared to the money spent on high-technology birth it would be negligible—and might
help prevent much misery. It might also save money in the long run.
Another possibility is that clinic visits could be made the occasion for some
ceremonial welcome back into society. Should church, mosque, temple and local self-help
groups be invited to collaborate with the clinic in some way? There are no easy answers,
but if we start to ask the questions then we just might begin to prevent or cure some of
the negative and depressed feelings that beset so many new parents.
Conclusion
In this article I have looked at modern obstetric practice from an anthropological,
rather than a medical perspective. I have presented a very simplified account of rites of
passage and shown how current birth practice closely follows the pattern of this rite. The
message of the rite reinforces the values of hierarchy and control over nature. It also
stresses that a parent’s needs are to be subordinated to those of the baby. There is
little in the rite to support and encourage the new mother, especially since the rite is
incomplete. This may be a contributory factor in some cases of postnatal depression and
parental anxiety. Clinics and health visitor might be instrumental in completing the rite
and perhaps alleviating some of the present adverse consequences.
References
Baer, B. & Baer, E. 1980, “The Obstetrician’s Opportunity: Translating
‘Breast is Best’ from Theory into Practice”, American Journal of
Obstetrics and Gynaecology September.
Dalton, K. 1980, Depression After Childbirth, Oxford: University Press.
Gennep, A. van 1960 (1908), The Rites of Passage, London: Routledge & Kegan
Paul.
Kitzinger, S. 1979, Women as Mothers, London: Fontana.
Oakley, A. 1980, Women Confined, Oxford:
Martin Robertson.
Sargant, W.
1957, Battle for the Mind, London: William Heinemann.
Seel, R. “It’s Only Natural?” New
Generation 2(3): 9.
Spencer, P. 1965, The Samburu, London: Routledge & Kegan Paul.
Welburn, V. 1980, Postnatal Depression, London: Fontana.
Wright, H. et al. 1983 “Prediction of Duration of Breastfeeding in
Primiparas.”, Journal of Epidemiology and Community Health, 37.
|