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by Richard Seel

First published in The Health Visitor June 1986 Vol. 59, pp: 182-184

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Summary

A review of the rites of passage experienced at various stages of life, with particular emphasis on those associated with birth, suggests that the incompleteness of birth rites may be a contributory factor in some cases of post-natal depression and parental anxiety.

Introduction

It has frequently been observed that modern obstetric practices have a ritual as well as an instrumental function (Kitzinger 1979). This article will look more closely at these ritual aspects, and ask whether the nature of such rituals may have a connection with postnatal depression. The rituals surrounding birth belong to a particular class known as rites of passage and in western society they are incomplete.

The nature of ritual

Rituals have two main areas of operation: they affect the individuals involved and they express social values. In turn, the social aspect have consequences for the individuals involved. Rituals are powerful and can have a significant and usually beneficial influence on the lives of the participants.

Taken as a whole, modern obstetric procedures have a powerful ritual value. Some procedures may be of little or no ritual consequence. but may be medically important. e.g. taking blood pressure. Others may be of little medical value but be ritually important, e.g. wearing masks in the delivery room. Most will have both ritual and medical importance, e.g. episiotomy.

It is important to be clear that labelling a procedure as ‘ritual’ is not a criticism of. that procedure. There seems to be a belief in some parts of our society that rituals are a bad thing. This is not generally so. Rituals can be very helpful to us all, especially in situations of uncertainty or change of social role. Having a baby is just such a situation: not only does a woman give birth, but she takes on a new role; she becomes a mother . Nearly every culture in the world marks this change ritually. The details of such rituals vary, but their form is largely constant. They belong to a class of rituals known to anthropologists as rites of passage (van Gennep 1960).

Rites of passage are found whenever a person changes his or her social states; initiation ceremonies marking the transition from child to adult; wedding ceremonies marking the transition from single to married; funeral ceremonies marking the transition from living to dead; and many others. Birth rituals mark the transition to parenthood. A rite of passage has three main parts, each of which may last for quite a long time and consist of a number of ritual actions. The rite of passage is only completed when all three parts have been performed.

Rite of separation

In the first part of the rite of passage, the person undergoing the social change (becoming a mother, in this case) is separated from her old environment. This is often achieved by removal to a special place, set apart from normal life: a sacred initiation ground or building. Rites of cleansing and purifying often take place and new clothing is adopted.

There are many elements in the preparation for labour and birth which parallel this description. There is normally a journey to a place set apart (the hospital) where the parents will be separated from normal society and from each other. Rites of cleansing and purifying may take place: the woman may be bathed, shaved, or given an enema. New clothing is given to her. Many parents remark on their feelings of confusion and alienation on admission to hospital.

The liminal period

The middle stage of a rite of passage is called the liminal period (from the Latin limen, a threshold). It is the period when those undergoing the rite have no status of any kind. They have left their old roles behind (indeed, they are often spoken of as having died, especially in initiation rites), but have not yet adopted their new roles. During the liminal period, they may be subjected to humiliation and strict discipline. In some initiation ceremonies, pain may be inflicted on those being initiated, and the liminal period may be climaxed by some bodily mutilation (circumcision, knocking out of a tooth, scarification, etc.) Most important of all, there is instruction, often in a symbolic form, about the nature of society and what is expected of the new role into which the person is transferred. A period of waiting before the end of the liminal period is also common.

Again, the parallels are clear .The woman in labour has little status in the hospital. She may well feel humiliated by her treatment: by the way that her natural functions are taken over by strangers, by the way she is unable to move because of monitors and drips, by the way her questions may not be answered to her satisfaction. Pain is, of course, commonplace during labour , though not inflicted by those in charge of the woman. At the climax of the labour there may well be that ‘unkindest cut’, the episiotomy (not to mention the ever more common Caesarean section). After the birth there is a further period of waiting, of ten days, before the liminal period is over. There is also instruction, in both plain and symbolic form, and I will return to this later.

Rite of incorporation

The final part of the rite pf passage moves the subject back into the world, but now in his or her new stats: as adult; husband or wife; or as parent. The new status will be publicly announced and celebrated, Special clothing may be worn, and there may be feasting and general rejoicing. Often those who have undergone the ritual will be granted privileges because of their new status, and will be accorded a new respect by society at large.

The parallel breaks down here. Although the first two stages of the rite are highly elaborated in western obstetrics, there is little or no rite of incorporation. We leave the rite of passage unfinished; the new mother and father are left in limbo, having to fend for themselves as best they can. The consequences of this incompleteness may be quite serious for some parents.

The mechanism of the rite of passage

Much of the ritual works to subjugate and humiliate the subject. To many people it seems pointless, even gratuitously cruel. Feminist writers tend to identify obstetric ritual with male dominance and a desire to control female fertility. There is much truth in this view, yet there is also evidence to suggest that the mechanism of the rite has a purpose, and that ultimately the rite could be beneficial and life-enhancing.

At the level of individual psychology some suggestions made by William Sargant (1957) may be relevant. Drawing on the work of Pavlov, Sargant argues that in initiation rites, “an overwhelming emotional stimulus carries the subject to the point of emotional collapse and increased suggestibility.” In this state of heightened suggestibility, the person being initiated can be more quickly and effectively conditioned to his or her new, adult place in society. Sargant sees this process as similar to that which occurs in brainwashing and ecstatic religious conversion.

The anthropologist Paul Spencer (1965) noted the distress of young girls going through a marriage ceremony (itself a rite of passage) in Kenya, but was surprised by how quickly they adapted to a strange home, strange husband and strange mother-in-law. Spencer has suggested that Sargant’s work can give an insight into all rites of passage; that the intense anxiety provoked by the rituals and ordeals can help the individual involved to adapt more quickly and completely to his or her new social identity.

Western birth ritual separates a woman from her normal environment and subjects her to humiliation and disorientation in a strange setting, where she is powerless and in pain. As a result of this she is more susceptible to the teaching she receives during the liminal period, which extends until approximately ten days after the birth. At the end of this time she should be welcomed back into society, honoured as a mother and nurtured and supported in her new status.

In this way the obstetric procedures necessary to bring about successful childbirth and the ritual procedures necessary to bring about a successful transition to parenthood should run parallel. In theory, this: mix of science and ritual should produce physically healthy babies and socially well-adjusted parents. In practice, it does not seem to work so well.

Post-natal depression

Various explanations have been offered for post-natal depression. The term itself is ill-defined. Yet it is undeniable that many women (and perhaps many men) suffer from some symptoms associated with depression in the early days and weeks of parenthood. Hormonal deficiencies (Dalton 1980) and birth experiences (Oakley 1980, Welburn 1980) have been suggested as contributory factors. I want to look more closely at the possible influence of birth experience and suggest how such experiences might contribute to depression. In particular, there are three aspects which are worth looking at in closer detail.

The message of the rite

Instruction and teaching play an important part in many rites of passage. Any heightened sensitivity engendered by the privations of the rite will tend to make such instruction very significant for the future attitudes of the person undergoing the ritual. The effect of staff attitudes and practices in this period on the long-term maintenance of breastfeeding is well known (Baer & Baer 1980, Wright et al 1983). What other instruction is given during our birth rite?

In fact, there is not much explicit teaching: how to bath the baby, fix him or her on the breast, clean the umbilical stem, etc. It should all be fairly straightforward, but somehow it often gets incredibly complicated, Many mothers find that the advice they get in hospital in those first ten days is confusing and conflicting. This is true to a lesser extent when the woman comes home before the ten day liminal period is completed, but any gain in this direction may be offset by confusion brought about by returning to society before the liminal period is over.

The problem of conflicting advice is a complex one, involving both variation in advice given and changes in need and perception by the new mother. This advice is not given and received in a neutral or value-free way, but rather in the context of an emotional and ritually charged episode in the mother’s life. This means that what in other circumstances might be dealt with rationally and calmly may here become a trigger for anger, frustration or depression (‘baby blues’).

The symbolism of the rite

The explicit postnatal tuition is not the only, or the most important, teaching given during the birth rite. There are many hidden assumptions and symbolic statements which can assume highly significant status for the new mother .Symbols used in rituals tend to express societal values. Sometimes they are of general relevance, e.g. in reaffirming the current social structure. Sometimes they are more specifically relevant to the experience of the participants in the rite.

Obstetric intervention and active management of labour are controversial subjects, whose importance goes beyond the purely functional. Ann Oakley (1980) has found a positive correlation between what she describes as medium/high technology birth and postnatal depression. It is not the technology as such which underlies the depression. Rather it is the way it is used, the reasons for its use, and the implications of its use which may have consequences for parents’ reactions to their new babies.

I have looked at some aspects of the wider implications of ‘natural’ versus ‘managed’ birth elsewhere, (Seel 1983) but briefly, there is reason to suppose that the values of managed childbirth are male values and the values of natural childbirth are female values. This does not mean that all men are in favour of intervention simply because they are male, or all women in favour of natural birth. However, it does mean that the ethos of our birth ritual, expressed as it is in terms of the symbolism of technology and control, may be profoundly upsetting to some parents.

This is not a matter of rational assessment, or scientific argument. In a highly charged context such as childbirth, symbols are apprehended intuitively. The common mode of childbirth today expresses certain ideas about the world and society. Some parents (those who see nature as threatening and find comfort in a clearly defined power structure) will find these congenial and will have their own values confirmed and strengthened. Others (those who view technology with distaste and believe in shared decision making) will find a conflict with their own values. For them the symbolism of birth may not be life-affirming, but rather perceived as sterile and mechanistic.

The questions of control and male/female values are general: they have more to say about the way we structure our society than the right way to be a mother. But there are other aspects of the medical approach to birth which have profound implications for attitudes to motherhood. For instance, modern obstetrics is child-centred. It is considered appropriate for the mother to suffer discomfort, alienation and even surgery in order that the supposed needs of the baby may be satisfied. If a mother questions an obstetric procedure she is likely to be controlled with a reference to possible harm to her baby.

The potential problem with this approach is its lack of balance, and its future repercussions. By denying the importance of the mother’s feelings during labour, the ritual is saying that if she wants to be a ‘good’ mother, she must subordinate her own needs and desires to those of the baby. This is almost bound to lead to feelings of resentment or guilt by the mother, as she is faced with the demanding reality of a new baby. If she acquiesces in the message of the rite and denies herself entirely for the sake of the baby she is likely to feel resentful. If she does the opposite she is likely to feel guilty.

Of course, the baby’s needs are very important, and to this extent the symbolism of the rite is both correct and vital, but where or when do we ritually celebrate and support the importance of the new mother? How do we convince her of her own worth and help her to trust her own judgements and feelings? If this does not happen in the liminal stag of the rite, then perhaps this celebration should come when she is reincorporated into society and starts her new career as a mother. Unfortunately, this rarely happens.

The incompleteness of the rite

Rites of passage appear in almost every known culture. The content and the symbols involved may change, but the form is constant. It is unlikely that such a rite would be so widespread if it did not fulfil a basic human social need. Regardless of any psychological mechanisms at work, the rite has its own logic and its own pattern. If that pattern is disrupted or left incomplete, serious distress could result. In order for any heightened suggestibility to have positive consequences, there must be a nurturing and welcoming climax to the rite of passage. Otherwise the participant is left high and dry, with feelings of alienation and distress.

The rite of incorporation should come at the end of the ten day period, when the mother is discharged from hospital or receives the last visit from the midwife. It is at such a time that many parents feel utterly lost and alone; cast adrift on an unwelcoming and uncharted sea of troubles. Now is the time when they need to be welcomed back and made to feel part of society again. This re-integration is crucial: if a new mother feels that her new status is valued by society and that she is part of a network of potential friends and helpers, any problems become much easier to solve.

The NHS sponsors the first two parts of our rite of passage for birth (even though it might do so unwittingly), but declines to be involved in any third part. The only possible NHS continuity is provided by the health visitor. Could s/he do more? Some countries give a new mother a medal—perhaps the health visitor could present her with a bouquet of flowers and a congratulations card! Health authorities might gibe at the outlay, but compared to the money spent on high-technology birth it would be negligible—and might help prevent much misery. It might also save money in the long run.

Another possibility is that clinic visits could be made the occasion for some ceremonial welcome back into society. Should church, mosque, temple and local self-help groups be invited to collaborate with the clinic in some way? There are no easy answers, but if we start to ask the questions then we just might begin to prevent or cure some of the negative and depressed feelings that beset so many new parents.

Conclusion

In this article I have looked at modern obstetric practice from an anthropological, rather than a medical perspective. I have presented a very simplified account of rites of passage and shown how current birth practice closely follows the pattern of this rite. The message of the rite reinforces the values of hierarchy and control over nature. It also stresses that a parent’s needs are to be subordinated to those of the baby. There is little in the rite to support and encourage the new mother, especially since the rite is incomplete. This may be a contributory factor in some cases of postnatal depression and parental anxiety. Clinics and health visitor might be instrumental in completing the rite and perhaps alleviating some of the present adverse consequences.

References

Baer, B. & Baer, E. 1980, “The Obstetrician’s Opportunity: Translating ‘Breast is Best’ from Theory into Practice”, American Journal of Obstetrics and Gynaecology, September.

Dalton, K. 1980, Depression After Childbirth, Oxford: University Press.

Gennep, A. van 1960 (1908), The Rites of Passage, London: Routledge & Kegan Paul.

Kitzinger, S. 1979, Women as Mothers, London: Fontana.

Oakley, A. 1980, Women Confined, Oxford: Martin Robertson.

Sargant, W.   1957, Battle for the Mind, London: William Heinemann.

Seel, R. “It’s Only Natural?”, New Generation 2(3): 9.

Spencer, P. 1965, The Samburu, London: Routledge & Kegan Paul.

Welburn, V. 1980, Postnatal Depression, London: Fontana.

Wright, H. et al. 1983 “Prediction of Duration of Breastfeeding in Primiparas.”, Journal of Epidemiology and Community Health, 37.