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Upright Birthing Positions: A Return to the Basics?

Africans ought to confidently explore their traditional medical practices and integrate those found to be efficient into modern medicine.
18th century south Indian carving representing a mother giving birth supported by birth attendants in a standing squatting position. Collection: National Museum, New Delhi.

The art of delivering babies has been around since time immemorial. Like any other societal reality common to all human societies, there might be one underlying general principle to delivery practices; however, the practice differs from one society to another. This explains why, in modern obstetrics, there is a constant debate over the best delivery practices. This debate centers on two main options for child delivery: upright position versus horizontal position, although these also have their respective variations. However, as in any scientific field, practitioners of either approach know there is always room for improvement. Accordingly, it shouldn’t be a matter of what is right or wrong but rather what is efficient. Nonetheless, despite the fact that the current common practice has been built around horizontal birth positions, most studies and archival evidence suggest that upright birth positions have fewer complications and better outcomes, giving rise to a call to return to the basics.

Upright maternal birthing positions are the first documented traditional approaches that were used in ancient civilizations. Upright positions include squatting, kneeling (commonly known as “all-fours”) or sitting in a birth chair. In that position, the pelvic diameter is at its widest, and the gravity pull aids in the fetal head descent; thus, significantly helping the mother in the process.

The labour process is a marathon rather than a sprint. Viewed from that lens, good physical preparation, combined with adequate positioning throughout and at the end of labour, is vital to a delivery process with fewer complications. These logic parameters seem to have been enough for our ancestors to systematically use variations of upright position during childbirth. Indeed, there is evidence, from statues to documents, that attests to the popular use of (variations of) this technique in the ancient global south: from South America with the Dumbarton Oaks birthing figure from the Aztec civilization, ancient Egypt with the great Egyptian civilization (that included the current Central and East Africa blocs), West Africa in Cameroon and Burkina Faso to South India. However, the practice seems to have lost ground to the horizontal position that is increasingly becoming the standard or default setting used in the western world.

The current widespread obstetric practice of conducting delivery in a horizontal position started around the 17th century in western countries. It became popular due to the comfort it afforded to the health providers to the detriment of mothers and evolved with the introduction of delivery forceps and the delivery bed as midwifery instruments. This practice was further popularized in Africa through the proliferation of hospitals that used western orthodox healthcare guidelines.

The horizontal positions include the lithotomy position (the mother lies on her back with her legs separated, fixed and supported by raised stirrups), and the supine position, which is the lithotomy position without the stirrups – the legs are held by the mother or birth attendants. There are numerous reasons for the complications associated with horizontal positions. One, these positions are uncomfortable to the mother. Two, horizontal positions promote perineal tears due to the stretching of the perineum caused by the separation of the legs. Third and most importantly, the pelvic outlet is not at its optimum widest dimensions.

Current evidence supports the ancient approach to maternal birthing

A research study published in 2016 in The Journal of Maternal-Fetal & Neonatal Medicine compared pushing positions in women who give birth for the first time. The study found that the squatting position has several benefits such as a shorter second stage of labour, lower levels of delivery pain, fewer labour augmentation requirements and more maternal satisfaction compared to the supine position. However, there were no differences in immediate post-partum maternal complications or neonatal outcomes between the two positions.

In 2017, a scientific paper, published by Aga Khan University and discussing the historical influences on upright birthing positions, pointed out that upright birthing positions are associated with less delivery pain, fewer instrumental deliveries such as episiotomies or forceps, a shorter duration of the second stage of labour, better neonatal outcomes, and higher maternal satisfaction when compared to supine birthing positions.

In the Journal of Psychosomatic Obstetrics and Gynecology, a meta-analytic review supported the ancient practices by concluding that there is no justification in the systematic use of the supine position. It revealed that the supine position was associated with an increased rate of delivery instrument, episiotomies and perineal tears, significant and intolerable pain, difficulty in bearing down for women giving birth for the first time. At the end of most of the evaluated studies, many women affirmed that they did not want to give birth in the supine position again if given a choice.

Yet another study, this time a review paper, published in the International Journal of Nursing Sciences in 2019 showed that upright positions are effective in shortening the second stage of labour by 34 minutes, increasing the pelvic outlet diameter by 20%, thereby speeding up the labour process and making women feel that they are part of the process, reducing episiotomies and improving neonatal outcomes. However, a slight increase in the estimated blood loss was noted in the squatting position groups.

A prospective randomized controlled trial published in The Lancet in 1989 compared the benefits of squatting positions to those of the conventional semi-recumbent position, which essentially is a variant of the lithotomy position with the head flexed. The trial revealed that the squatting group had fewer deliveries involving the use of forceps, significantly shorter second stages, fewer perineal tears, but slightly more labial tears. Neonatal outcomes, blood losses were similar in both groups.

We should note, however, that current recommendations from the majority of international health institutions, including the UK’s National Institute for Health Care Excellence (NICE guidelines), endorse the practice of women utilizing alternative birthing positions in labour and discourage the use of supine positions in normal childbirth.

The evidence-based philosophy upon which the “modern” medical industry is built proves that ancient natural health approaches are generally more efficient and cost-effective; this shows that Africans ought to confidently explore their traditional medical practices and integrate those found to be efficient into modern medicine.

Safe obstetrical practices have been and will continue to be at the core of every nation’s heart, and the best possible safe techniques have for long been the focus of medical research. African health leaders are duty-bound to strengthen our health systems and ensure the implementation of guidelines proven to be safe. Clearly, safe childbirth doesn’t necessarily require expensive equipment; it can be achieved and sustained with the available basic knowledge of best practices combined with effective tailored health systems.


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