Copyright 2004 Elsevier Ltd. All rights reserved.

The rhetoric of natural in natural childbirth: childbearing women's perspectives on

prolonged pregnancy and induction of labour
Rachel Emma Westfall

,a

and Cecilia Benoit

,b

Department of Anthropology, Box 3050, University of Victoria, Victoria, BC, Canada

V8W 3P5
b

Department of Sociology, Box 3050, University of Victoria, Victoria, BC, Canada

V8W 3P5
Available online 21 February 2004.

Abstract
It is widely known that the notion of prolonged pregnancy, defined medically as 41+ or
42+ weeks gestation, has been hotly debated within the medical and midwifery
communities for many decades. Within this debate, pregnant women's voices have
rarely been heard. Presented here are the results of a qualitative study of self-care in
pregnancy, birth and lactation with a non-random sample of women in British
Columbia, Canada. A panel of 27 women was interviewed in the third trimester of
pregnancy, and 23 of the same participants were re-interviewed post-partum (50
interviews in total). Interviews were tape-recorded, transcribed, and analyzed
thematically. Many of the women said they favoured a natural birth and were opposed
to labour induction at the time of the first interview. Yet all but one of the ten women
who went beyond 40 weeks gestation used self-help measures to stimulate labour. These
women did not perceive prolonged pregnancy as a medical problem per se. Rather they
saw it as an inconvenience, a worry to their friends, families and maternity care
providers, and a prolongation of physical discomfort. The findings are interpreted by
examining the literature on the medicalization/healthicization of childbirth.
Author Keywords: Pregnancy self-care; Prolonged pregnancy; Natural childbirth;
Medicalization; Canada

Article Outline
Introduction
Method and sample
Thematic analysis
Results
Women's views in the third trimester
Women's views in the postpartum period
Discussion and conclusion
References

Introduction
The length of human gestation is calculated from the first day of the last menstrual
period, and is expected to be 280 days/40 weeks (Cooke, 1997). Yet there is variation,
for some women will conceive earlier or later in their cycles, cycle lengths vary, and the
babies of other womenfor reasons still unknownwill simply require a shorter or
longer gestation period. Finally, health problems affecting some women or their babies
may result in the early or late onset of labour.
Despite such variation due to health and biological processes, there are strong
differences of opinion within the scientific community regarding the actual length of
human gestation, and the degree to which intervention is necessary when pregnancies
go beyond a particular timeframe. Indeed, the length of gestation has been debated in
the medical literature for over a hundred years (Ahn & Phelan, 1989). Some experts
maintain that there is no set optimum gestational period ( Keirse, 1991). Others allude to
an erroneous interpretation of old medical texts that calculate the length of gestation
from the end of the last menstrual period, rather than the beginning, meaning that we
habitually underestimate the average length of gestation ( Baskett & Nagele, 2000). The
date of conception itself can be inaccurately marked. To complicate matters, dating the
pregnancy through ultrasound technology creates the impression that male babies are
significantly more likely to be carried beyond term than female babies, as seen in a
Swedish study including 656,423 deliveries ( Divon, Ferber, Nisell, & Westgren, 2002).
This phenomenon has been attributed to a dating error in ultrasound fetometry, due to
the fact that dating is based on fetal size, and male babies tend to be slightly larger on
average than female babies ( Kitlinski, Kallen, Marsal, & Olofsson, 2003).
All told, prolonged pregnancy is often misdiagnosed, perhaps even as much as half the
time (Henriksen, Wilcox, Hedegaard, & Secher, 1995; Gardosi, Vanner, & Francis,
1997; Boyd, Usher, McLean, & Kramer, 1988; Nichols, 1985; Shearer & Estes, 1985).
In spite of the difficulties surrounding the issue of pregnancy dating, the 40-week rule,
based on ultrasound dating of the pregnancy, is almost universally applied in countries
where such technology is available.
As a result of this uncertainty in identifying the appropriate length of human gestation,
whether or not a pregnancy is overdue, post-date or prolonged is also contested.
Currently, the World Health Organization and the International Federation of
Gynecology and Obstetrics consider prolonged pregnancy to be 42 completed weeks of
gestation, or 294 days (Cooke, 1997). Forty-two weeks is the most commonly used
definition in the literature, though different researchers have used 41 weeks, or 41
weeks and 3 days, or 43 weeks gestation as indicators of prolonged pregnancy (
Bakketeig & Bergstro, 1989).
The medical concern with prolonged pregnancy is hinged upon observations of an
increased likelihood of perinatal complications with advanced gestation. In the past,
such complications were believed to include wasting of the unborn child due to
placental degradation (Clifford, 1954; Vorherr, 1975). This wasting, also known as postmaturity syndrome, is typified by the infant's peeling skin and reduced body fat.
However, this condition has been shown to not only affect postdates babies ( Shy, 1991;
McLean, Boyd, Usher, & Kramer, 1991), and evidence indicates it is more frequently
seen in term babies ( Mannino, 1988). In addition, diagnosis of post-maturity syndrome

is highly subjective, and its clinical significance is questionable ( Shearer & Estes,
1985). Recent concern had also been raised about macrosomia (large size) in postdates
babies ( McLean et al., 1991), and higher recorded incidence of neonatal asphyxia
(suffocation) and meconium aspiration syndrome (respiratory difficulties resulting from
inhalation of faeces in the amniotic fluid) ( Mannino, 1988; Cooke, 1997). Recently, it
has become apparent that small babies (those with a birth weight that falls below the
10th percentile) are more likely to present with oligohydramnios (low amniotic fluid
volume) or abnormal non-stress test results, and are therefore more likely to be
delivered by Cesarean, according to a trial of 792 expectantly managed pregnancies at
or beyond 41 weeks gestation ( Sylvestre, Fisher, Westgren, & Divon, 2001). Also,
some statistical reports also show a gradual rise in the perinatal mortality rate with
prolonged gestation ( Hilder, Costeloe, & Thilaganathan, 1998; Bakketeig & Bergstro,
1989; Kassis, Mazor, Leiberman, Cohen, & Insler, 1991; Usher, Boyd, McLean, &
Kramer, 1988; Eden, Seifert, Winegar, & Spellacy, 1987; Sachs & Friedman, 1986;
Devoe & Sholl, 1983). However, these findings contrast with those of Onah (2003),
who worked with data on 1094 twin and singleton pregnancies in Nigeria, and reported
a consistent and significant decline in the stillbirth rate and the proportion of babies
with 1-min Apgar 1 scores less than 4 up to 42 weeks (P=0.00000) (Onah, 2003, p.
255). In spite of such contradictory information, the hypothetical increase in risk to the
infant with prolonged gestation is most often used as the rationale for a policy of labour
induction beyond 40 weeks.
Some members of the medical community have responded to the uncertainty associated
with prolonged pregnancy by implementing a policy of routine induction. Prolonged
pregnancy has in fact become the primary indication for induction of labour (Gardosi et
al., 1997). In Canada, gestation that exceeds 41 completed weeks is currently considered
to be a valid reason for induction of labour. This policy is guided by a report from the
Society of Obstetricians and Gynecologists of Canada ( SOGC, 1997). The report's chief
author, M. Hannah, also headed a trial of medical induction of labour versus expectant
management, a watch-and-wait approach. That trial found lower rates of Cesarean
section and other complications in the induction group ( Hannah et al., 1992), and
concluded that induction at 41 weeks was preferable. The Hannah study has not only
influenced Canadian guidelines; it has also influenced policy in the UK ( RCOG, 2001).
A small number of studies lend support to the findings of the Hannah trial, reporting
better outcomes when labour was induced, as compared to expectant management (
Grant, 1994; Crowley, 1995; Dyson, Miller, & Armstrong, 1987). However, its findings
have raised controversy in the midwifery and obstetric communities, due to
methodological problems, such as the high rate of induction in the expectant
management group, as well as the use of prostaglandin gel as a part of the induction
process in the induction group but its exclusion from the induction process used for the
induced participants in the expectant management group ( Menticoglou & Hall, 2002;
Goer, 1996).
A few smaller studies support the findings of the Hannah trial by reporting better
outcomes with induction as compared to expectant management (Grant, 1994; Crowley,
1995; Dyson et al., 1987). However, other clinical studies have shown better outcomes
with expectant management than with routine induction, such as lower rates of Cesarean
section ( Alexander, McIntire, & Leveno, 2000; Olofsson & Saldeen, 1996; Wigton &
Wolk, 1994; Johnson, Harman, Lange, & Manning, 1986; Gibb, Cardozo, Studd, &
Cooper, 1982; Cardozo, Fysh, & Pearce, 1986; Augensen, Bergsjo, Eikland, Askvik, &

Carlsen, 1987; Boyd et al., 1988; Katz et al., 1983; Devoe & Sholl, 1983; Hauth,
Goodman, & Gilstrap, 1980), and other studies have found no appreciable difference in
outcome ( Roach & Rogers, 1997; National Institute of Child Health and Human
Development Network of Maternal, 1994; Martin, Sessums, Howard, Martin, &
Morrison, 1989; Witter & Weitz, 1987). Alexander, McIntire, and Leveno (2001)
studied an American population of 1325 women who reached 41 weeks gestation, and
noted that induction was associated with a higher rate of Cesarean section. However,
once corrected for independent risk factors for Cesarean section (epidural analgesia,
undilated cervix prior to the onset of labour, and this being the woman's first baby), the
relationship between induction and Cesarean section disappeared. In short, though
obstetric policy in Canada currently favours induction of labour, the literature shows
that both the clinical evidence and the maternity care community are divided on the
issue.
In all this debate over the appropriate management of prolonged pregnancy, women's
voices have rarely been heard. One retrospective study looked at the experiences of a
convenience sample of 32 women who were post-dates (Shearer & Estes, 1985). These
women had gone past their physician-calculated due dates by a minimum of 12 days. In
telephone interviews, the women were asked about their own calculations of the babies
due dates, their doctors calculations, the birth experience, the baby's weight and
condition at birth, the baby's temperament, and whether they or anyone around them had
felt worried or wished for induction. The researchers were surprised by mother's
reports that they were not especially anxious about being overdue ( Shearer & Estes,
1985, p. 110). However, this was a retrospective study and the authors did not ask the
respondents at what point they considered the pregnancy to be prolonged and if they had
taken any actions to stimulate labour. A second study compared women's perspectives
on a policy of expectant management, before and then after the pregnancy ( Roberts &
Young, 1991). A convenience sample of 500 women at a military hospital in the United
Kingdom completed a survey instrument at 37 weeks gestation, and 122 of these
women were still pregnant at 41 weeks gestation when they were asked to complete the
survey again. None of the 500 women had predisposing risk factors, such as medical
conditions that would make the continuation of pregnancy unwise. At 37 weeks
gestation, a slight majority of women (55%) said they would prefer medical induction if
their pregnancies were prolonged. Of the 121 women who had not given birth by 41
weeks gestation, the number who said they would prefer medical induction had risen to
69%. No inquiries were made, however, into whether the women had attempted to
stimulate their labours proactively.
This leaves us with a number of questions: how do pregnant women define prolonged
pregnancy? Does their definition reflect the variation in the medical and midwifery
communities? Or do women, when given the choice, prefer to watch and wait, to have
a natural childbirth? In the study reported on below, we aim to discover birthing
women's own views on prolonged pregnancy, whether they believe some kind of
intervention is warranted, and, if so, when and what kind of intervention is desirable.
There are two special characteristics to study: first, the women respondents were
interviewed at two points in timebefore and after their birthsmaking it possible to
trace changes in their views on prolonged pregnancy as their pregnancies advanced.
Secondly, the respondents were purposively selected as interested in self-care. At least
on the surface, they were not unlike anthropologist Robbie Davis-Floyd's (1994, p.
1133) sub-sample of homebirthers who tended to reject medical definitions and

value judgements in favour of their own lived experience. On the basis of the findings
of other researchers studying the medicalization of childbirth and its alternatives (
Cartwright, 1979; Corea, 1985; Martin, 1984; Davis-Floyd, 1992; Oakley, 1984), we
hypothesized that our respondents, all of whom had joined our study precisely because
they were ideologically in favour of self-care, would challenge medicalization head on
i.e., the process whereby increasingly more aspects of everyday life fall under
medical influence and control ( Zola, 1983). We predicted, in short, that the women in
our sample would be for the healthicization of childbirth, taking it out of the medical
arena and placing it squarely in the health domain ( Conrad 1992, p. 223). They would,
we thought, be in strong in favour of letting nature bring out the babies, staying
closely attuned with what was happening with their bodies (remaining embodied,
Duden, 1993), and strongly opposed to interfering in what is essentially a healthy
natural female process. We first describe the methods used to gather data for our study,
then present our tentative findings, and finally attempt to fit them into the larger debate
surrounding medical intervention during prolonged pregnancy.

Method and sample

An interview-based research project was conducted in British Columbia (BC), Canada
over a 13-month period in 20022003. This was a particularly interest-rich setting for a
study of childbearing experiences, given the diversity in styles of maternity care
available to women in BC. The North American lay midwifery and home birth revival
movements began in this region and on the Northern California Coast in the late 1960searly 1970s, and BC even today carries the reputation as the birthplace of the new
Canadian midwifery (Bourgeault, Benoit, & Davis-Floyd, 2004). In BC, since 1998
certified midwives have been legally permitted to attend both home and hospital births
(which is not the case for physicians). Indeed, certified midwives in BC are actually
required to do so by their regulatory body if they want to get their annual license
renewed (CMBC, 2003). Midwives are regulated at the provincial level, and the laws
are not consistent between provinces. Prior to 1998, midwifery was alegal (neither legal
nor illegal) in BC, and while current legislation incorporates midwifery into the formal
health care system and certified midwifery care is paid for by public health insurance,
lay midwifery is now outlawed.
In spite of the integration of midwifery into BC's health care system, maternity care
continues to be physician-dominated in the province, with certified midwives attending
only 1334 out of 39503 births (3.38%) in BC in 2002 (BC Vital Statistics Agency,
2003). Meanwhile, small pockets of women choose to have out-of-system births, either
with lay birth attendants (who cannot practice legally in the province) or unassisted.
This research sample drew from each of these categories of birthing women: those with
physicians, midwives, lay birth attendants, and those who chose to give birth without
the aid of formal maternity caregivers.
Two sets of semi-structured interviews were conducted with a non-random sample of 27
women who were in their third trimester of pregnancy. Twenty-three of the research
participants were available for a second interview, for a total of 50 interviews. The
follow-up interviews took place between 1 and 4 months post-partum. The 4590 min
long interviews were all tape-recorded and transcribed. Research participants were
given an opportunity to review and revise the transcripts before the data were analyzed,
and in this manner, some errors in the transcripts were eliminated (no fundamental

changes were requested). Most participants mentioned their discomfort in reading their
speech transcribed, due to the sometimes-awkward syntax, but nevertheless voiced their
appreciation for receipt of the transcripts, which served as a sort of time capsule of their
pregnancies. Overall, the process of reviewing the transcripts together encouraged a
feeling of collaboration between the researcher and the participants, as it demystified
the research process.
Participants were recruited by means of a recruitment flyer that asked pregnant women
to agree to an interview on the subject of self-care and health care in pregnancy. The
flyer was posted in several high-traffic locations in the province's two large
metropolitan areas, circulated in the offices of certified midwives, the Home Birth
Association of BC, and the Best Babies program in the capital city., 2 This recruitment
technique targeted women who had an interest in self-care as related to pregnancy; this
is known as purposeful sampling. As Patton (1990, p. 169) explains: The logic and
power of purposeful sampling lies in selecting information-rich cases for study in depth.
Information-rich cases are those from which one can learn a great deal about issues of
central importance to the purpose of the research, thus the term purposeful sampling.
Lincoln & Guba (1985, p. 40) also use the term purposive or theoretical sampling in
the same manner, maintaining that it increases the scope or range of data exposed
(random or representative sampling is likely to suppress more deviant cases) as well as
the likelihood that the full array of multiple realities will be uncovered. Nonetheless,
the self-recruitment method introduced the possibility that some individuals had other
motives for volunteering for the study, such as a desire to talk about their pregnancies;
volunteers were not screened for a true interest in self-care.
The research participants ranged in age from 19 to 43, and had experienced between
zero (i.e., this was their first pregnancy) to three previous pregnancies. Most (22) were
Canadian born; others were born in the United States, Germany or Asia. Most (20) were
Caucasian, though a few were Mtis (of Aboriginal and French Canadian mixed
heritage), Asian, or had some other mixed genetic background. All the participants had
completed high school, and the majority (22) had some post-secondary education; ten
women held undergraduate and/or graduate degrees. Overall, the sample was slightly
more educated than would have been found in a random sample, then, and women under
the age of 19 and those over 43 were not captured in this sample.
At the time of the initial interview, 14 of the 27 women were planning home births. This
was unusual for women in BC, where the overall rate of homebirth was 1.48% in 2002
(BC Vital Statistics Agency, 2003), and reflects the particular character of our sample as
discussed above. Seven women were receiving their primary maternity care from family
practitioners or obstetricians, and eleven had chosen to be attended by certified
midwives. Five other research participants had hired traditional birth attendants; these
women paid the fees of their lay birth attendants out of pocket, at a cost of around
$2500 (CAD) per course of care, usually paid in small instalments over the course of the
pregnancy. Finally, four of the study participants requested no assistance from any type
of maternity provider whatsoever, choosing instead to give birth with just their families,
family and friends, or with doulas , 3 in attendance. Like those who chose traditional
birth attendants, the women who chose unassisted birth (i.e., they were not assisted by
a provider paid by the public health care system) expressed a distrust of professional
maternity care providers, yet either traditional birth attendants were not available to
attend them, or they did not perceive a need for such attendance.

Compared to the average Canadian woman giving birth today, then, our research
participants would likely fall outside the norm and towards the less conventional, more
radical or fringe end of the spectrum where medical technology and artificial
intervention into the birthing process are likely to be viewed with scepticism, if not
totally rejected out of hand.
The participants chose the location of the interviews; whenever possible, interviews
took place in the women's homes, as this was often most convenient for soon-to-be and
new mothers. By necessity, one interview was done by phone, and one interview was
done by email. Two interviews took place in a coffee shop. The first author conducted
all of the interviews. Out of necessity, and as a means to establish rapport, she took her
youngest childa babe-in-armsto many of the interviews. Often the research
participants infants and small children were also present during the interviews. The
interview atmosphere was mostly casual and the interview style conversational. This
process facilitated the sharing of very personal information regarding the experiences of
pregnancy and childbirth, though the researcher often needed to stop the tape recorder
while a mother (the interviewer or interviewee) handled the small crises that punctuate
the daily lives of small children. Such breaks tended to be short and did not prevent us
from covering all of the interview questions. The interviews were guided by a set of
interview schedules, which included items relating to the following issues, addressed in
no specific order.
the woman's socio-demographic characteristics (first interview only);
self-care practices, 4;
experiences with maternity care, in this pregnancy and past pregnancies, including
how the care provider was chosen, and his/her attitude towards self-care;
perspectives on issues such as herbal medicine, pharmaceutical drugs, and induction of
labour;
primary sources of self-care information and support;
prolonged labour/labour induction;
birth experience, and sense of satisfaction with it (second interview only);
advice she would give to other pregnant women (second interview only).
With relevance to this specific paper, in her third trimester of pregnancy, each of the 27
research participants was asked to give her view on prolonged pregnancy and induction
and whether or not she was open to the use of proactive measures, either under the
recommendation of physicians or midwives or by taking the matter into her own hands.
Those women who had been through an herbal (n=2) or medical (n=3) induction before
were also asked about this prior experience.

Thematic analysis
Thematic analysis, the analytical method used here, is frequently employed to process
qualitative data (Webb, 1999; Weiner, Swain, Wolf, & Gottlieb, 2001; Phipps, 2001;
Kitzinger & Willmott, 2002). One of the strengths of thematic analysis is its ability to
bridge positivist (hypothesis-testing) and interpretive (hypothesis-generating)
methodologies by translating qualitative data into forms that can be interpreted and
evaluated by hard scientists ( Boyatzis, 1998; Denzin & Lincoln, 1994; Miller &
Crabtree, 1992).

Though the main focus of this research was on self-care, the interview transcripts
comprised a rich textual data set that provided far more than a catalogue of self-care
strategies used. The study also allowed for a window on women's experiences of
pregnancy, birth, lactation and overall maternity care. Through the lengthy process of
conducting and transcribing the interviews, an intimate knowledge of the data emerged,
and broad patterns became recognisable. These patterns formed the foundations of the
paper's thematic analysis (Boyatzis, 1998).
Thematic analysis began with the identification of themes that were inherent in the
interview questions, such as the women's use of alternative and conventional remedies
and their thoughts and feelings behind the decision to medicate or not. Once such
themes were identified throughout the text, they were catalogued and compared for
consistency and patterns, for instance the relationships between women's perspectives
on self-medicating and their age, parity, and style of maternity care. Thereafter, deeper
analysis was conducted into themes which were not built into the interview questions,
but rather emerged from the data. These included social issues such as how pregnancy
was received in the workplace, and with particular relevance to this paper, how friends,
family members, and maternity caregivers responded to pregnancy beyond 40 weeks
gestation.

Results
Women's views in the third trimester
Many of the women we interviewed in the first wave (during the third trimester of
pregnancy) said they were prepared to induce labour. During the first interview, nearly
half of the women said they would take a proactive approach to avoid prolonged
pregnancy. Some appeared were more willing to do so than others; those who were
more reluctant indicated they would want solid indication that something was wrong
with the baby's health or development before they would take the step. In either case,
the women adopting a proactive approach described special foods, activities, and herbal
medications that they would use before reaching 42 weeks gestation, at which point they
were willing to have their physician or midwife recommend medical induction.
The other half of the women interviewed said that they would not adopt proactive
measures to birth their babies. This included the three respondents who described
having taken such measures in past pregnancies and expressed reservations about doing
so again. This sentiment was most strongly expressed by a woman whose previous
labour was induced with Pitocin (intravenous synthetic oxytocin). As she described it,
with the Pitocin, youre sitting there watching the nurse press a button, and that's how
your labour is progressing I would do just about anything to get out of being induced
again, because it was just horrible. As for the other two women, one's labour had been
induced with prostaglandin, and the other by enema and rupture of the amniotic
membranes; both of these women described the experience as disempowering but
otherwise not disagreeable. Yet, as one of these women said, I felt that [my baby] just
wasnt present when he was born. Like he just wasnt ready. I kind of wish Id just left
him alone.
Others without prior experience of induction said that they were also opposedin their
case on a philosophical ground. In the words of one of these women, maybe the baby's

got an astrological moment that it wants to kick it off in the right direction in life. I
dont see any problem with carrying my baby around in my belly until it's ready to come
out. These women shared the philosophy of natural childbirth and that nature knows
best. They went on to note that they were not really certain as to the actual date of
conception, anyway, and they felt that the policy of mandatory induction after 42 weeks
does not reflect the best interests of mothers and babies.
Women's views on labour induction (whether by taking proactive measures or allowing
physicians to intervene into the birthing process) were loosely associated with style of
maternity care. None of the women in physician care said they were philosophically
opposed to medical or do-it-yourself induction of labour. These women also strongly
approved taking proactive measures to avoid prolonged pregnancy, including herbal
medications. Only one of the six women in physician care said she would avoid
induction unless there was a medical reason for it (other than prolonged pregnancy). In
contrast, women with registered midwives were more likely to be opposed to any form
of induction, and relatively less likely to use proactive measures to stimulate their
labour. Women with lay birth attendants, and those who were unassisted, were even less
likely to support medical induction and the most unwilling to take proactive measures to
end a prolonged pregnancy. These latter groups of women said, almost universally, that
they supported natural childbirth and wanted to let nature take its course.
These findings may simply indicate that women who feel strongly against medical
intervention of any sort are more likely to choose midwifery care, or to avoid the formal
health care system entirely. It may also indicate that maternity care providers had given
the women information that influenced their views on labour induction. For instance,
certified midwives in this province are likely to advise their clients to use a variety of
proactive measures to avoid prolonged pregnancy because their regulatory College does
not support homebirth after 42 weeks gestation, at which point they are mandated to
refer the woman to an obstetrician (College of Midwives of British Columbia (CMBC),
2002). In this fashion, midwives are compelled to follow the medical standard of
induction of labour in post-dates women. Ellen Annandale (1988) found this to also be
the case in her study of midwives attempt to shape women's views of natural
childbirth in a birth center in the US. According to Annandale (1988, p. 108), these
center midwives had to engage the professional medical model, using its very
definitions to maintain the independence and alternatives they sought.
Apart from the style of maternity care each had chosen, there were no other distinct
differences between those opposed to routine medical induction and those who would
use proactive measures. The groups did not differ in terms of age, parity, educational
background or occupational status. There were also no clear divide between women
choosing home birth and those choosing hospital birth. Hence it is not possible to create
a typology along structural lines or choice of birth place of either the inductionfavouring women, or those preferring to watch and wait. This finding differs from a
study by Robbie Davis-Floyd (1994) in which birthing women fell roughly into two
broad categories: professional women who were comfortable with highly
technologized, medicalized birth and in favour of induction and Earth Mothers who
rejected the medical model entirely in favour of homebirth and letting nature take it
course. Davis-Floyd described how the first group of women embraced a technocratic
model of birth, in which technology is better than untrustworthy nature, and the latter
group who embraced a holistic model, whereby nature is best, and can be trusted (

Davis-Floyd, 1994, p. 1136), with a small group of other women falling somewhere inbetween. In the study reported on here, research participants educational and
occupational backgrounds had no bearing on whether they chose home or hospital birth,
or on whether they said they would have labour induced if they went post-dates.
To sum up at this point, when asked their views on prolonged pregnancy and labour
induction while in their third trimester of pregnancy, under half of the 27 women
interviewed agreed with labour induction by either taking the matter into their own
hands and using proactive means, or giving themselves over to the medical profession.
The majority were either opposed to induction outright, or they would agree to
induction only if there were health problems for mother and/or baby; these women were
more likely to have chosen non-physician styles of birth attendance. In their common
view, it seemed best to let nature take its course and have a natural birth, to restrain
from capturing women's wombs (Oakley, 1984) and intervening to produce their
babies on someone else's time ( Martin, 1987).
Women's views in the postpartum period
Perhaps the first thing to note is that none of the women interviewed expected to
actually give birth on their estimated due date. While two women did actually do so,
both expressed surprise and delight at this turn of events! Technically, these women
interpreted prolonged pregnancy as the medical community did; the due date was only
an approximation, and they had some leeway on either side of that date. Pregnancy, in
their view, was not prolonged until sometime after the due date had passed.
Of the 23 women who were interviewed post-partum, ten experienced pregnancies that
continued beyond 40 weeks. Though we hypothesized that the majority of these women
would favour a watch-and-wait natural childbirth approach, based on the findings of the
prenatal interviews, to our surprise all but one chose to use proactive measures after
they passed 40 weeks gestation. (None reported using proactive measures to stimulate
labour prior to the 40-week mark.) Two women who were approaching 42 weeks
gestation attempted to induce labour with castor oil or blue cohosh, and in one case (the
woman who used castor oil), this self-imposed technique appeared to be successful.
Meanwhile, one woman used evening primrose oil suppositories to encourage cervical
ripening. To encourage the onset of labour, several women used homeopathic
preparations. Others had sex with their partners in an attempt to stimulate labour, and
for these two women, labour began within 12 h. As one woman put it: We were too
scared to have sex for a while because we thought that that would bring the labour on,
and sure enough, it did!
Following failed self-help attempts to induce labour, two womenboth in midwifery
careunderwent medical induction, at 42 and 43+ weeks gestation. Both of these
women had indicated in the first interview that they would use proactive measures to
avoid prolonged pregnancy. In both cases, it was a first pregnancy, and the women had
concerns (due to pre-existing health conditions) that their cervices might not dilate
without assistance. Both women indeed used self-help methods of induction before
undergoing medical inductions. Only one of these medical inductions was successful.
The other led to a repeat induction, which was followed by a Cesarean section due to
fetal tachycardia (elevated heart rate). This is a potential side effect of all labour
inducing agents, as they can cause uterine hyper-stimulation leading to fetal hypoxia

(oxygen deprivation), which affects heart rate (Scialli & van Tonningen, 2001). This
woman expressed her disappointment with the birth outcome (a planned home birth
ending in a Cesarean), and she felt that her choice to have a medical induction was
frowned upon by her friends. As she put it, I felt uncomfortable even saying that I
chose the Cervidil [prostaglandin E2] induction, and then this happened. Yes, it's my
fault, and it was the Cervidil. This hinted at some stigma surrounding medical
intervention in childbirth which may be only apparent in the natural childbirth
community, but warrants further investigation.
Seven of the other eight women whose pregnancies went beyond 40 weeks gestation
used self-help measures to stimulate labour. Of those who said in the initial interview
that they were philosophically opposed to induction, three went beyond 40 weeks
gestation, and paradoxically, all three used proactive measures to stimulate labour. It is
also notable that none of the women requested a medical induction at any time; they did
not consider prolonged pregnancy to be a medical problem in and of itself. Rather, they
preferred to take matters into their own hands. Only one woman who passed the 40week mark made no attempt to induce labour, in spite of pressure from her family
physician; she gave birth at home at 42 weeks gestation, with a lay birth attendant
present. Rather than attempting to start her own labour, she chose to avoid seeing the
physician for the remainder of her pregnancy:
The doctor started asking, well when would you induce, since you dont want to do it
at ten days or whatever? And I was like, I dont know actually, I dont think I would
induce, it's not my plan. Unless there was a reason to, a strong reason besides the fact
that Im overdue. And so it was just kind of awkward, and then we left it at that. Then I
said, Im not going to go see any more doctors until after she's born because I didnt
want to feel like there might be something wrong with her, and that Id be an
irresponsible mother not to, you know, check that out, when I felt that everything was
fine. So that's what I did.
Apart from this one individual, we wondered, why were these womena purposeful
sample specifically chosen for the study because they embraced self-carenot willing
to let Mother Nature run her course? Some women said that they felt pressured by
their midwives, who were no longer able to support the choice for women to have a
homebirth once they passed the 42-week mark. One woman became increasingly
defensive as her team of midwives put on more and more pressure for her to consent to
medical intervention. Though she believed her pregnancy was normal and her baby was
fine, she described how with the pressure of their guidelines and their policies and
procedures, it was really hard to stay focused and to stay positive. Though she still
considered herself to be within the normal range, her midwives interpreted her
pregnancy as increasingly high-risk as time went on. For these women planning
homebirths with registered midwives, there was the confounding factor of the regulation
restricting home birth after 42 weeks gestation, mentioned above (CMBC, 2002),
paralleling the standards of care followed by physicians, who do not attend homebirths
as a rule, but nonetheless appeared to lean towards induction as their clients approached
the 42 week mark. This regulation encouraged the women to use proactive measures
(such as homeopathy, herbs, sex, vigorous exercise, and nipple stimulation) to avoid
prolonged pregnancy, and also to accept offers of medical induction. Proactive measures
were in fact used by all five of the midwifery clients who had carried their babies
beyond 40 weeks, as well as by all of the women in physician care. In addition, to avoid

the possibility of losing the opportunity to give birth at home, one midwifery client said
that she moved the date of her last menstrual period back a week at her initial midwifery
visit, buying herself an extra week at the end. She said, We werent a hundred percent
truthful about when the first day of my last menstrual cycle was, just so that we could
have some extra time. We have no desire at all to be induced. Two others said that, in
retrospect, they wish they had done the same and would do so in any future pregnancy.
This practice of moving the date of conception back in time is also found among
Aboriginal women in small northern communities of Canada who want to avoid have to
be evacuated to southern hospitals where they are expected to deliver their babies
sometimes thousands of kilometres from their homes ( Kaufert & ONeil, 1993).
Other women took proactive measures due to pressure from family and/or friends. As
one woman said, People were calling every day, and I felt like I was doing something
wrong that I hadnt produced this baby yet. Because of this pressure, going beyond 40
weeks gestation was associated with an increasing sense of isolation. In the words of
another woman, I felt like I needed a circle of women that I could join, and then stand
and chant with or something. At the end, I was alone.
For three other women experiencing health challenges or severe physical discomfort
while pregnant, prolonged pregnancy meant continuing physical discomfort and
sickness. As one woman said, regarding her insulin-dependent gestational diabetes, it
ruins your pregnancy. You get really sick of being pregnant. Another woman who
induced her labour with acupressure said, I was so ready to be done. I had bad edema,
and half an hour after [my husband] let go of my ankles, there were still thumb prints
there.
For a few women, other non-health related factors shaped their decision to intervene in
their pregnancy. Some male partners had used up vacation time waiting for the
pregnancy to end, time that theyd planned to spend with the new baby and assisting
their partner in her recovery. As a result of this problem, one woman searched the
internet for self-help induction methods, and also performed vigorous exercise,
including rock-climbing. As she put it, I tried to find some [induction] drugs, but I
could not find any. I searched the internet, Chinese websites. Some foods can help. It's
very simple; you just make rice soup, and add a [particular] vegetable. Another woman
whose partner's vacation was drawing to a close also tried numerous induction
techniques, none of which proved to be successful. Other research has also reported
how family and friends tend to influence the decisions women make about childbirth
alternatives (Annandale, 1988).

Discussion and conclusion

We began this study with the assumption that pregnant women who identified
themselves as espousing self-care would be inclined to let nature take its course and not
choose to intervene in their post-date pregnancies. As noted above, however, our
assumption was proven to be false; we found that most of the women we interviewed
were inclined to intervene when their pregnancy went beyond an estimated 40 weeks
duration. Do-it-yourself interventions were much preferred over medical interventions,
likely because self-help methods of induction allowed this particular group of women to
guide their own care rather than follow their caregiver's orders, and they were readily
available. In addition, do-it-yourself induction techniques could be used early, often (if

necessary), and in the privacy of the women's own homes. Even family members and
friends did not have to know.
One sociological interpretation of women's proactive behaviour following prolonged
pregnancy is that it indicates personal agency on their part and their strength at resisting
technological dominance over their reproductive health and find a woman-centred
alternative to male-medical control (Rothman, 1986; Oakley, 1984; Corea, 1985;
Graham & Oakley, 1986). Conrad (1992) points out that increased use of self-care
practices, among other challenges from enlightened clients, can result in the
demedicalization of a life event such as childbirth and its healthicizationi.e.,
return to its rightful moral domain under the control of women themselves. As one
participant pointed out about how she was self-monitoring her pregnancy: it's good to
establish a baseline blood pressure, I think. But Ive never had high blood pressure in
my life, so I just tend to go by what I feel like. Havent been to a doctor in years. While
she was aware of the health complications that occur in some pregnancies, she preferred
to do the monitoring herself, and would seek medical attention only if she discovered a
serious problem.
A second interpretation is that women's views of reproduction, like other human
processes, reflect the larger culture in which they are embedded. Though there is some
indication that pregnancy and childbirth are amazingly medicalized in high-income
societies (Martin, 1987; Davis-Floyd, 1992; Oakley, 1984), other evidence suggests that
there exist many and often times competing definitions of reproductive and other life
events that impact their medicalization/demedicalization ( Conrad, 1992, p. 220;
Annandale & Clark, 1996). In the case of prolonged pregnancy, there appears to indeed
be several competing definitions, within as well as outside of the medical establishment
( Van Teijlingen, Lowis, McCaffrey, & Porter, 2000). As we showed in the introductory
portion of this paper, there is even disagreement among obstetricians, family physicians
and midwives regarding just how dangerous prolonged pregnancy is, whether it requires
medical intervention, and if yes, then at what stage action should be taken. This study
has shown that women espousing self-care also hold competing views of prolonged
pregnancy, ranging from its interpretation as a natural event to the need to intervene for
a variety of reasons, some health-related, others social and still others out of fear of
medical intervention. In fact, some of the women in this study were inclined to
intervene in their pregnancies not long after the 40 weeks gestation mark had passed
even before their health providers would recommend action be taken. Tess Cosslett
(1994, p. 3) argues that pregnant women under certain conditions are able to resist
medical control and negotiate their own personal experiences, but that this does not
necessarily mean that they do so completely outside of the domain and power of
biomedicine:
[T]he consciousness of a birthing woman, whether constituted in an autobiographical
account, or as a character in a fiction, involves a process of negotiation with prevailing
ideologies, whose aim it is, I would argue, power: in terms of writing, the power to take
over the story, in terms of childbirth the power to control the experience; or, in both
cases, the power to protest or celebrate lack of control.
Such ideologies are more or less embraced by the woman's friends, family, significant
others, and even themselves. Annandale and Clark (1996, pp. 3031) make a similar
point: [w]e would argue that alternatives such as natural birth are relational

concepts constituted through dialogue with biomedicine The frameworks of women,

their partners and friends, midwives, nurses and obstetricians are unlikely to be opposed
in an ontological sense but instead may elide and collide in response to local contexts
(emphasis in original). While the women in our study were unusual in that they
mounted strong opposition to medical interventions, they are nevertheless typical of the
majority of birthing women in high-income countries such as Canada in that they took
action rather than letting their pregnancies run their course (Devries, Benoit, van
Teijlingen, & Wrede, 2001). Like the rest of us, many of the women who experienced
pregnancy beyond 40 weeks learned about possible interventions through social
networks, including their friends, family, and maternity care providers. For example,
one woman said: I heard [about blue cohosh and other herbs] through other women
who have birthed naturally with midwives at home. While the receipt of such
information is sometimes empowering, as shown above, these social contacts can also
have a negative impact to the extent that they pressure women into feeling deviant if
they allow their pregnancies to continue beyond a socially acceptable local norm.
Meanwhile, these women face the stigma, particularly from the natural childbirth
community, of having given in to medical pressures if they accept a medical induction.
Women who do not easily give in to the dominant cultural tendency to intervene and
take action, are left isolated, alienated and abandoned by their social networks. As
quoted earlier, At the end, I was alone.
In conclusion, it was apparent that for these women, the social, physical, psychological
and practical implications of prolonged pregnancy are sufficient to convince women to
attempt labour induction on their own. This action was taken proactively by many of
them; it preceded any medical attempts at induction.
Our findings are similar to those of Roberts and Young (1991) who found that women
were more likely to say they would prefer an induction after they actually passed their
estimated due dates. As a solution, Roberts and Young suggest that the first step must
surely be to abandon the term expected date of delivery (1991, p. 1105). Their
investigation did not go into women's reasons for desiring an induction; the problem
was assumed to be solvable through education. However, as we discovered, women's
comprehension of the approximate nature of the due date did not alter the likelihood
that they would choose to intervene after 40 weeks gestation.
This research was conducted with a community of women who had expressed an
interest in pre- and post-natal self-care. Research in other geographic regions and with
other communities of women would further our understanding of the central themes that
emerged here. Women's views on labour induction are heretofore under-investigated,
and additionally, more research is needed regarding the impact of prolonged pregnancy
on women's lives. Our preliminary findings, for example, suggest those women whose
pregnancies go beyond 40 weeks gestation may have an elevated need for social
support. Social support is known to have a positive impact on perinatal outcomes
(Feldman, Dunkel, Sandman, & Wadhwa, 2000; DaCosta, Dritsa, Larouche, & Brender,
2000; Dejin Karlsson et al., 2000). A perceived lack of social support for post-dates
women along with the high risk classification imposed by their maternity care
providers ( Menticoglou & Hall, 2002) may in themselves account for some of the
adverse outcomes reported in association with prolonged pregnancy. Yet we need
additional comparative data to find out if a lack of social support is as problematic for

women whose pregnancies go beyond 40 weeks gestation, as out tentative findings

suggest.
Any future research in this area should first-and-foremost place women's views centre
stage, and recognize that women can under certain circumstances be active managers of
their own health and not merely disembodied subjects of medical intervention.
However, whether or not women are able or indeed want to resist the cultural tendency
to intervene on their own initiative in natural processes such as childbirth remains to be
seen.

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Corresponding author. Department of Anthropology, University of Victoria, Box

3050, , Victoria, BC , Canada V8W 3P5. Fax: +1-250-721-6215
1

An Apgar score is a measure of the vitality of the newborn, based upon readily
identified characteristics such as the infant's responsiveness to stimuli, breathing and
skin tone. It is widely used in obstetrics to document infants health immediately
following childbirth.
2

Best Babies is a government-sponsored community program that targets women who

are at risk of having low birth-weight babies due to low income or recreational drug,
alcohol, or tobacco use.
3

Doulas are hired caregivers who provide emotional and practical support for
childbirth. Their duties can include (but are not limited to) the following: childcare,
meal preparation, massage, herbalism, provision of waterbirth equipment, and so on.
4

Self-care was addressed with an open question: What do you focus on when taking
care of yourself? Self-care issues included physical aspects (such as nutrition, exercise,
getting enough rest, and avoiding toxins), psychological aspects such as avoiding stress,
and social aspects such as cultivating a support network.