We drive an hour and a half in the dark and pull up to a small house in the woods. My mom, the midwife, hurries inside to assess the situation. I pull the large purple birth bag out of the back of the Subaru, tuck the wooden birthing stool under my arm, and lift the heavy oxygen tank. Once inside, I methodically begin my duties: pour olive oil from the jar into a peri bottle and set in a pot of warm water; saturate sanitary pads under kitchen faucet and place in freezer; take stock of fridge contents; lay out sanitized instruments; prep oxygen tank; make sure blankets and clean cloths are ready.

… one must first soothe the pains by touching with warm hands, and afterwards drench pieces of cloth with warm, sweet olive oil and put them over the abdomen as well as the labia and keep them saturated with warm oil for some time…she [the midwife] should anoint the region with oil — bewaring of such oil as has been used for cooking. —Soranus Gyn. 2.4

I bring the warmed oil into the living room where the woman is laboring in a birthing tub, partially submerged in the warm water. The room is dim, lit by candles. The woman moans and rolls up onto her hands and knees. Now her back is exposed, so we lay towels on her to protect her from the early spring chill in the room. I pass the warmed olive oil to my mom, who rubs her hands together to generate heat. She squirts the oil onto her hands and rubs it around the opening of the woman’s vagina, where the slightest slit of a dark-haired head peeps out and back in with each of the woman’s contractions. This peeping goes on for hours. The olive oil keeps her vulva lubricated and prevents her perineum from tearing.

… if the gravida is weak and toneless one must deliver her lying down, since this is less painful and causes less fear. If, however, she happens to be strong, one must make her get up <and> place her on the so-called midwife’s stool… —Soranus Gyn. 2.4

A couple of years later, this time in the melting heat of August: it is dark again and we drive. The laboring woman is 22 and physically fit, with a three-year-old daughter. She is in the bathroom, leaning against the far wall of the bathtub, sitting on the wide edge of the tub. She labors quickly and without incident, doesn’t make a sound. My mom has to lean, crouch, bend to get in under her and catch the baby. We move her and the baby into the bed prepared with blue pads. I make scrambled eggs and we all laugh and examine the baby, checking her tonality and the flexibility of her limbs, the shape of her ears and toes, her automatic reflexes (“The infant that is suited by nature for rearing will be distinguished … by the fact that it is perfect in all its parts, members and senses; that its ducts, namely those of the ears, nose, pharynx, urethra, anus are free from obstruction; that the natural functions of every member are neither sluggish nor weak; that the joints bend and stretch,” Soranus Gyn. 2.10).

There should be three women helpers, capable of gently allaying the anxiety of the gravida even if they do not happen to have had experience with birth. Two of them should be at the sides and one behind holding the parturient woman so that she may not sway with the pains. But if the midwife’s stool is not at hand, the same arrangement can be made if she sits on a woman’s lap. However, the woman must be robust, that she may bear the weight of the woman sitting upon her and be able to hold her firmly during the pangs of labor. — Soranus Gyn. 2.5

Jacmel, Haiti, 2011. My mom and I have come for a month to work at a birth clinic run by international midwives. We arrive and learn that the clinic is actually, functionally being run by an indomitable Haitian woman named Ninotte Lubin. She is training with the foreign midwives who come for temporary stays and is close to achieving full certification in her own right. Melinda, a young midwife from Canada, has been there for a year. My mom is the senior midwife in experience and age, but most novice in the language and customs of Haiti. I’m there to make food and to work on my Haitian language skills.

We’ve been at the clinic for a few weeks and already assisted with more than a dozen births. A woman arrives near midday. She is an important woman in the community. She already has five children and her husband is the pastor at the local church. They have some money, unlike most of the women we see. It is 37 degrees Celsius and the white, geodesic dome tent that serves as the clinic is as hot as an oven. The woman wants to labor in the breeze outside, on the pallet beds where midwives hold prenatal visits and teach classes. There is a raised cement platform with one cement wall at the back, the other three sides open with supporting beams at intervals for a roof. Four beds are lined up, spaced a few feet apart from each other and about two feet from the wall. The woman lies down on her back on one of the pallets and we — Melinda, Mom, Ninotte, and I — hang white sheets for privacy curtains. Mom is going to deliver the baby. Melinda delivered a baby the night before and Ninotte has malaria.

Ninotte lies on the next pallet over and offers encouragement to the woman through her own feverish episodes of malaria. (Most of the women at and around the clinic have malaria at some point during our visit). The woman is in pain on her back; she needs to sit up in the bed. But there is nothing for her to lean back against. So Melinda climbs in behind her and holds her up like one of those boyfriend pillows. After several minutes, Melinda’s body is aching. So I sit on the edge of the pallet, back to back with Melinda. I stick my legs out straight in front of me and push into the concrete wall with the flat of my feet. I am able to push Melinda and the laboring woman in front of her back upright. We stay like this for an hour while the woman pushes her baby out. I have never done anything so physically demanding in my life. I’m not even convinced actual childbirth will be harder. My legs ache for days afterwards. It turns out I also have malaria.

I have spent my whole life around homebirth midwifery. My mother is a Certified Professional Midwife (CPM) and she has been taking me to births since I was seven years old. I have assisted or been present at over thirty home or clinic births and have seen many varieties of laboring humans and birthing conditions.

I also have a PhD in Classics and wrote a dissertation on childbirth and midwifery in ancient Rome. When people hear about my research, they often ask me what childbirth was like in the ancient world, assuming that it was terrible and that we should thank god for modern medicine. But the truth is that in reading Soranus’ Gynecology (the text I have quoted above), a handbook on midwifery and gynecology written by a physician in the 2nd century CE, I am often struck by how similar ancient midwifery seems to modern homebirth midwifery. How similar to stories I have heard from my mother and scenarios I myself have witnessed.

In the first place, the basic tools of the trade are strikingly similar: warm water, olive oil, soft cloth, a birthing stool, clean hands, fresh fruit, a kind smile, and words of encouragement. In his description of childbirth, Soranus shows women helping women — the oldest definition of what can feasibly be called the world’s oldest profession (sorry, prostitution). And birth in the ancient world took place at home. There were no clinics or hospitals that women went to to deliver their babies.

Further, as we saw from the above passages, Soranus advocates for a variety of labor positions, depending on the woman’s strength, energy level, and her own preferences for mitigation of pain and ease in giving birth. Modern homebirth midwifery holds the philosophy that women should be free to choose the birthing position that seems best to them. I have seen women deliver babies lying on their backs, lying on their sides, squatting, sitting on a birth stool, sitting up in bed, standing, leaning over and grasping onto a support (as in that famous description of Leto at Hymn to Apollo 117), on hands and knees, in water, out of water, and variations on all of these. Moving around in labor and trying out a variety of birth positions to find the most suitable one allows women to jump-start stalled labor, to mitigate the pain of labor and delivery, and to give birth without the aid of pain relief.

Modern hospital birth, on the other hand, privileges ease of delivery not for the laboring woman, but for the attending physician. Although such practices have started to change lately, for the second half of the 20th century and into the 21st century, women who give birth in the hospital have often been laid flat on their backs, with their feel up in stirrups (the lithotomy position) and even strapped down to hospital beds. Such positioning allows easy access to the birth canal for the obstetrician, but is not necessarily optimal for labor and delivery. In fact, in such a position the baby emerges upwards, negating any assitance that might be offered by gravity (Robbie Davis-Floyd, Birth as an American Rite of Passage 86–87; 121–122).

And when it comes to hospital birth, one intervention, even one so benign as a prescribed birthing position, often leads to a “cascade of interventions” (also see Sarah Scullin’s article on this concept). It goes something like this: the woman is laid out on her back, which causes labor to slow down. So she is given Pitocin, a drug that induces contractions. Because the contractions are induced and “artificial” (that is, brought on by a source outside the woman’s body), they are intense and unremitting. So a woman seeks pain relief and is given an epidural. At this point, the baby and the woman require constant monitoring by machine to make sure that heart rates, blood pressures, and circulation remain normal. Any deviations from the norm can easily lead to a c-section — the c-section rate in the United States is currently at more than 30%.

In the ancient world, c-sections were only performed if the woman had died and it was suspected that the infant was still alive. While c-section today is a much safer procedure than in the ancient world (and one that women can reasonably expect to survive, although it carries a risk of death three times greater than vaginal birth), it is a still a major surgery that carries substantial risks, including endometritis, blood clots, wound infection, and increased risks during future pregnancies. (There is also evidence that infants’ immune systems are made more robust by passing though the bacteria of the vaginal canal on their way out of the womb. Such fortification is not supplied to infants born via c-section.)

I am in no way condemning women for giving birth in the hospital or for having c-sections, whether voluntary or not. This is all just to say that birth might not have been such a risky proposition in the ancient world, and that in some ways, new risks have been introduced by modern hospital birth that were not present in the ancient world.

The episiotomy — an incision made in the perineum to enlarge the birth canal — is another procedure in the modern hospital that can actually increase the riskiness of birth. Obstetricians will perform episiotomies if they determine that the infant is too large to emerge with the birth canal intact or if they think that they need to remove the infant quickly. Unfortunately, episiotomies heal more slowly with greater risk for infection than the tears that happen on their own if an episiotomy is not performed.

In the ancient world, there is no recommendation that the midwife cut the perineum to enlarge the birth canal. In fact, the Hippocratic Oath explicitly forbids using a knife, which we might read as a prohibition against episiotomy as much as against surgery (see my previous article on the enduring legacy of the Hippocratic Oath in gynecological care).

Finally, people often assume that birth in the ancient world was a dirtier, more germ-filled affair. Indeed, Soranus’ treatise was written many hundreds of years before the advent of germ theory. But we do see an emphasis on cleanliness in the birthing and post-partum environment. He advises that warm water be used to cleanse “the parts” (a euphemism for female genitalia), that the birthing cloths used on the newborn babies be clean (2.14–15), and that the midwife and her attendants avoid using “such oil as has been used for cooking” — that is, previously used oil. All of these practices would have mitigated the risk of introducing germs and bacteria into the birthing space. Similarly, in modern homebirth midwifery, while metal instruments used to cut the cord and the gloves that the midwife and attendants wear are sterilized, everything else is merely “clean,” not sterile. Yet homebirth midwifery has a low incidence of bacterial infection.

I do not mean to argue that modern homebirth and ancient birth were equivalent. In fact, there are places in his treatise where Soranus advocates for a startling amount of medicalized intervention. Once labor has started, Soranus writes, “the midwife, having first annointed her hands with warm oil, should insert the forefinger of the left hand, the nail of which has been cut short, and first dilate the orifice gently and gradually…” (Soranus Gyn. 2.4).

While breaking the amnionic sac prior to delivery is a common practice in the hospital, the general wisdom in homebirth midwifery is to leave it intact. The amniotic sac cushions the baby as it comes down the birth canal, and leaving it intact (until it breaks on its own) can help to prevent infection during delivery.

During active labor, Soranus recommends that the midwife, “insert her fingers gently at the time of dilatation and pull the fetus forward, giving way when the uterus draws itself together, but pulling lightly when it dilates….” (Soranus Gyn. 2.5).

The Midwives Model of Care maintains that a woman labors and a baby is born on its own schedule and that the body knows what to do. Midwives avoid manual checks of the cervix as much as possible so as to prevent the introduction of bacteria into the area. At most, the midwife might perform manual intervention if the infant’s head has emerged, but its shoulders are stuck, preventing it from coming out the rest of the way. In such cases, a midwife will need to slide her fingers into the vagina and manipulate or rotate the shoulders to guide the baby out. In the hospital, one can still find forceps and vacuum extraction used in delivery — though the practice is on the decline, as the risks to the infant and the laboring woman receive more acknowledgement.

Soranus was a physician, not a midwife. So what we see in his treatise on gynecology is not a simple midwifery training manual. Rather, it is a document in which the female-centered practice of midwifery is being adopted and incorporated into male-centered medicine. So the manual interventions that we see in the treatise, which are not part of modern midwifery, instead align more closely with modern obstetrics.

What Soranus’ midwifery treatise really gives us is a view into the early period of the medicalization of childbirth — a process that has happened again and again at different points in history. In the early modern and modern periods, midwifery was oulawed in many places throughout Europe and North America as male medical doctors took over the practice of delivering babies, arguing that their medical training and surgical techniques were better suited to dealing with childbirth than the traditional knowledge and practices of midwives. As a result birth outcomes declined precipitously, with greater infection and mortality rates until the mid 1800s when Hungarian Physician Ignaz Semmelweis recognized that physicians moving from working with cadavers straight to delivering babies were transfering infectious materials from the one to the other.

So what should we make of this comparison between ancient and modern midwifery? In the first place, we should be wary of assuming that childbirth in the ancient world was inherently risky and dangerous. We don’t have statistics — any demographic numbers you might see for the ancient world are taken from modeling systems based on much later and dubiously comparable societies. In many ways, the fundamentals of midwife-attended birth are the same then and now, and such fundamentals lead to positive birth outcomes for mothers and babies.

In the second place, we should recognize that the conflict between traditional midwifery and medicalized obstetrics is very old. Fortunately, it seems that both sides are now learning from each other. Some hospitals have begun to supply the benefits of a homebirth or birth clinic setting with all the technological assistance of the hospital nearby, including hospital rooms that mimic apartments with cooking facilities, birthing tubs, and a variety of labor support equipment.

Nowhere in my life have I encountered greater vitriol than among those who decry the practice of homebirth midwifery. They argue that homebirth is dangerous, that people who choose homebirth are irresponsible because they are putting themselves and their unborn children at risk, or that people who practice homebirth midwifery are quacks. But the data does not back up these assertions. CPMs, the largest group of midwives who attend homebirth, are highly trained medical professionals who carry oxygen tanks and autoclaved instruments. They are versed in the latest techniques for assisting in difficult birth. And while the statistics show pretty even outcomes for riskier births (you will see countless article on either side), low-risk, “normal” birth generally proceeds better in a homebirth setting, with attendance by a CPM or a CNM (Certified Nurse Midwife).

As we confront the current maternity crisis in the United States, we should keep this whole history in mind. There is something important to be learned from the traditional practice of midwifery, particularly in its modern iteration. Sometimes the “great” advances of modern medicine do not have the intended effect and are rooted not in data, but in patriarchy.

Tara Mulder is a Visiting Assistant Professor of Greek and Roman Studies at Vassar College and the managing editor emerita of Eidolon. She serves on the advisory board of Grace Community Birth Center, a nascent birth center project in Grand Basin, Haiti. You can read more of her work here.

Thanks to Sarah Scullin, Donna Zuckerberg, and Kathi Mulder.

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