Methods of childbirth preparation: a study of printed matter published in Brazil in the mid-twentieth century

Abstract

The article explores the dissemination of natural childbirth practices through an analysis of the books Parto natural: guia para os futuros pais, written by U.S. obstetrician Frederick Goodrich Jr. in 1950, under the title Natural Childbirth: a manual for expectant parents, and first published in Brazil in 1955, and of Parto natural sem dor, written by Brazilian obstetrician Beutner in 1962. Both books found a place in Brazilian culture and influenced thinking about childbirth and delivery in the field of Brazilian obstetrics and in representations of women. Based on Roger Chartier’s contributions and on concepts of medicalization, we conclude that these new practices for childbirth preparation shared the period’s prevalent medical views of childbirth and delivery.

birth; natural childbirth; painless childbirth; manuals

Resumo

Discute-se a difusão das práticas de parto natural por meio da análise dos livros Parto natural: guia para os futuros pais, escrito pelo obstetra americano Frederick Goodrich Jr. em 1950 e publicado no Brasil a partir de 1955, e Parto natural sem dor, escrito pelo obstetra brasileiro George Beutner, em 1962. Ambos tiveram boa entrada na cultura brasileira e influenciaram a forma de pensar o parto e de parir, tanto no âmbito da obstetrícia brasileira como no que concerne às representações das mulheres. A partir das contribuições de Roger Chartier e das concepções sobre medicalização, concluímos que essas novas práticas de preparação do parto compartilhavam as visões médicas sobre o parto e o nascimento predominantes no período.

nascimento; parto normal; parto sem dor; manuais

Methods and techniques for childbirth preparation have acquired a growing audience among readers, spectators, and institutional spaces. In Brazil, this has brought the appearance of a variety of communication devices, including books, manuals, magazines, journals, newspapers, television reports, and internet sites, which are intended to teach women, their partners, and their families the best way to experience pregnancy, give birth, and mother.

This concern with teaching women and their families about childbirth derives in part from the development of the alternative techniques for childbirth preparation that emerged in the field of medicine in the 1930s and gained much ground in the 1950s. “Birth without fear,” “natural childbirth,” and “painless childbirth” became the watchwords of a group of obstetricians who introduced women to new childbirth practices that involved less intervention and greater comfort. Already well known in Europe and the United States, these new childbirth theories were disseminated in Brazil through printed matter, conferences, and courses starting in the mid-twentieth century. Their advocates argued that women and their families should be prepared for childbirth. They also highlighted the importance of education for childbirth, and a good number of obstetricians suggested that parturients should read books that recommended the appropriate care during this process (Ayres, 2014).

In Brazil, the spread of new childbirth models was tied to the growing medicalization¹ of urban life, which likewise dates to the mid-twentieth century. One of the innovative features of this process was the popularization of medical concepts and practices through printed matter, often released by physicians or representatives of consumer product industries. Kobayashi and Hochman (2015) point to changes in habits among the urban middle classes subsequent to the appearance of new industrialized health and hygiene products and their promotion in the press and through advertising. Freire (2008) notes that the role of hygienist physicians acquired legitimacy through discourse in women’s magazines that condemned the way in which motherhood was traditionally exercised. In an analysis of the childcare manual A vida do bebê (Baby’s life), by Brazilian physician Rinaldo de Lamare, first published in 1942, Santos (2011) showed how this book played an educational role by teaching parents how to deal with their children, while it also circulated medical culture among the urban classes.

Writings by Brazilian physicians complemented imported books. For many years, Brazil imported foreign books that were highly marketable among those with greater earning power. These imports rose in the 1950s, especially from the United States, which became Brazil’s biggest supplier (Hallewell, 1985). Most of the books were from the fields of medicine, engineering, physics, chemistry, and technology in general, and also from the arts (Lopes, 1978). It was in this context that books on normal childbirth began to be imported from countries such as the United States, England, France, and the Netherlands (Ayres, 2014).

One of the most notable of these books for women was Natural Childbirth: A Manual for Expectant Parents, written by U.S. physician Frederick Goodrich Jr. in 1950 and translated into Portuguese and published by Livraria Atheneu in 1955 under the title Parto natural: guia para os futuros pais.² The book was central in disseminating the ideas of the natural childbirth movement, initiated in the 1950s. It was well received in Brazil, and new editions were published in 1957, 1960, and 1964. A look through its pages leaves it apparent that the book directed an educational discourse at women with the goal of shaping thinking, actions, and cultural practices in the realm of normal childbirth. The book can consequently be classified as an educational manual, which, according to Chartier (1988, 2004), is a kind of publication that seeks to invest non-specialists with habits and practices necessary or convenient to society.

The present study analyzes the book Parto natural: guia para os futuros pais and uses it as a counterpoint to Parto natural sem dor (Painless natural childbirth), which was written by Brazilian gynecologist George Beutner (1962), with the goal of circulating the main theories of natural childbirth. We argue that while both books disseminated the principles underlying these new conceptions of childbirth, which were aimed at enhancing the comfort of mothers-to-be, they also fulfilled a prescriptive educational role by promoting specific behaviors consonant with the normative power of a group of physicians, yet without expanding women’s autonomy during childbirth.

We have followed the path of the historian Paula Michaels (2010), who examined the birth narratives that French obstetrician Fernand Lamaze and colleagues used to circulate his childbirth method. Michaels’ study revealed the dubious, conflicting nature of the distribution of power between women and obstetricians in choices about pregnancy and delivery. Our analysis of the two books employs the conceptual perspective of French historian Roger Chartier and cultural history studies. This perspective offers a way of questioning reality by bringing culture into the picture and underscoring the role of representations (Chartier, 1988).

It has been postulated that cultural practices (related to author, editing/publishing, and production) and representations come into play when a book is produced (Barros, 2011). The cultural practices conveyed through these final products have to do with how humans speak, keep silent, discuss, converse, sit, walk, eat, drink, fall ill, and die. Once produced, a book imparts new representations and new practices. These practices engender patterns of daily life, while they also create uses and representations that cannot be reduced to the intentions of those who produced the printed matter. Models and proposed messages are accepted through the arrangements, departures, and, at times, resistance that manifest the singularity of each appropriation (Chartier, 2004). Therefore, among the Brazilian women who consumed these materials, the act of giving birth can in no way be reduced to what is represented in their pages but instead to new practices, re-created and co-constructed through their relationship to these written products.

The dissemination of methods of childbirth preparation

The 1950s witnessed the growing medicalization of childbirth. The marked expansion of hospital care and of the biomedical apparatus cemented the hospitalization of birth, a process that had been underway in a number of European countries and the United States since the dawn of the twentieth century. On the other hand, criticisms of the model of medicalized childbirth were spurred by the notion that labor pains were not, as the church held, a problem inherent to childbirth but rather a consequence of the parturient’s fear and of her bodily and psychological preparation. This perspective was consonant with criticisms of excessive medical intervention during childbirth and of expectant mothers’ passive role in the process. New perspectives on the childbirth process emerged from this wave of criticisms, prompting obstetricians to devise alternative childbirth methods; known by various names, the methods can be grouped within the painless childbirth movement (Diniz, 2005).

In the 1930s, British physician Grantly Dick-Read devised a theory for childbirth preparation called “natural childbirth.” He claimed that childbirth itself did not cause pain but that this suffering stemmed from socially disseminated fears, entrenched in the minds of parturients. Furthermore, he held, this suffering could be eliminated through a new kind of training and education for childbirth. While his first book, Natural childbirth (Dick-Read, 1933), was not well received, his second, Childbirth without fear (Dick-Read, 1942), was a success with the public in the United States (Freddi, 1973; Moscucci, 2003). Likewise in the 1940s, three physicians at Yale University, Frederick Goodrich Jr., Herbert Thoms, and Robert H. Wyatt, introduced the concept of emotional and physical preparation for childbirth, which likewise became known as the theory of natural childbirth (Goodrich Jr., 1953). Lastly, in the early 1950s, Lamaze designed the method known as painless childbirth. While on a work trip, Lamaze had learned that Soviet maternity wards were using hypnosis to prepare women for childbirth, and he subsequently adapted the technique in Paris (Lamaze et al., 1956).

With the support of the Left in France, Lamaze promoted the painless childbirth method there. Through his efforts, a law was passed that guaranteed French women a certain number of childbirth preparation classes using the Lamaze method.

Supporters of the Lamaze method preached that preparing a woman for childbirth kept her from losing control of her emotions, especially in labor, a stage during which many women suffer severe pain. The idea was to give women back their lead role in childbirth and free their mentalities from the weight of the Catholic-Christian imagination, so strong that it robbed them of the ability to tolerate pain. It was believed that labor pain could be controlled, soothed, and even replaced by feelings of pleasure, so long as women were rationally educated, thereby countering the biblical prophecy of the sorrowful mother, whose corollary is submission to male power (Tornquist, Spinelli, 2009, p.136).

According to Salem (1983), this movement to revise childbirth can be seen as an effort by heretical currents within obstetrics, then fighting to gain legitimacy and power within the biomedical field. They shared the notion that women could have more comfortable and even pleasurable deliveries if they played a larger role in the process and if medical intervention was curtailed. These ideas gave rise to new ways of thinking about and experiencing childbirth, in the long run contributing to recent ideas about the humanization of childbirth.

These new childbirth practices appeared at a time of mounting worldwide concern over the obstetrical care offered to women and newborns. In 1951, the Expert Committee on Maternity Care, of the World Health Organization (WHO), released its first report, which defined the following goals of “maternity care:” ensure women’s health throughout pregnancy and breastfeeding, teach mothers how to care for their children, and allow them to have normal deliveries and bear healthy children. The committee recommended that mothers be instructed in such matters as the psychology of pregnancy and childbirth, the somatic and psychological changes that may occur during pregnancy, the need for tests, and physical and psychological preparation for childbirth (OMS, 1952).

The medical field in Brazil took an interest in these new childbirth practices. In Rio de Janeiro in 1953, Arnaldo de Moraes (1953), director and owner of Anais Brasileiros de Ginecologia, one of the country’s leading journals of gynecology and obstetrics, described parts of Dick-Read’s book Childbirth without Fear, published in Brazil in translation in 1951. Moraes said that obstetricians at colleges and teaching establishments in many countries were then turning their attention to psychosomatic aspects of childbirth. He also said that Brazilian participants at the twelfth British Congress of Obstetrics and Gynaecology, held in 1949, had visited the University of London Maternity Hospital, where they had become acquainted with Dick-Read’s ideas when they observed sessions of muscle exercises that prepared women for natural childbirth.

Moraes (1953) reaffirmed the value of the medicalized program of natural childbirth preparation. He observed that Herbert Thoms and Frederick Goodrich Jr. had achieved excellent results with Dick-Read’s method at the Yale University Department of Obstetrics and Gynecology, where they had implemented an educational program that encompassed physical training for expectant women and lessons in early pregnancy and during the second half of the third trimester (after the 30th week of pregnancy). He stressed that when doctors and nurses equipped women with an understanding of the physiology of pregnancy and childbirth, it lowered their anxiety and boosted their confidence. Moraes also said that these measures should be applied at prenatal clinics in Brazil.

Interest in the topic grew when articles were translated into Portuguese and published in the news sections of Brazilian science journals. Information was soon released on applications of the method or experiments with it. One example is the article entitled “Introdução à obstetrícia psicossomática” (Introduction to psychosomatic obstetrics), written by physician Edgard Braga and published in 1953 in the Revista de Ginecologia e d’Obstetrícia. Braga cited Pavlov’s conditioned reflex method and explained that researchers had devised a new method based on it:

The so-called ‘psychoprophylactic method of analgesia:’ grounded in education, it consists of decreasing or eliminating fear and negative emotions by dissuading pregnant women from the idea that suffering is inevitable, either by forging a new, cordial relationship with the notion of childbirth itself, through suggestion, or by teaching that it is merely a natural, wholly physiological phenomenon, paradox aside. The unveiled field of incipient psychosomatic obstetrics is thus vast (Braga, 1953, p.30).

An analysis of the Anais Brasileiros de Ginecologia shows that the journal featured the topic frequently, albeit irregularly, especially after the 1950s, in the form of abstracts, information on training courses, and essays about the method (Ayres, 2014). Beutner reported that those who promoted natural childbirth methods were often labeled charlatans, since skepticism was still strong among the lay public, the educated, and even those in orthodox medicine. Beutner (1962) pointed out that ideas about the method quickly gained ground in the field of Brazilian obstetrics, because of results achieved by pioneers.

The book Parto Natural: guia para os futuros pais

When analyzing a written work, it is helpful to return to the printed object and interrogate its structures, as this object prescribes forms of reading, ways of understanding, and audiences to be enlisted. The strategies that shape these reading devices can be recognized in the materiality of the book and the work’s editorial devices (Chartier, 1988; Toledo, 2010).

The book Parto Natural was a medium-sized (14cm x 19cm) trade paperback. This smaller format became popular in Brazil in the 1950s as a way of engaging new readers, especially those who were interested in reading but had little time for it (Szakacs, Durão, 2011). The size of the book was attractive because the reader could carry it around and open it comfortably in any social space and at different times of the day, even on a crowded bus or during a break from a job or household tasks.

Covers are also vital in promoting books. Readers often choose a book on the basis of its cover, which serves as a form of advertising or kind of invitation. The cover helps construct an identity; in her first visual or manual contact with a book, the reader can identify its content and tell to whom the book belongs and for whom it is meant (Manguel, 1997). In the case at hand, the elements of the cover reflect the initially targeted community of readers, that is, future parents, especially mothers, people whose skills, expectations, and perceptions allow them to identify the cover’s representations of normal childbirth.

The covers of the first, third, and fourth editions feature a black-and-white drawing of a woman and baby, which occupies about 42% of the space on the page (positioned in the center, in the case of the first and third editions, and at the top, in the case of the fourth), thereby highlighting and lending visibility to the maternal figure and the mother-child relationship. The happy mother can be seen as representing an imaginary model; this illustration of a woman (mother) holding her child close reinforces the woman’s social role as procreator and also the role of motherhood. Mothers are thus placed in the foreground and effectively urged to take up the role of caregiver for their children within the heart of the family, right from conception. In other words, readers see a model representation of maternity in the metaphor of a smiling face portrayed at an unparalleled moment of life. The figure represents the women who can buy, read, and enjoy the book. The image is linked to the title and suggests that the book might afford women immeasurable happiness at the time of childbirth.

The book’s title also says much about its authors’ goals. We believe the word “natural” is used not only to designate an underlying theory; it also serves to remind the public of a gender trait associated with women since the eighteenth century: the idea that women are closer to the natural world and have greater respect for its limitations and determinisms. The title also seeks to bring both mother and father into the birth process by highlighting the image of family and home, while also drawing women closer hospital birth, without the assistance of midwives and outside the home.

The book displays some tendencies that derive from its discursive and material forms, which are more educational than scientific. Most of the content is scientific, while many adaptations have been made so that non-specialized lay readers with little academic training can grasp the material. The book is organized into numbered chapters, with sub-titles that provide clear, direct descriptions of the topics addressed. Araújo (2008) notes that a science communication book must display this quality, since clarity of information is paramount.

A number of illustrations are distributed throughout the text; these are grouped together and not tied directly to content nearby. Some depict the female reproductive system, the fetus inside the uterus, and the fetus’s relation to the umbilical cord and uterus. Others are drawings of pregnant women’s bodies that illustrate the best positions for relaxation and respiration techniques. All of the illustrations are black and white, with some gray tones. Images play an educational role different from the discourse found in texts (Chartier, 2004). The book’s emphasis on images reinforces the proper way to practice relaxation techniques and exercises.

As with other printed matter, the images are used to render the book more enticing and to reinforce its characterization as an established text. The drawings of pregnant women in crouching positions, of relaxation and respiration techniques, and of exercises like pelvic rocking are intended to help readers understand the content and call attention to the premises of the theory of natural childbirth, which advocates courses and training in the application of these body techniques.

This enticement is directed at a specific public, as Parto natural is aimed primarily at educated women from the urban middle classes. These more well-to-do social groups could afford to buy the book and consume some of the products it mentions, like clothing, body crèmes, and food. Furthermore, these women possessed the specific skills needed to follow the plan laid out in the book, that is, to prepare for pregnancy, childbirth, and the postpartum period. As pointed out by Tornquist and Spinelli (2009), in Brazil, childbirth preparation was limited to private clinics in the 1950s and 1960s, since the method was seen as a differentiated form of care, “something extra” that doctors could offer their female clients.

In terms of its organization, Parto natural follows the development of a pregnancy. Chapter 1 offers a history of natural childbirth, followed in chapter 2 by a parable illustrating how childbirth should be viewed as natural. Chapter 3 provides a detailed description of the anatomy and physiology of the reproductive organs, while chapter 4 portrays a visit to the doctor’s office and describes laboratory tests and pelvimetry. The first trimester of pregnancy is addressed in chapter 5, while chapters 6, 7, and 8 teach relaxation techniques, exercises, and diet. Following the course of pregnancy, chapters 9 and 10 talk about the second and third trimesters. Topics related to breastfeeding and rooming-in appear in chapter 11, while the physiology and psychology of childbirth are addressed in chapters 12 and 13. The postpartum period and the mother’s return home are discussed in chapters 14 and 15.

Most of the paragraphs are long, sometimes exceeding 50 lines, but the sentences are often short and objective. Ideas are organized according to editorial standards, that is, beginning with a central idea and then exploring it in depth (Araújo, 2008). The content is somewhat familiar to readers and the reading goes fast and easy, because the language is colloquial, engaging, and often times in the form of dialogue. But the density of the long paragraphs means readers must be able to pause in their reading, possibly to mark in the book, and they must possess intellectual skills. These characteristics, especially the weight of the information presented and the limited number of illustrations, evince the idea that the book was aimed at educated, middle-class women.

In terms of linguistic style, like other educational manuals, access to the text is facilitated through the use of simple, objective sentences and limited reliance on technical language, despite the book’s scientific content. Within this spirit, Parto natural employs colloquialisms and jargon like cacete (pest), pimpolho (child; kid), tolice (silliness), precisely to ensure that the lay community can grasp the content.

This use of colloquial vocabulary lends the text a tone of playful curiosity, meant to create the effect of a supplemental reality. The text also gives the reader a chance to take part in a kind of decoding game, a strategy that allows the community of readers to feel a sense of satisfaction as a secret is revealed and also to enjoy metaphorical, regional, pleasant vocabulary. The use of this kind of jargon produces amusing results by twisting and subverting authorized language and the rules of legitimate writing (Chartier, 2004). In other words, Parto natural denatures a scientific text by employing this linguistic style. It also allows for interplay between the authors and community of readers.

Women’s magazines were at that time already employing such devices as informal lexicon, confessional narratives, and first-person articles. This style creates a closer relationship between reader and magazine, as if the magazine were an older sister or more experienced girlfriend (Heberle, 2004). Through its clear language and colloquial vocabulary, Parto natural employed this same strategy, using slang, metaphors, popular sayings, and other linguistic devices. For example, when talking about the tip of the spine, known as the coccyx, the book says that “this represents what is left of our tail” (Goodrich Jr., 1955, p.36). When explaining how to prevent problems like anemia in pregnancy, it says “an ounce of prevention is worth a pound of cure” (Goodrich Jr., 1955, p.55).

Certain techniques were employed in Parto natural to draw the reader in. The second-person singular pronoun “você” (you), which is a more informal option in Portuguese, is used quite often. Although the book’s language is primarily direct and accessible, it is also the discourse of a physician who is informing, explaining, presenting arguments, and ordering. By adopting a direct, imperative voice that orders behaviors and practices, the intent was to ensure that these practices would be better assimilated by those who usually have greater access to information sourced from popular knowledge, which is passed down from generation to generation and which is often negated and rejected in the book. In this regard, the goal was to establish a medicalized practice of childbirth, in a way that concealed the orders prescribed to women.

Natural childbirth, a new form of medicalization of birth

Right from its opening pages, Parto natural presents itself as a publication meant to guide lay women in an activity governed by medical knowledge. Starting in the introduction, the book records the advance of obstetrics, based on the valorization of physician care for pregnant women. First viewed as simple deliverers of babies or even banned from taking part in births, over the past three centuries physicians have become accepted in the childbirth setting and begun working to reduce the risks of birth and to increase the safety of unborn babies and mothers. But if doctors had been successful in ensuring safer childbirth, the same could not be said about the pleasure of giving birth, and this was the book’s goal.

Parto natural emphasizes the importance of the medical provider, as apparent in a number of excerpts, such as “but before doing so, it’s best to consult your doctor” (Goodrich Jr., 1955, p.169). This specialist, possessor of scientific knowledge, is presented as the professional qualified to convey the correct information and advice. Affirmations and legitimizations of the figure of the physician appear frequently in the book and reveal mechanisms intended to encourage women to accept representations of doctors and their way of leading the process. Complementarily, women’s knowledge and cultural practices are discredited and painted as inferior and foolish. The combination of these two approaches constitutes a mechanism for interiorizing the cultural illegitimacy of women during their own pregnancy and for reinforcing medical authority over the expectant mother’s body.

The word “médico” (doctor or physician) appears 266 times in the book’s 239 pages (1st edition). The devices adopted in the book support the idea that the physician is a woman’s central support and can offer her useful guidance during pregnancy. Through the set of textual elements, readers can readily recognize the medical provider as the authorized spokesperson in matters of pregnancy and childbirth. The book thus puts forward a medicalized view of the pregnant woman, and while it presents itself as offering a form of natural childbirth, it is filled with dictates, themes, and care that come from the world of obstetrics.

As a book for communicating medical knowledge, Parto natural displays a contradiction found in other manuals that inform the lay public of knowledge and practices generally exclusive to physicians (Guimarães, 2005), that is, the book might make some information and counseling practices unnecessary. To circumvent this problem, the author states in the first chapter that his book is meant to supplement the care a woman should receive from her doctor: “He is probably a busy man and, since he has limited time to spend with you, he can’t help you prepare for childbirth as he would like to” (Goodrich, 1955, p.3).

The second chapter of the book features a fictional narrative about the pregnancy and childbirth experiences of two couples: Maria and Fernando, and Vera and Jorge. Maria and Fernando’s experience is influenced by stories and superstitions published in newspapers and told by girlfriends and family members, which generates misinformation, suffering, fear, tension, and pain during labor. The couple’s situation is unfavorable because of the physician’s absence; while their doctor provides adequate care, the narrative makes it clear that his profession demands that he exercise many duties, reducing the time and attention he can devote to the woman and her family (Goodrich Jr., 1955, p.5-12). The story ends with Maria waking up after delivery without realizing what has happened. Because of the situation in which she finds herself, the first thought that pops into her head when she calls the nurse and learns she has given birth is “never again.”

In the second story, Vera and Jorge buy books about pregnancy and read them. Vera avoids listening to her girlfriends’ stories and rejects imaginative tales. The couple attends classes for mothers-to-be and visits the hospital, while Vera does all the exercises indicated during her classes. Vera feels confident and understands the phases of pregnancy and childbirth and the guidance offered by her physician (Goodrich Jr., 1955, p.13-19). The story ends with Vera in good physical shape and feeling “over the moon” with her child.

The closing paragraphs of this chapter illustrate the main difference between the two stories: Vera had trained better and more for childbirth than Maria, and she was physically, intellectually, and emotionally prepared. This excerpt drives home the book’s idea that expectant mothers should prepare for childbirth, along with the notion that, while doctors have many duties to fulfill and this can hamper women’s access to their care and guidance, the book would make up for the provider’s absence. These hypothetical situations thus serve to justify why expectant mothers need to read the book.

Chapter 3 addresses various aspects of the female body, particularly those involved in childbirth. The skeleton and reproductive system are analyzed in depth, followed by an explanation of the physiological processes of conception and birth. The section ends with an explanation of miscarriage and its causes and symptoms. Chapter 4 focuses on visits to the doctor and how the doctor first detects the pregnancy and then takes measures to ensure a healthy outcome. The text describes the physical exams the doctor should do, including measurement of the pelvis, and lists the laboratory tests to be ordered, accompanied by a lengthy explanation of their importance and purpose.

The book also teaches women about the physiology of childbirth, about medical practices for gaining knowledge of a pregnant woman’s body, and about the diagnosis of possible problems. What is striking about all these descriptions is the underlying expectation that women will have a submissive attitude; the implication is that they should be able to recognize the foundations of the doctor’s knowledge and the dynamics of his professional practice so they can accept and apply these more readily. The following excerpts leave this clear:

During your pregnancy, there will be moments when you’ll think you have to call your doctor ... Don’t insist on talking to the doctor himself when the nurse answers the phone. She’ll give your message to your doctor and let you know his answer. If there’s any need for you to speak directly to the doctor, he’ll understand that and will come quickly to the phone or call back later.

When you call, whoever answers, be sure you know what’s worrying you. If you have a question about some new symptom, your doctor will want to know when it started, how long it has been going on, and similar other details. Be sure to call if a question arises, but try to get used to the routine at a doctor’s office and don’t insist on speaking to him personally when they tell you it’s not possible (Goodrich Jr., 1955, p.67).

In the next chapters, the book teaches women about the various symptoms that can occur during pregnancy and their relation to the physiological changes taking place. Length of pregnancy, moment of conception, and symptoms like nausea, bleeding, increased urination, and constipation are explained in detail. The text is not constructed much differently from other medical manuals on the topic and it underscores the need for rest and relaxation to minimize the unpleasant symptoms of pregnancy.

A lengthy part of the book is devoted to relaxation and diet. It argues that rest and relaxation are important in fighting everyday stress, especially during pregnancy.³ The term “relaxation” is used in the sense of carrying out an activity with the least effort possible. A specific form of relaxation is recommended for expectant women, which involves altering breathing patterns and finding a comfortable position in a cozy spot. The text presents a series of exercises aimed at relaxation, muscle strengthening, and preparing the breasts for breastfeeding. In terms of nutrition, the book emphasizes the value of an appropriate diet and provides advice on what foods to eat, food groups, and nutrients. It also emphasizes weight control as a way of avoiding complications. This is followed by information on the importance of breastfeeding and instructions on how to breastfeed without causing the mother any suffering.

A key focus in Parto natural is the painstaking description of relaxation techniques and other exercises that form the foundation of its underlying theory. In addition to devoting an entire chapter to the topic, the book talks about preparatory exercises during each trimester. As in other technical communication books, this repetition is a strategy for convincing and persuading the reader and for teaching the method.

Chapter 12 discusses childbirth itself, its physiology, stages, induced labor, and the episiotomy. The author finds himself engaged in a discursive effort when it comes to the episiotomy, since he states earlier in the book that the exercises recommended in its pages will make the pelvic floor more elastic, facilitating childbirth; however, he explains, very often the exercises are not enough to avoid the need for this procedure. In explaining this paradox, the author tries to show that an episiotomy is not to be feared, as it causes no subsequent pain or trouble. Without stating this explicitly, the book effectively blames women for the need for this procedure, which was then seen as natural.

There’s no reason to believe that an episiotomy is anti-natural or a result of the woman’s failure. If she does everything she can to increase the efficiency of the muscles of the perineum, an episiotomy might not be necessary, but in any case, the woman will always feel the satisfaction of having made an effort to prepare for her delivery (Goodrich, 1955, p.193).

The book continues with its advice to future mothers, discussing sensations during labor and aspects of post-partum. It focuses particularly on pain during delivery and the use of relaxation and breathing exercises to overcome it. The increasing intensity of contractions and how to deal with them is explored in depth, and information is provided on anesthesia options. The closing chapters look at the post-partum period and provide advice about the mother’s return home and her diet, hygiene, and emotional readjustments.

While Parto natural presents the notion of natural childbirth, its content encourages consumption, a heavy reliance on technology, and dependence on the doctor’s opinion, thereby associating the book with the growing medicalization of childbirth then underway. In this sense, the childbirth model advocated in its pages is neither less normalized nor led by women’s desires.

This framing induces the perception that the doctor manages the event and prevents risks. This viewpoint was embraced throughout the twentieth century and still holds true in Brazilian maternity hospitals, in that both society and healthcare providers continue to see normal childbirth as pathological. Doctors thus wield knowledge and power over women, opening the door to procedures that these women might not want and that may even run counter to prevailing scientific evidence (Nakano, Bonan, Teixeira, 2015).

Educational manuals for childbirth preparation in Brazil

Parto natural: guia para os futuros pais boosted the publication of similar books in Brazil. Using the labels “natural childbirth” or “painless childbirth,” these books promoted the normalization of pregnancy and birth from the perspective introduced by Goodrich. Among the titles translated and published in Brazil were Parto sem dor (Painless childbirth), by Lamaze and his team (1956); O que é parto sem dor: método psicoprofilático baseado na teoria dos reflexos condicionados de Pavlov (What is painless childbirth: the psychoprophylactic method, based on Pavlov’s conditioned reflex theory), by Schor, Lamaze, and Petrovich (1958); Parto sem dor (Painless childbirth), by Spanish obstetrician Adrian Vander (1974); and O parto sem dor (Painless childbirth), by French obstetrician Achille Economides (1977).

Brazilian obstetricians likewise addressed the topic. In 1958, Gerson de Barros Mascarenhas published Parto sem dor pelo método psicoprofilático (Painless childbirth through the psychoprophylactic method) and in 1962, Beutner released Parto natural sem dor, which was published by Editora Fundo de Cultura. We will compare the last of these with Goodrich’s book. We were unable to obtain much information about the author, other than the fact that he was an obstetrician and his book targeted two audiences: the lay public and healthcare providers (Ayres, 2014).

Beutner (1962) did not dwell on a discussion of the day’s methods of normal childbirth but instead devoted his pages to advocating the “psychoprophylactic method of childbirth preparation.” In addition to its title, the book bears some other resemblance to Parto natural, including size, format, cover, and target audience. While Goodrich’s book was aimed emphatically at parents, and especially at mothers, it was also used by healthcare providers and can be found on the shelves of health libraries at some of Brazil’s public universities (Ayres, 2014).⁴

Unlike Goodrich’s Parto natural, explored in the previous section of this paper, some parts of Beutner’s book present dense content drawn from certain medical specialties, perhaps making it hard for the day’s community of readers to grasp. However, according to the author, he conducted a survey among readers and ascertained that they found the book clear and concise. This dialogue between author and audience shows that the book was designed for the educated middle and upper classes.

Much like Goodrich, Beutner addresses such topics as anatomy, physiology, and labor. He also gives a thoroughgoing explanation of conditioned reflexes, based on the work of Russian physiologist Ivan Pavlov. He writes about the value of exercises, breathing, and relaxation as ways to relieve the pain and discomfort of childbirth. This part, much of which is quite dense, lends credence to the idea that one of his targeted groups was healthcare providers, especially nurses.

The author also underlines the importance of childbirth preparation classes. He describes a model practical course to prepare women for delivery, with classes starting early in pregnancy. He felt this training should be collective and adapted to the skills of the target audience. The course would be divided into two parts and conducted by a doctor, preferably an obstetrician, who would be responsible for the theoretical content, while a nurse would oversee the practical part. A nurse, preferably one holding a higher degree, would then bring the theoretical and practical parts together and would, when necessary, correct any mistakes and evaluate how well the women had understood the material.

The theoretical part – and I cannot stress this enough – must be taught by a doctor, preferably an obstetrician. Not out of vanity or professional ‘jealousy,’ but because an obstetrician wields influence and inspires the confidence of the expectant mother, for she recognizes him as a guide equipped with authority and knowledge, who will, in an adverse situation, apply his art to her benefit (Beutner, 1962, p.95).

In the field of obstetric health, monopoly control over authority and scientific skill was at stake. Culturally and historically, an agent or institution is granted the authority to speak or act, that is, their speech or actions are deemed legitimate. Women had to be made to see and believe in the representation of the doctor, who in turn had to command respect and hold true to this representation, thus giving the provider the endorsement of medicine and power over nursing. Goodrich, in Parto natural, and Beutner, in Parto natural sem dor, clearly delineated which responsibilities fell to the physician and which to the nurse in assisting women during preparation courses, pregnancy, and childbirth.

Beutner’s Parto natural sem dor also used women’s discourses, experiences, and the positive results of surveys on the method to highlight the importance of this practice and lend it credibility. The book includes a research study designed by the author to assess experiences with his method. The study was in the form of a questionnaire that was given after delivery and attached to the woman’s chart. It can be observed that the use of this type of questionnaire was common among those who employed the childbirth preparation method and was meant to promote the method’s “good” results.⁵

Lamaze had been the forerunner in publishing testimonials as a way of communicating new childbirth practices; his collaborators collected testimonials by his patients and published them in book form in 1956 (Vellay, Vellay-Dalsace, 1956). The French obstetrician wanted to reinforce the value of his method by offering evidence of its scientific validity. To this end, he put forward a scientific pedagogy of childbirth informed by the physician’s authority. “From the first courses, [the women] understand that we will never try to persuade them; to the contrary, in order to educate them, we will use demonstrations to bring facts and proof to every case” (Lamaze et al., 1956, p.102).

Chapter 9 of Beutner’s Parto natural sem dor featured 14 questionnaires that proposed to demonstrate what each woman took away from application of the method. The last question was: “Briefly speaking, what is your impression of the psychoprophylactic method?” The answers were intended as testimony to the method’s successful application: “it was great, rational and efficient;” “good and interesting;” “nothing else like it;” “it’s wonderful;” “the best of inventions.” We believe this chapter was designed to convince readers of the scientific validity of the psychoprophylactic method by providing evidence of successful results.

The writings on new forms of childbirth published by Brazilian physicians reflect the Brazilian medical field’s interest in cultural communication about childbirth in the 1950s. Tornquist (2002) points out that while this movement first appeared in France, England, and the United States, Brazil was on the travel itinerary of obstetricians working with childbirth preparation theories right from the first generation. She notes that Lamaze was in Brazil in 1956, more specifically in Rio de Janeiro, where he lectured on painless childbirth, sparking further interest in the new practice (Tornquist, 2004). Lamaze’s visit no doubt helped promote his theory, as well as other ones, and had an early influence on books written by Brazilian authors who wanted to disseminate childbirth preparation methods. These events indicate that the time was right in Brazil for obtaining, producing, reading, and disseminating books on theories and methods for childbirth preparation.

Final considerations

The appearance of manuals on childbirth preparation methods in Brazil fueled medical and editorial interest in the topic and prompted similar endeavors on the part of Brazilian authors, who embraced their foreign counterparts’ goals and ways of disseminating information among women. Whether by foreign or Brazilian authors, these cultural products were aimed at an emerging and expanding urban middle class in Brazil’s large cities. The guidelines, values, and advice presented through these methods were not applicable to women from the lower classes, many of whom were accustomed to forms of childbirth irreconcilable with the medicalized parameters proposed in these books.

The form of childbirth presented in these books under the label “natural childbirth” introduced a new way of giving birth that had little to do with the term applied to it. The books in question were based on different techniques drawn from medical knowledge, which mobilized a new form of intervention and control over the pregnant body. By promoting a model of childbirth idealized by women, their pregnant bodies were made docile.

The historian Paula A. Michaels (2010) studied the testimonials of women who were submitted to the Lamaze method. Her findings reveal the conflictive nature of the method, which was couched as a liberating way to empower women and give them control over their bodies, but which also proved to be a way for obstetricians to maintain power over women and childbirth by bolstering their professional authority. Similarly, our analysis of these two manuals reveals the development of a model of childbirth that is still promoted today and that, at its core, circumscribes women’s ability to exercise their freedom in childbirth through the institutional organization of biomedicine and the power of obstetricians (Davis-Floyd, Sargent, 1997).

In this regard, these manuals can be characterized as agents of the medicalization of childbirth, a process that intensified in the mid-twentieth century. In a narrower sense, the manuals encouraged women to entrust their bodies to their physicians from early pregnancy on – or even before conception, in the form of prenuptial physical exams – until after the birth of their child (Lima, 2007). From a broader understanding of the idea of medicalization, the manuals were part of a process by which medicine steadily expanded its jurisdiction into various facets of life. While they evoked a more conscious type of childbirth, they played a role as the cultural products of a certain time by explaining the biological workings of the body and advancing a less painful and uncomfortable delivery. In this regard, they were instruments for legitimizing the power of obstetrics over women (over mothers and future mothers), and they established new practices that strengthened control, discipline, and the medical homogenization of the process of childbirth.

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• 1
  Today, a number of perspectives engage with the concept of medicalization: population strategies in health; the transformation of behavioral disorders into diseases; the expansion of the consumption of medications; the expansion of the jurisdiction of medicine into various aspects of life and society, and so on. This article uses the term as employed by Foucault, who believed that medicalization is associated with an inability to think and live experiences with our body independently from medicine. In other words, in our contemporary world, individuals and society are increasingly constructed and understood through concepts and practices related to medicine (Zorzanelli, Ortega, Bezerra Júnior, 2014).
• 2
  The first edition came out in the United States in October 1950. A second edition was released in November of the same year; a third in June 1953; and a fourth in April 1954. All were published by Prentice Hall, in New York.
• 3
  In regard to the exercises to ensure comfort in the birthing position, the book states that it was common to squat during delivery in primitive societies. This is described as a mechanically efficient position, given the effect of gravity, but the posture was modified to make delivery easier for doctors; women should lie on their backs and place their legs up and back into supports, a position that would be good for both the woman and the doctor.
• 4
  In an earlier study, Ayres (2014) found the book in libraries at the Universidade Federal de Minas Gerais, Universidade Estadual Paulista, Universidade Federal de Brasília, Universidade Federal do Estado do Rio de Janeiro, and Universidade Federal do Rio Grande do Sul.
• 5
  To provide evidence of the advantages and disadvantages of the Natural Childbirth program, Thoms and Wyatt (1950) stated that they had over 600 questionnaires in their files and claimed that these had contributed to refining the method.

Publication Dates

• Publication in this collection
  Jan-Mar 2019

History

• Received
  30 Nov 2016
• Accepted
  3 Mar 2017