Departing from Straightline Obstetrics and Timelines

The attempt to define and predict the “normal” and “abnormal” in labour came into fashion in the 1950s, when Dr. Emanuel Friedman, of Columbia University, published a study that mapped how long 500 Caucasian women at his centre took to dilate during labour. He plotted dilation by the hour on a table that suggested how quickly the birthing persons in his sample progressed(Friedman 1955 and 1956). What became known as the “Friedman curve” was based on very interventive obstetrics, including a 55% forceps rate and 13.8% induction and augmentation rate in the study.

Widely adopted for use in obstetrics worldwide, the Friedman curve became adopted for use as a means by which medical intervention could be prescribed to limit the length of labour, even though it's restrictive concepts of "normal" did not necessarily equate with adverse outcomes when not followed. Today if birthing persons do not conform to these strict guidelines of progress, sometimes slightly adjusted, they are augmented or are subjected to forceps or cesareans. A parallel might be drawn that Friedman had created, like Einstein, an invention that had unwittingly lead to a metaphorical time bomb in obstetrics. His analysis “for purposes of mathematical simplification” became a tool that was used to restrict labour rather than merely enhance an understanding of it.

Practising for over a decade in Latin America and rural Alabama 1975-1982, initially with minimal standard obstetric or midwifery training, Betty-Anne was at first unaware of Friedman’s work. When she discovered it, she could see that the Friedman curve did not very accurately describe how labours progress in the births she had been attending in Latin America, Alabama, or Canada. She had training from traditional midwives and women whose major rules were to follow what their body told them--that is, trust what was actually happening to them. She recognized that labour occurs in fits and starts, and that trying to describe it in straight lines as Friedman had done did not reflect the reality of the populations with which she worked in home birth settings. Worse, she observed that his work was limiting practitioners' perceptions of “how long” they would permit birthing persons to labour. And it did not appear that what she called “the straight-line obstetric theory” took into account emotional issues or issues such as posterior babies who need more time to turn.