As a family physician attending childbirth, I often find I am faced with concerned couples and women trying to answer for themselves questions about what “natural” childbirth means. They sometimes seem surprised that I don’t automatically recommend pain medication.

In order to understand what differentiates “natural childbirth” practices, it would help to know a little about the history of childbirth practices in this country. Until the 1900s, midwives were the main attendants of largely home births in this country. By the mid-1900s, it became the norm to have a hospital birth attended by a physician. During this time, some medical advances made childbirth safer, especially the introduction of antibiotics. However, medicine was also becoming more intrusive. The use of medications like opium or chloroform for pain relief was common. They induced a state in which little could be recalled later, especially the so-called “twilight sleep”. In addition, they often slowed down or stopped contractions, as can opioid medications given to women in labor nowadays. Forceps were often used in a variety of styles, when anesthesia stopped labor. The use of forceps was one of the earliest ways in which a physician separated his skills from those of a midwife, and the first use of forceps in France in the last century was a very closely guarded trade secret. By this time, in the 1940s, breastfeeding was discouraged because it was thought that it interfered with the mother’s rest after her ordeal. The woman in labor was typically separated from her family, in order to prevent distraction for the hospital staff, and was reunited only after the birth of the child. The experience of childbirth was a very medical one.

It was following this time, as early as the 1950s and increasingly in the 60s, that the idea of a “natural childbirth” began to surface. Then, in the late 1960s and 70s, a few influential physicians and childbirth educators began to encourage pregnant women to avoid pain medication, with great effectiveness. Some of these early pioneers were a British obstetrician Grantley Dick-Read, and a French obstetrician Fernand Lamaze.

The medical treatment of women in labor and our understanding of techniques for natural childbirth have changed enormously since then. The development of spinal anesthesia, the use of fetal monitoring and the increase in cesarean sections have been some of these changes.

It would be beyond the scope of this article to study each of these developments and what they have meant to the safety and the experience of childbirth. What we can say is that many of our advances have led to much safer childbirth, especially the appropriate availability of cesarean sections. On the other hand, we have also found that we can avoid the excessive use of surgery, such as repeat c-sections in any one who has had to have one before. We have discovered that some of the very widespread practices we use, such as routine continuous electronic fetal monitoring, may not make a big difference in creating healthy outcomes for mother and baby, when compared with older methods of following the baby’s heartrate.

The goal of a natural childbirth is to use an understanding of the process of childbirth as it takes place in a woman’s body, techniques for relaxation to replace the use of pain medications, and a team approach with a doctor or midwife, to achieve the healthiest outcome. The advantages of an unmedicated birth include: greater alertness for baby and mother afterwards, increased ease with breastfeeding, and a lower chance that use of medication will slow down labor and lead to the need for other procedures. For example, Pitocin might be needed to increase contractions or there may be a decision made to do a c-section because of a stalled labor. Intravenous pain medication, usually an opioid such as demerol or morphine, is transmitted to the baby and can affect the infant after birth, decreasing its breathing reflexes. Spinal anesthesia can provide pain relief without such direct effects to the baby, but often means staying in bed and being less active, and may lengthen labor. It is not clear whether spinal anesthesia may increase the chance of needing a c-section.

Many women are naturally nervous at the thought of facing the pain of childbirth. The best preparation is to know that reading, classes and the ability to use relaxation techniques in labor can make a difference in easing childbirth. A prepared husband, partner or other labor support including possibly a doula (a trained labor attendant) has been shown to decrease c-sections just by providing encouragement and support. No pain medication that is used today will completely remove the sensation of contractions, or guarantee a painless childbirth. Most importantly, thinking of childbirth as a path taking you closer to that wonderful moment of first seeing your newborn will remind you that it is worth going through. Many women express gratitude that the experience of childbirth, contractions and all, was an intense emotional passage that they would not have wanted to avoid. This is especially true when you are able to remind yourself in labor that the seemingly easy path of using pain medication can sometimes make labor longer, slower or otherwise more complicated.

While natural childbirth is used synonymously with unmedicated birth, there are other aspects that can make a difference in the childbirth experience. These include the use of positions or other techniques in the stage of pushing to minimize tears or the need for an episiotomy (the surgical cut that is sometimes made at the opening of the vagina as the baby’s head is born). Hospitals are increasingly conscious of providing a relaxing, home-like environment in which labor and birth can occur in the same room and the baby can be allowed to stay with the mother afterwards. There is more emphasis on breastfeeding support, although there is still a long way to go in making it easier for women to begin breastfeeding without the temptation to add formula.

However, having said all of this, it’s very important to keep in mind that labor is a process that takes its own course, and can be unpredictable. A large part of labor preparation is about doing everything we can to keep medical interventions to a minimum, and yet being able to let go of our expectations if indeed it becomes necessary to use procedures or medications. For example, in some situations, both intravenous medication and spinal anesthesia can play an important part in actually increasing the effectiveness of labor by relaxing someone who is very tense or experiencing a very long and fatiguing labor. These are areas that are good to discuss with your physician or midwife before and when they arise in labor. The judgement of your doctor and her explanation as to why this may be helpful as a particular situation arises, should help you if this were to be recommended.

Overall, those who have worked with women in labor and postpartum, and women’s experiences themselves, reinforce that childbirth preparation, good labor support, and motivation to avoid pain medication, often help prevent complications, lead to healthier mothers and babies and speed up the recovery process.