For most of human history, women gave birth upright, squatting, kneeling, sitting, even standing, using gravity, movement, and instinct to assist the process. Today, in most Western hospitals, women are routinely placed on their backs in a supine or lithotomy position. This position is neither natural nor optimal, but has become the global norm. Why? The answer, as with so many issues affecting women’s bodies, lies not in science but in power.

Upright Birth: The Original Norm

Throughout history, birthing was governed by women and female midwives. Archaeological records, traditional cultures, and historical art consistently show women delivering in positions that utilised gravity, squatting, sitting on birthing stools, or standing. Upright positions widened the pelvis, shortened labour, reduced interventions, and allowed women to follow their own bodily cues.

Even the World Health Organization recognises that encouraging women to assume positions of comfort, including upright postures, improves outcomes and maternal satisfaction.

The Shift: From Midwives to Male Surgeons

The shift to supine positions did not occur for medical reasons. As male physicians and surgeons inserted themselves into the birthing chamber from the 17th century onward, birthing became medicalised and centralised under male authority. Instruments such as forceps, developed in secrecy by the Chamberlen family, gave surgeons the tools, and the excuse, to take over difficult deliveries.

Surgeon-accoucheurs (male surgeons specializing in childbirth, also known as man-midwives), promoted the lithotomy position, flat on the back, legs raised in stirrups, because it offered them the best visual and manual access. Midwives were increasingly displaced, accused of incompetence or ignorance whenever adverse outcomes occurred, even when complications arose from poor medical management. Birth was no longer about what was best for women but what was most convenient for male practitioners.

The Persistence of Supine Birth

Despite clear disadvantages to the supine position, including longer labour, increased interventions, higher rates of episiotomy, and more frequent assisted deliveries, it remains dominant. Today, approximately 68% of women deliver on their backs.

Multiple studies confirm that upright positions result in:

• Shorter second stage of labour
• Reduced need for assisted delivery
• Lower risk of severe perineal trauma
• Improved maternal satisfaction and comfort
• Improved oxygenation for the baby

Yet, hospital protocols, medical convenience, and outdated beliefs continue to discourage alternative positions.

The Epidural Factor: Immobilising Women

The widespread use of epidural anaesthesia further entrenched supine birthing. Immobilised by spinal blocks, women were prevented from assuming upright or mobile positions during labour. Instead, they were coached to push in directed, forceful ways that have been shown to cause more trauma and are less effective than spontaneous, instinctive pushing.

As one study bluntly summarised: “Despite irrefutable evidence that prolonged, directed pushing is of limited value and may, in fact, have negative consequences for both mothers and babies, it remains the standard of care in many hospitals.”

Blame, Power and Control

The displacement of midwives by male surgeons was not merely about improving care—it was a battle for professional dominance. When complications arose, male practitioners often blamed midwives for delay or incompetence, while claiming credit for successful interventions. Women, both patients and practitioners, became pawns in a medical culture increasingly ruled by hierarchy, litigation fears, and reputation management.

The birthing chamber became a battlefield where medical men asserted superiority not only over midwives but over each other, jockeying for prestige while using women’s bodies as the arena.

The Feminist Question: Who Controls Birth?

At its core, the question of birthing position reflects a deeper issue: who controls women’s bodies? Birth, once a sacred female rite, was recast as a medical procedure to be managed and controlled by others. The supine position symbolises this broader cultural disempowerment.

Women’s comfort, instincts, and autonomy have been subordinated to a system that prioritises efficiency, convenience, and medico-legal defensiveness over evidence-based practice. Even today, many women are not offered meaningful choice or information about birthing positions.

Towards Reclaiming Birth

Evidence-based care demands that we centre the needs of labouring women—not the convenience of practitioners. This means:

• Informing women of all birthing positions and their benefits
• Training practitioners to support upright, mobile, and instinctive birth
• Resisting medical practices rooted in outdated patriarchal traditions

As researchers have concluded: “Changing the culture of birth will not be easy but appears inevitable as evidence-based care becomes the expectation throughout health care.”

Women must reclaim authority over their own births. The supine position is not “normal”—it is simply what has become convenient for others.

References

• DiFranco, J.T., & Curl, M. (2014). Healthy Birth Practice #5: Avoid Giving Birth on Your Back and Follow Your Body’s Urge to Push. The Journal of Perinatal Education, 23(4), 207–210.
• Satone, P.D., & Tayade, S.A. (2023). Alternative Birthing Positions Compared to the Conventional Position in the Second Stage of Labor: A Review. Cureus, 15(4), e37943.
• McTavish, L. (2006). Blame and Vindication in the Early Modern Birthing Chamber. Medical History, 50, 447–464.

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