While on a vacation in Maui recently, my husband and I ate dinner at a Japanese restaurant in Lahaina with a young couple from Washington D.C., he a computer programmer, she a finance analyst in managed health care. As the multi-talented chef saut}ed vegetables while juggling spatula and knife, the pair learned that I was a midwife and asked the inevitable question: "Why would anyone want to have a midwife and a `natural' birth instead of going to the hospital with an Obstetrician and have drugs?" The tofu lobbed off of my chopsticks in midair as I drew in a deep breath and asked them if they had the whole evening....

How does one begin to explain to a new generation of childbearing couples the inner fire that flames my commitment to preserving birth as an incredible life transforming process?

One can outline the basics of the history which has shaped the attitudes and practices which prevail at the end of this twentieth century. One can explain how birth, once the province of midwives for the bulk of the population, became the domain of medical doctors who, for geographical and socioeconomic reasons, funneled healthy mothers into hospitals. These low risk mothers, removed from safe, familiar environments and from attendants who understood and supported the normalcy of childbearing, began to replace age old strategies for coping and comfort with fear and uncertainty. With this fear came increased pain and discomfort, leading doctors to begin to administer anesthetics and analgesics.

In their misguided attempt to relieve pain and suffering, these practitioners wrested all control over the birth process from mothers and created dozens of harmful side effects from drugs for their babies. Childbirth became a hotbed of iatrogenic problems whose solutions snowballed into the technological approach to birth prevalent in modern obstetrics. Marsden Wagner in his book Pursuing the Birth Machine provides a history and survey of these technologies which have put the United States at the bottom of the industrialized countries in infant and maternal mortality.

Certainly such a perspective explains how the natural childbirth movement gained momentum in the 60's and 70's, as documentation on the harmful effects of drugs during pregnancy and birth encouraged many women to choose unmedicated deliveries. Yet two decades later we live in the wake of the introduction of the epidural, that magical anesthetic which promises complete pain relief with no harmful side effects. With the availability of such beneficent medications, why then would anyone choose to experien ce the pain of labor and birth?

First and foremost, an epidural is not proven to be 100% "safe." According to Penny Simkin, physical therapist and Childbirth Educator the use of epidural anesthesia increases the chance of Cesarean section 2-3 times in first time mothers. It can slow labor necessitating the use of pitocin to speed up contractions. This oxytoxic creates unnatural contractions whose intensity more easily creates fetal distress, requiring that the baby be continually monitored with an external or internal monitor (electrodes screwed into the baby's scalp while in utero.)

An epidural can cause a drop in maternal blood pressure and a subsequent reduction in blood flow to the uterus increasing the potential for a decrease in fetal heart rate. It can also cause the mother to have a significant fever without having an infection; because maternal fever puts the fetus at risk regardless of the source, the mother may now be treated with antibiotics (as will her baby following birth.) The mother is no longer free to eat or drink and must be fed intravenously; she may experience nausea, vomiting, or itching. She can no longer walk or squat and may need to be catheterized in order to urinate. In short, complete control of the labor process has been given over to medical personnel.

In spite of the common notion that epidural narcotics do not "reach the baby," the manufacturer of bupivacaine hydrochloride (one of the common drugs used for epidural analgesia) warns that "local anesthetics rapidly cross the placenta and when used for ... epidural anesthesia can cause various degrees of maternal, fetal, and neonatal toxicity." The FDA has given bupivacaine hydrochloride a C rating for use during pregnancy indicating that human studies are lacking and animal studies are either positive for fetal risk or lacking at all.

In the most positive scenario, epidural anesthesia provides complete pain relief, allowing the mother to relax, rest, and progress to complete dilation. The epidural can be permitted to wear off for second stage, allowing the mother to feel contractions and push out her baby. If recovery is incomplete the mother may not be able to push effectively, and arrested progress, forceps, vacuum extraction and/or C-section may result. According to Suzanne Arms, author of Immaculate Deception II: Birth and Beyond, the chance of C-section is 50% when an epidural is given at two cm of cervical dilation, 33% when given at three cm, and 26% when given at four cm.

This is not to negate the relative merits of epidural anesthesia. When a woman is tense, fearful, or exhausted, has inadequate physical or emotional support, a prolonged labor or excruciating back pain, an epidural can be merciful. It can assist dilation by allowing the mother to relax. For pregnancies and/or births complicated by the true need for C-section, this anesthetic is far easier to recover from than spinal anesthesia, with its consequent headache, or the disorienting grogginess of a general. Many women "loved" their epidural as they felt no pain while remaining mentally cognizant.

In contrast, women who choose to give birth without pain medication utilize time-honored tools to help deal with labor. Deep abdominal breathing, sounding, walking, squatting, warm baths and showers, cool compresses, massage, reflexology, acupressure and counterpressure are but a few of the comfort measures which assist mothers in relaxation.

The choice of an environment that most appropriately meets the needs of the individual woman, be it home, hospital, or birth center, will help the laboring mother feel protected and secure. Music, scents, candles, and lighting are external aids that can contribute to making a space feel private and safe. It is critically important to surround a woman in labor with companions who can offer encouragement and reassurance, and support her vision of how she wishes to give birth. It is a known fact that the intrusion of strangers or people whom the mother finds uncomfortable, for whatever reason, can stop labor contractions cold!

However, the most important "tool" for coping with labor is the empowerment brought by the understanding that childbirth is a healthy, normal process. The more information that can be learned through reading, childbirth education classes, and interaction with supportive peers and/or health professionals, the more confidence a woman gains in herself and her ability to cope.

A mother's attitudes and beliefs about birth and pain will strongly influence how she experiences the sensations of labor. Such positive or negative belief systems may have been handed down from parents or grandparents for generations, and been reinforced by the culture at large. Vanjie Bergum in her book Woman to Mother outlines some of Western society's attitudes toward pain: "pain means something is wrong, pain means punishment, pain should be avoided or taken away."

In American society, pain is viewed as something to be feared, rather than as a physical indication that something in our bodies or our lifestyle may need to be balanced or changed. The average person is used to taking Tylenol for a headache instead of examining why the headache exists.

During childbirth, the chief source of "pain" is the contraction of the uterine muscle as it works to open the cervix. The uterus is capable of exerting over sixty pounds of force per square inch in active labor. The sensation is intense and may be compounded by the discomforts of back pain or pressure on pelvic bones and ligaments.

But labor pain is not a feedback mechanism telling the neocortex of the laboring mother that something is wrong, but rather a means of letting her know that a process is taking place which will lead to the birth of her baby. The deeper the mother's perception that this "pain" is not harmful to her body or her baby, the more she will allow it to progress without fear and tension.

Labor is challenging, a powerful process marking the miracle of bringing forth a new life and a new being onto this planet. It is a rite of passage, a psycho spiritual training ground for both mother and child. The laboring woman must put aside her own comfort and learn to surrender to a process so intense that it threatens to consume her. She must have the willingness and openness to dive deep within herself and find the stamina to endure, to focus, and to trust. She may have to stretch beyond her own perceived limitations in order to experience this act of creation in the now.

How many mothers' eyes have filled with tears as they asked "When will it be over?" only to be told to "take each contraction as it comes, be with it, and let it go, for as long as it takes." As she copes with the successive waves of contraction she develops patience and persistence. She forms a bond with this child she is birthing that is all the deeper because it has been forged with hard work and sweat and tears. It may be the most difficult work she has ever done. It is a labor of love and the most precious gift she can give to herself and her baby.

At some point during labor, many women may come face to face with some form of fear: fear of pain, fear of the inability to cope, and at a deeper level, fear of death. It may be that some part of her ego must "die" in order to get out of her own way and surrender control to the instinctual part of her being that knows how to give birth.

When a woman is able to release into her own intuitive consciousness, she gives birth to the spirit of the "Divine Mother" within, opening herself up to experience birth at a profound spiritual level.

Gerald Jampolsky wrote in his book Love is Letting Go of Fear that there are only two emotions, love and fear.

Fear always distorts our perception and confuses us as to what is going on. Love is the total absence of fear. Love asks no questions. Its natural state is one of expansion and extension, not comparison and measurement. Love, then, is really everything that is of value, and fear can offer us nothing because it is nothing. As we let go of fear...we start to see beyond our old reality as defined by the physical senses, and we enter a state of clarity in which we discover that inner peace and Love are in fact all that are real.

Through the process of letting go of fear, a birthing mother may begin to experience a personal transformation which will prepare her to be a more loving mother, a mother who loves unconditionally.

Perinatal psychologists have researched the long term effects of the birth process on women and their families and conclude that giving birth is a momentous event which can impact all involved psychologically and spiritually for an entire lifetime. Pushing a baby out of her body with her own efforts can be one of the most exhilarating and joyful accomplishments of a woman's life. And yet, indisputably the most important outcome is a healthy infant and mother, and not where or how birth takes place.

Those mothers who attempt natural childbirth and fail to achieve their desired goal due to life threatening emergency or medical complications often feel extremely angry, frustrated or depressed. If they perceive that the cause of their difficulty could have been avoided either through more in depth personal examination or with different management of their birth, they may be motivated to educate themselves, or explore other available options in childbirth for subsequent births.

Mothers who feel that they made the best possible choices throughout the course of their pregnancy, labor and delivery, and still required intervention are offered a different but no less profound lesson in empowerment. Having done their best to manifest their ideal, they have the o pportunity to learn surrender and humility, and embrace this "birth" process on a higher level. As one inspiring mother expressed so beautifully after having had a C-section for the second time after an undescended breech;

"The important thing was that we were both alive and thriving, not that she (her daughter) be born vaginally. It's not what happens to you in life, it's how you perceive it. I could feel like a victim or a victor. I chose to see the opportunity for growth. I did everything in my power and then let go. Even though I didn't get what I wanted, I accepted the experience and I found peace."

And so, "Why have natural childbirth?" Because it is our birthright; because the capacity to experience giving birth and mothering is one of the greatest gifts God has bestowed on women. Because we can, and when we do, we are changed in some way forever.