Commusings: “What Choice Do I Have?” by Gabor Maté and Daniel Maté

Apr 08, 2023

Dear Commune Community,

When Schuyler became pregnant with our first daughter, she registered us for a weekend workshop in lower Manhattan with Ina May Gaskin. Gaskin is famously known as the “mother of midwifery” and co-founder of the Tennessee-based intentional community “The Farm.” 

I was unfamiliar with Gaskin at the time. Candidly, I had never really considered “alternative” means of birthing. I was a “forceps baby” and am, curiously, still somewhat reluctant to go out into the world. My mother’s labor was slow in progressing so I was grabbed by a pair of obstetrical tongs and guided out the birth canal. I grew up with the assumption that all babies are delivered like me — by a man in a white coat in a big municipal building. In other words, childbirth was a medical procedure.

I dutifully accompanied Schuyler to the Gaskin seminar. 15 pregnant women and me in a small third floor living room. Gaskin, 64 at the time, was both severe and captivating. Tall, angular, with a tongue as razor sharp as her mind. For two days, she unraveled all my preconceived notions of childbirth.

Since the inception of our species, there have been 117 billion births. Until around 1900 in the United States, virtually 100% of births transpired at home. By 1938, home birth rates fell to 50%. Today, home birth rates hover around 1%. Of the 117 billion members of our species, approximately 14 billion have been born in a hospital. These statistics simply illustrate that childbirth is a natural process that has become, relatively recently, perceived as a medical procedure.

Gaskin explained how the modern medical model largely treats childbirth as an illness, the outcome of which is reflected by rates of maternal and perinatal mortality. In this paradigm, the mother is a passive patient. The United States registers the worst maternal death rate among industrialized countries with 32.9 deaths per 100,000 live births.

I remember leaving the seminar with this revelation: There is no singular “right” way to birth a child. While our three daughters were all born safely at home, there should be no orthodoxy related to childbirth. Modern medical science has made important contributions to ensuring the health of both mother and child. Still, childbirth needs to be understood as a normal and natural process, the success of which is measured holistically. And that the mother is not a patient. In fact, she leads the process as an empowered and active participant in the miracle of new life.

Today’s essay addressing childbirth is an excerpt from one of the most important books of our generation, The Myth of Normal, penned by Dr. Gabor Maté. Commune and Gabor have collaborated on a marvelous course, A Return to Wholeness, the first session of which you can enjoy for free.

Here at [email protected] and waxing and waning on IG @jeffkrasno.

In love, include me,

• • •

“What Choice Do I Have?”

by Gabor Maté and Daniel Maté

Excerpted from The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture


Thirty-seven years old and healthy, Courtney was expecting an uneventful delivery. At thirty weeks the physician phoned her to announce, as if by decree, that given her age, labor would be induced at thirty-nine weeks. This, the doctor said, was “the office protocol here” for anyone older than thirty-five. “She had known my age from the beginning, since I walked into her office last May,” Courtney said. “I was so shocked that I hung up the phone—I barely said a word. I had to have half a glass of wine. I was so upset, I didn’t sleep all that night.” It went downhill from there. Courtney recalled with pain “the sudden disappearance of flexibility and the imposition of a tyrannical dictate. It was not the kind of care I expected. I’m not used to being bullied by doctors or talked down to. The tone became so toxic . . . and then she also kept saying, ‘The baby is huuuge. He’s going to be huuuge.’ I said to her, ‘Wait, I heard that growth scans are notoriously bad at predicting weight.’ She responded, ‘Not at Sinai. He’s going to be nine pounds at least.’ ” (The baby’s actual birth weight: less than eight pounds.)

Courtney considered looking for a new physician, but this late in pregnancy and still in awe of the specialist’s credentials, she stayed put. “By week thirty-eight, she was saying, every week, ‘This is really not looking good for vaginal, it’s really not. I don’t know what to tell you.’ I just kept saying, ‘I really don’t want a C- section.’ And this was our dynamic week after week. I was in a terrible state of mind for the last three or four weeks of the pregnancy: sobbing, nervous breakdown . . . At the appointed time, we show up at Mount Sinai, and it’s a horrible scene. We’re in this waiting room for three hours, a million different things going on, and I kept saying to my partner, ‘Why the fuck am I here? We are totally within our rights to go back to Brooklyn and go into labor naturally.’ ” Feeling disempowered, having her intuition invalidated at this most vulnerable time of her life, being intimidated by a highly extolled medical specialist, and having been raised in a culture where “expert” authority trumps one’s own, Courtney lacked the wherewithal to assert herself. She finally acceded to the induction and, after fifteen hours of fruitless labor, the inevitable surgery.

“I was so weak. I’d been throwing up. Everything about this was like the biggest nightmare. I said, ‘Fuck it—let’s just do the C-section. Like what choice do I have at this point?’ So we roll into the OR, and I’m throwing up on the table, and I’m a basket case, sobbing. Scared out of my mind, shaking. They start the surgery; it takes forever. She then says to me, ‘Oh, I didn’t realize your abdominal muscles were this strong.’ They were, because I’ve done Pilates for twenty years. I’m thinking, ‘Why didn’t you realize it? You’ve been examining me regularly for nine months and anticipating this surgery for weeks.’ And the following morning she said to me – can you even make this up? – ‘I’m going to call the Mount Sinai scanning department and complain about how inaccurate your growth scans were!’ All that week in the hospital I would just lie awake at night, sobbing at how violated I was.”

I asked Courtney whether she had thought of working with a midwife. “I’m not that left-wing,” she said. “I’m not that far-out. I completely bought into the system.”

Now consider that this galling story took place in a privileged, white, middle-class context. For poor women, especially women of color, treatment of mothers in labor can be considerably more brutal, with consequences that range all the way to fatal. According to a 2019 World Health Organization report, “42% of the women [in a global survey] said they experienced physical or verbal abuse or discrimination during childbirth in health centers, with some of the women being punched, slapped, shouted at, mocked, or forcibly held down.” Nor is this limited to the so-called third world. In my own country, a cell phone video emerged recently of hospital staff in a Quebec facility taunting and verbally abusing an Indigenous woman in labor. Nurses “are heard calling her stupid and saying she’s only good for sex and would be better off dead.” Minutes later, she was.

• • •

Over my decades as a family physician, I attended nearly a thousand deliveries. Standard operating procedure was to perform an episiotomy on every woman giving birth, just as I’d learned in medical school. “Time to make a little cut now,” I would announce as the infant’s head reached the perineum, ready to exit the birth canal. Having injected local anesthetic near the vaginal opening, I would make an incision a few inches long, “catch” the baby, and hand it to the nurse. I then set about repairing the wound I had inflicted. I knew no other way.

Years later I happened to learn from some midwives — who, in the Dark Ages of the 1980s, were still working illicitly here in British Columbia — that episiotomies are completely unnecessary in most labors. There was an organic process trying to happen, they kindly explained, which allowed a child to be born without my surgical intervention: Who knew? More surprises followed. Women can, it turns out, deliver babies without their feet in stirrups and even without reclining on a narrow metal contraption. “Try taking a shit while lying down and your legs in the air,” a midwife suggested when I questioned her wisdom. Other startling news was that, barring complications, the newborn is best handed to mother for skin-to-skin contact, rather than being poked and prodded under bright lights and having plastic suction tubes shoved in its mouth. Nor does the cord have to be cut immediately: it can be allowed to complete its pulsations, delivering more oxygen-carrying red blood cells to the infant. It’s almost as if Nature knows what it’s doing.

These once-heretical practices have since been validated by solid medical research. At long last, doctors now have – more accurately, ought to have – permission to support in good conscience what human beings, with or without any “professionals” assisting, have been doing for hundreds of thousands of years. As the American journalist Anne Fadiman describes in her illuminating work on the clash of medical cultures besetting Hmong immigrants to the United States, these Asian women stubbornly resisted some of our “best practices” in favor of their own ways, including “squatting during delivery and refusing permission for episiotomy incisions to enlarge the vaginal opening…Many Hmong women were used to being held from behind by their husbands, who massaged their bellies with saliva and hummed loudly just before the baby emerged.” In short, they had tradition, intuition, innate body sense, Nature and – no doubt unbeknownst to them – the most up-to-date science on their side. Not to mention their husbands, who literally had their backs.

The advent of modern obstetrics has brought much to be grateful for, sparing many women and infants from avoidable suffering, illness, and death. The problem is that, along with its triumphs, and in line with the mechanistic approach of Western medicine in general, obstetrical practice ignores the genuine and natural needs of mothers and babies – in fact, it often runs roughshod over them. Bringing infants into the world is not simply a question of pushing and pulling and cutting and catching. It is a major threshold in human development, and how it is crossed has potentially lifelong consequences. By pathologizing the birth process, present-day medical practice contradicts the wisdom of Nature and of the human body. More damningly, it frequently violates even its own commitments to align itself with science and to, first, “do no harm.” We need not abandon the great achievements of medical work to honor traditional wisdom, rooted in age-old experience. We can embrace both.

Ilana Stanger-Ross summed up traditional wisdom and modern science in words that, in a saner system, wouldn’t even need to be said: “We need to approach someone in labor as a full person who is experiencing a sacred life passage,” she told me. “They’re not a sick patient. They are a person in labor— which is a very normal thing to be.”

The issue is autonomy, an indispensable human need. Birthing practices express the hidden or overt values of a culture in terms of who wields power and how much genuine control people are able to exercise over their own bodies. Sarah Buckley – a New Zealand-based physician, advocate, and author of a highly regarded overview of the normal physiology of childbearing – explains the rapidly growing rates of medicalized interference. Her response was sharply perceptive as to how acculturation into the much broader myth of normal takes place. “Doctors,” Dr. Buckley said, “are the agents of our society’s expectations that we imprint on mothers, when they are very open and vulnerable, that technology is superior to the body and that women’s bodies are intrinsically bound to fail. It really is obvious that the culture wants to impress upon women this view of their bodies as inherently defective and needing high-level technological care.” And that will carry on, she added, “into how she brings up the child to be in accord with the demands of the culture.”
Though systemic sexism tilts the playing field against women in particular, there is also a more specific cause of unnecessary medical interference, one foundational to the Western medical view: a distrust of natural processes and fear of what can, may, or will go wrong. Throughout my medical schooling and internship, I was trained to anticipate the problems, complications, and dangers of birth. The problem was, nothing in my training encouraged me to align with Nature. It was left to my patients and my midwife colleagues to teach birth to me as something more than a mechanical procedure of extracting a baby from the mother’s body – something with ingrained, evolutionarily derived purposes, both physiological and emotional.

To learn about the physiology of childbearing is to marvel at the innate wisdom of Nature and its highest evolutionary achievement, the human body. The biological bottom line is this: Mammalian labor is more than a process of expelling an infant from a womb. It is preparation for life. Labor, as Nature designed it, promotes the release of hormones such as estrogen, oxytocin, and prolactin that activate a host of neural systems governing the emotions and behaviors, ensuring the baby’s well-being in the short and long terms: warmth, nurturing, bonding, protection, and so on. In other words, birth prepares the template for the mother-infant relationship, which itself is the central locus of the child’s early development. 

This is a partial excerpt of Chapter 17 from THE MYTH OF NORMAL by arrangement with Avery Books, a member of Penguin Group (USA) LLC, A Penguin Random House Company. Copyright © 2022, Gabor Maté

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