In most northern industrial cultures we have come to expect a certain kind of birth.

It takes place in a hospital, and among strangers. Pregnancy and birth are “managed” by care-givers who assume that they know more about what is happening than the woman who is bearing the child. Her body is treated as a machine which is constantly at risk of breaking down. The safe removal of the baby from the maternal body which threatens it depends on expertise which is restricted to professionals with a closed and esoteric system of knowledge. So birth is a medical, and often a surgical, event. And care-givers, in turn, rely on technology that is designed to warn of impending disaster.

The medical model of birth is only one among many. In this book I look to history, cross-cultural anthropology, and the expression of human values through art in an endeavour to understand the nature of birth in technocratic as well as in pre-industrial and traditional societies.

Childbirth in northern industrial culture is very different from the birth ways practised for many thousands of years in cultures across the world. Most women have always given birth among people they know in a place they know well, usually their own home. Knowledge about birth has been shared between the participants. Traditionally, relationships and emotions were believed to influence the progress of birth. To enable it to go smoothly they might need to be explored, and, if necessary, transformed, so that they helped rather than hindered the birth. The act of bringing a baby into the world was a social, and rarely a medical event.

A wanted pregnancy: for any woman the meaning of what it is to be with child has its roots in the culture. A pregnancy may be proof of womanhood, a sign of a man's strength, the seal on a relationship and acceptance by a man's family, and an important stage in the interlaced network between different families. It may represent the fruit of romantic love, fulfil an aching desire to become a mother, be a symbol of hope for the future, entail the reincarnation of an ancestor, replace a child who has died, and, as throughout Africa and the Indian sub-continent, promise another hand to carry water and firewood and to weave cloth, or to shepherd the goats and till the land. Pregnancy can mean all these things, and more.

Our new knowledge about the baby in utero would come as no surprise to people in traditional cultures, where ritual acts are designed to guard the baby from being harmed by things that happen in the world outside the uterus and keep it safe and happy.

The journey through birth, like the journey through death, can be a significant life experience. More and more women are being denied that experience or are choosing not to be aware of it. It can be one which draws human beings together in love and compassion.

From pre-history on, birth – coming into life, like death – going out of it, has been a spiritual matter. It has been shaped by myth and magic, patterned by ritual, infused with hope and longing expressed through sacred acts. Birth was the domain of the Great Mother Goddess, the giver of all life.

Northern technological culture has turned birth into a medical event that is conducted in an intensive care setting. It remains a drama, but it is a hospital drama in which women and their babies are entirely dependent on the life-saving skills of a medical team.

Woman-to-woman help in childbirth is the norm almost everywhere in the world. Men are usually absent, and emotional support, practical help and spiritual succour is offered by women friends, neighbours, in-laws or kin.

A midwife: a word that can mean many different things. She may be a trained nurse, a direct entry midwife with both academic learning and empirical skills derived from apprenticeship and personal experience, a "lay" midwife all of whose skills come from apprenticeship and direct experience, as are many American midwives today, a healer who also delivers babies, a young woman barely out of college who has never given birth herself, a grandmother or mother who has borne many children and helps women in her community give birth, or perhaps a woman with the knowledge to procure abortion and bring down women's "courses" with ergot, pennyroyal, savin or other herbs, and who knows how to mix up love potions. She may be a highly respected authority figure, a nana, like the traditional midwife in rural Jamaica, who is one of a female triad - midwife, school teacher and postmistress - through whom all the politics of the local community are conducted, or a woman who is of low caste because she deals with the "dirt" and pollution surrounding childbirth, as is the dai in rural India. She may have understanding of women's mysteries and the holiness of birth or may simply be concerned to process parturient women through the hospital system. She may work alone, in a partnership, or as one of a team. She may be a friend or a complete stranger. She may even be a man.

A midwife's art is in understanding the relation between psychological and physiological processes in childbirth. Rather than being the provider of a technical service to support a doctor, or someone who scuttles around getting ready for an obstetrician and clearing away after him, her skills lie at the point where the emotional and biological touch each other and interact. She is not a manager of labour and delivery. Rather, she is the opener of doors, the one who releases, the nurturer. She is the strong anchor when there is fear and pain. And she is the skilled friend who is in tune with the rhythms of birth, the mountain tops and chasms, the striving and the triumph.

Everything women do in childbirth and everything other people do to them is profoundly affected by the setting in which birth take place. Spontaneous behaviour and freedom to move depends on an environment where a woman is not constrained or inhibited. She needs to be able to control the birth territory. In northern industrial culture today the majority of women get little or no choice: it is hospital. Though they may have a choice of hospital, home birth is out of the question. The only country in which hospital birth is not the norm is the Netherlands, where one third of births still takes place at home.

A vital element in both the art and the science of midwifery is the skill of the midwife's hands. Together with her eyes and her ears, they are her most valuable tool. When necessary she can use her hands to transform the potentially pathological into the normal. But they are more than a tool. She communicates with them. She receives information through the sensitivity of her touch, and gives comfort, confidence and courage by touch. A good midwife knows exactly how and when to touch just as she also knows when to be hands off.

In many cultures the newborn baby is thought of as hovering between the spirit world of the ancestors and the world of here and now. A baby is in a state of becoming. Its soul has not settled firmly into the little body.

Birth does not end with the delivery of a baby. It is part of a continuum that develops into the relationship between a mother and her baby at the breast. Breastfeeding is not only a method of getting milk into a baby. It is a way of loving. The relationship between them grows out of the interdependence that the mother and baby had while the child was still inside her body. But because the baby is not longer in her uterus it is possible to fragment it, even to destroy it utterly, by choice, by accident, or because a child-rearing culture forces a woman to break the intimacy of that relationship.

Out of the interdependence between a mother and her baby a child's independence grows. From this closeness between them comes a child's ability to move out with confidence into the world

According to the technocratic model, typical of North America and Europe today, birth is a potentially pathological process and only 'normal' in retrospect. Labour and delivery are the work of an obstetric team rather than the woman herself. Each pregnant woman is evaluated in terms of risk categories, and from early pregnancy on she is turned into a patient, someone who is the object of medical care, concern and screening. There is often little continuity of care and a large number of different, and often anonymous, specialists may be involved. Emotional and spiritual aspects of birth are usually ignored or treated as embarrassing.

The social model, in contrast, defines birth as a social event and normal life process. It entails hard work that is done by the woman, her close family, female friends and other women in the neighbourhood, including a midwife who is well-known in the community. Her helpers are almost exclusively women. She has continuity of care and a continuing relationship with those who are providing care. The mother is seen as passing through a major life transition in which spiritual forces must be invoked to support her and evil spirits and negative psychological influences kept at bay. Emotional and spiritual aspects of birth are central to the experience of everyone participating.

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