Orgasmic birth, alternatively referred to as ‘ecstatic’ birth, and the idea of sexual pleasure in childbirth are notions that have circulated in anecdotal literature for decades, and yet these perspectives have not translated into midwifery or anthropological spheres of research (Buckley, 2010; Caffrey, 2014). The terms encompass the range of sensation and emotional release within the birthing process when experienced as pleasurable by women (Davis and Pascali-Bonaro, 2010). The likely first modern scientific exploration of this concept within medical literature was by Niles Newton (1955), who discussed similarities between sexual and birthing behaviours. Pioneers of research on the human sexual response, Masters and Johnson (1966) also alluded to ‘orgasmic birth’ over 50 years ago, recalling 12 women who reported intense orgasmic sensation during the second stage of their labours.
Many authors argue that childbirth exists as a fundamental component within the female sexual cycle (Harel, 2007; Buckley, 2010), yet the transformations that occur to women's sexualities through motherhood are largely ignored within contemporary discussion (Friedman, 2015). Prior to the 17th century in Europe, the birthing environment was predominantly female led, projecting a private atmosphere, prohibiting men from the process (Tew, 1998; Buckley, 2010). Emergence of male birth attendants and the transition of birth from home to hospital settings dismantled the intimacy that allowed recognition of the sexuality of childbirth (Buckley, 2010), creating an asexualisation through medicalisation. Dissociating procreation and female pleasure and motherhood and sexuality over the course of history explains why birth is not depicted as intrinsically sexual for much of western society, in addition to the fact it contradicts cultural belief that childbirth is meant to be a painful event (Harel, 2007; Postel, 2013).
Despite this, the discussion of orgasmic birth is growing in prevalence amongst women, featuring as a trending topic in internet forums and entertainment journalism. Publications of numerous articles including ‘What it's really like to have an orgasmic birth’ featured in Cosmopolitan (Moore, 2015) and ‘Whoa, you really can have an orgasm during childbirth’ published in Women's Health (Creveling, 2019), highlight women's increased demand for bodily autonomy and control over their birth choices, however ‘controversial’ they may appear. Women seek to experience childbirth as a personal, positive experience where they can freely express intuitive and uninhibited behaviour (Kitzinger, 2012).
Understanding the physiological parallels between birth and sex
Through his exploration of orgasmic states in episodes of human sexual life, obstetrician Michel Odent draws attention to the relationship between what he terms the ‘orgasmogenic cocktail’ of hormones powering both women's sexual lives and childbirth (Odent, 2009). Mammalian parturition involves four major ‘ecstatic hormones’; oxytocin, beta endorphins, adrenaline and prolactin (Buckley, 2015). When these hormones synchronise within an undisturbed birth, women are able to experience the ecstatic feeling (Buckley, 2018) synonymous with pleasure in a woman's sexual life.
Oxytocin
Oxytocin is an essential hormone within a woman's sexual and reproductive cycle, influencing behaviour, parturition and lactation (Magon and Kalra, 2011). Released from the pituitary gland, oxytocin mediates rhythmic uterine contractions during labour, as well as influencing maternal bonding behaviour (Buckley, 2010). Levels increase throughout pregnancy and labour (Uvnäs Moberg et al, 2019), reaching a peak at the moment of birth. Central to all orgasmic and ecstatic states, oxytocin not only influences behavioural effect within maternal physiology (Uvnäs-Moberg et al, 2019) but in sexuality too, with a surge of oxytocin with orgasm, as well as in response to touch, nipple stimulation and kissing (Exton et al, 1999; Uvnäs Moberg, 2011).
Beta-endorphins
Beta-endorphins are a group of opiate-like peptides released from the pituitary gland in response to stress and pain, with the same analgesic effects as exogenous opiates such as pethidine (Buckley, 2015). High levels of endorphin release have been described as inducing euphoric, orgasmic states of pleasure (Bodnar, 2008; Veening and Barendregt, 2015), acting as the body's natural pain relief in undisturbed labour (Myles, 2014). Although poorly understood, it is suggested that the role of beta-endorphins in human sexual behaviour may parallel its release during labour and birth, with high post-orgasmic endorphin levels functioning to promote satisfaction and bonding between sexual partners, reflective of the attachment effects between mother and baby.
Adrenaline and noradrenaline
Adrenaline hormones are released in response to stresses (for example, labour), triggering the ‘fight or flight’ response (Odent, 2009; Buckley, 2015). As in labour, adrenaline and noradrenaline levels also both rise with sexual arousal, peaking at orgasm (Exton et al, 1999). Conditions for labour parallel those required for sexual intercourse, with the potential for and magnitude of orgasm decreasing significantly when fear of performance is present, with privacy being both crucial in sexual relationships and birthing (Pascali-Bonaro and Davis, 2009).
Prolactin
Prolactin levels increase during pregnancy and lactation for the synthesis of breastmilk, in addition to promoting instinctive mothering behaviour (Hashemian et al, 2016). Levels decline during labour until around the period of full dilatation, where they rise and peak following the birth (Rigg and Yenn, 1977; Buckley, 2010). This pattern of release mirrors its role post-orgasm to promote sexual satiety. Krüger and Brody (2006) demonstrated that prolactin levels increase following orgasm, and further studies suggest that the amount of prolactin secreted post-orgasm correlates to sexual satisfaction and orgasm quality (Leneers et al, 2013); yet another hormonal similarity between both birth and sex.
In addition to the hormonal relationship, there is also the consideration of anatomical parallels. Postel (2013) highlights that the compression of the suburethral fascia and genital channels during childbirth may involve erogenous zones unknown to the mother, and that stretching of the ischiopubic and bulbospongiosus muscles by the baby's head as it descends through the vaginal canal, in turn compresses the vestibular bulbs and the clitoral crura. Stimulation of the same nerve pathways may therefore occur in birth as in orgasm, and aid understanding of women's association of sexual pleasure and birth.
The pleasure-pain continuum and orgasm as analgesia
The concept of pleasure in the birthing room contradicts the generalised perception of birth as a painful event. Although pain is a normal physiological element of childbirth, attitudes of western culture generally regard labour pain as pathological, requiring pharmacological treatment (Mander, 2010) and pain takes precedent within women's birth stories. This is statistically evident considering that an anaesthetic or analgesic was administered for 61% of deliveries in the UK between 2018–2019 (NHS Digital, 2019).
Dick-Read (2004) highlighted the fear of pain as the biggest disturbance to the natural course of labour. Tension as a cause of pain is associated with sphincter law, with involuntary sphincter muscles being inhibited by fear and environmental stress, working best in privacy (Gaskin, 2011). The body's response during sexual activity reflects this, where potential pleasure can be perceived as pain (Thomtén and Linton, 2013; Wrobel et al, 2015) depending on the sensitivity of the sexual partner and the emotional participation of the female (Gaskin, 2003). In birth, this concept applies to rectal, cervical, and vaginal sphincters, which function best in an atmosphere of privacy, restricting if levels of adrenaline in the bloodstream increase (Gaskin, 2003; Hotelling, 2009).
Childbirth activist Kitzinger (2012) reports that for many women there is a narrow separation between intense pleasure and pain, and that the sensations can often be bittersweet. Emerging neuroscientific evidence indicates clear similarities between the neurochemistry and neurophysiology of the pain and pleasure systems (Leknes and Tracey, 2008; Moccia et al, 2018), and studies have illustrated the significance of the opioid and dopamine systems in modulating both pain and pleasure, with either sensation inhibiting the other (Wager et al, 2007; Leknes and Tracey, 2008). Suzanne Arms (1994) depicted this relationship as a paradox, suggesting that if fear can influence perceptions of pain and subsequently the course of labour, then alternatively anything that increases a woman's wellbeing, such as pleasure, will lessen her perception of pain.
This theory is applied when exploring the potential of orgasm as an alternative mode of analgesia in childbirth (Mayberry and Daniel, 2016). Human studies have demonstrated that genital self-stimulation can elevate pain thresholds, activating a powerful analgesic process, that is distinctly separate from a distraction process (Whipple and Komisaruk, 1988; Komisaruk and Whipple, 2000). Studies show that when pleasurable vaginal stimulation is applied, a woman's pain threshold can increase by over 75% and by over 100% in those who experience orgasm, (Whipple and Komisaruk, 1988; Komisaruk and Sansone, 2003).
Gaskin also advocated the potential benefit of clitoral stimulation during labour, reporting it to increase vaginal engorgement, with potential to reduce the risk of perineal tears and act as a method of relaxation (Gaskin, 2003). Gaskin (2003) explains that application of sexual energy in birth can ease the intensity of labour and improve its effectiveness. Women who engage with the sexuality of birth report the use of clitoral stimulation significantly eases pain during contractions (Davis and Pascali-Bonaro, 2010). Inducing pleasure as a form of pain relief is not exclusive to genital stimulation however, and has been advocated through other forms of intimacy, including nipple stimulation, touch and kissing (Harel, 2007; Gaskin, 2011; Khajehei and Doherty, 2012), all stimulating release of oxytocin.
The role of the birthing environment
The World Health Organization's (2018) recommendations for a positive birth highlight women's desire for both a clinically and psychologically safe environment during intrapartum care. Evidence shows the orchestration of ecstatic birth hormones is easily interfered with and disrupted by the environment in which a woman births (Buckley, 2018). At present, the majority of women in the UK give birth within an obstetric unit, with only 2.1% of births occurring at home (Office for National Statistics, 2019).
Intimate settings are essential for women to engage with the sexual qualities of birth, and therefore the clinical environment of the hospital does not necessarily recognise or encourage sexuality in childbirth (Buckley, 2010; Mayberry and Daniel, 2016). It is suggested that the unusual flexibility to behave without inhibition or disturbance within the home environment allows women to discover sexual experiences (Kitzinger, 2012). Ecstatic birth is likely only achievable when the neocortex of the brain is at rest, with stimulants such as light, conversation, lack of privacy and danger, all inhibiting the natural hormonal cycle of hormones and affecting labour progress (Odent, 2009).
Accounts of orgasmic birth show that the majority of these women give birth at home, with only a small number reportedly having experienced orgasms within a hospital setting (Harel, 2007; Buckley, 2010). Within Caffrey's (2014) study, six out of seven of the women birthed at home and felt that this environment supported the sensuality and sexuality of birth best. Three of these women had experienced previous traumatic hospital birth experiences and made personal connections of this trauma to the technocratic, highly controlled ward environment (Caffrey, 2014). Those that gave birth at home in Harel's (2007) study depicted sensations as ‘spiritual’, ‘orgasmic’ and ‘sensual’, categorising it as a passionate birth, whereas for those who birthed in hospital, it was unexpected. Considering this, the encouragement of intimate environments, particularly home births when it is clinically indicated, would be the most supportive environment for sexual birth experiences.
How does the choice of analgesia affect the sexuality of birth?
The choice of birth environment will also determine the analgesia available to women, which in turn may influence the possibility of ecstatic birth. Gaskin (2003) observed that the presence of orgasmic birth is greatly reduced in women whose labours are medicated with narcotics, epidurals or barbiturates. The options for pharmacological analgesia are limited within a home birth setting in the UK but include inhalational entonox (a 50:50 mixture of oxygen and nitrous oxide) and opioids (National Institute for Health and Care Excellence [NICE], 2014), with availability dependent on local guidance. Within a hospital environment, women are given the option of epidural analgesia in addition to the above.
Table 1. A summary of reports from women that were interviewed about their orgasmic birth experiences
| Descriptions of orgasmic birth | |
|---|---|
| Sexual experiences of women during childbirth (Harel, 2007) | ‘…it got really intense and I was walking around but never, not even once did I not enjoy the power and the intensity of it and to me it all felt very sexual’‘…I was making sounds as if I was being made love to…’‘As I was birthing him, there was this incredible orgasmic tantric relief’‘The only way I could deal with the pain was through masturbation’‘The birth itself felt like an orgasm, this sensation of feeling her passing through me’‘The actual expulsion of the baby, when the baby moves out of your body is like a massive orgasm’‘I felt a wonderful expel that was very much like an orgasm’‘I had been moaning deeply during the pushing and when I felt him rush out, I had an orgasm’ |
| Experiences of pleasurable childbirth: uncovering a blind spot in anthropology (Caffrey, 2014) | ‘It was just a feeling of being stretched and stimulated that was pleasant’‘It was very much more like sort of the long build up you get to an orgasm, more than the actual orgasm itself … It wasn't exactly the same, it's just that it's the closest parallel’‘…the shuddering, the sort of shuddering and the contractions that you get in your body but also in your vagina, all of that was also there’ |
Reportedly, the most effective for m of pharmacological analgesia is an epidural, with minimal effect on the fetus, as well as increased maternal satisfaction compared to alternative forms of analgesia (Anim-Somuah et al, 2018). Epidurals are also associated with a longer second stage of labour, increased risk of instrumental birth and more intensive monitoring (NICE, 2014). Experienced midwife and academic Walsh (2009) expressed concerns that the side effects for the normality of birth with epidural use are not being communicated sufficiently to women, and implications of ubiquitous epidural use on the pain-pleasure paradox are not yet known. When women view epidural as a benign intervention, or part of a normal labour continuum, then the physiological purpose of pain in labour is neglected (Walsh, 2009).
The higher rate of intervention associated with epidural use, in addition to its effect on the physiology of orgasmic birth, means that sexual sensation from the birthing process may be removed (Kitzinger, 2012). Administration of epidural medication disrupts oxytocin production by numbing stretch receptors in the vagina that maintain a positive feedback mechanism, regulating the hormonal cycle (Pascali-Bonaro and Davis, 2010) as well as the nerve pathways that may induce orgasmic sensation during fetal expulsion (Postel, 2013). The separation of sense from sensation may contribute to women's inability to comprehend the connection between birth and sexuality, and may also be a factor in the higher prevalence of ecstatic birth experiences within home birth settings where it is not possible to arrange an epidural. The vast majority of orgasmic birth accounts are documented to be unmedicated, supporting the literature in its suggestion that pharmacological analgesia interferes with and reduces the likelihood of a sexual birth experience.
Harel's (2007) study on sexual birth experiences demonstrated a trend of the use of clitoral stimulation as analgesia within orgasmic birth experiences. One of the participants of the study recalled that the only way she coped with the pain was through masturbation, utilising her sexuality to birth her baby (Harel, 2007). The use of clitoral stimulation is described to ‘match’ the intensity of contractions, so that pleasure overrides the discomfort of their strength. This concept alludes to the previously discussed theory that the brain cannot respond to pain and pleasure simultaneously, and that when one sensation is predominant, the other is reduced (Arms, 1994).
A systematic review on what matters to women during childbirth demonstrated that most women place high value on their capacity to give birth physiologically, without technical or pharmacological intervention, (Downe et al, 2018). Healthcare professionals must therefore ensure their care supports women's choice (NICE, 2014). This is especially pertinent in regards to alternative coping mechanisms including clitoral stimulation and orgasm, considering its proven benefit for the majority of women who utilise it. Aspects of maternity care that support physiological birth include fostering privacy and reducing anxiety in labour, ensuring non-pharmacological comfort measures for pain relief are routinely available, and using analgesic medications sparingly (Walsh, 2009).
Addressing female sexuality in western birth culture
In addition to influencing women's perception of pain and choice of analgesia, the environment may also affect women's instinctive birthing behaviour, with the threat of social stigmatisation. Wiederman's (2005) social script theory illustrates the idea that much of sexual behaviour follows a script, and certain cues and behaviourisms reflect the influence of cultural beliefs (Mayberry and Daniel, 2016). Women's expression of sexuality during childbirth could therefore resemble the way in which it has been conditioned in her upbringing (Stanway and Stanway, 1984). Researcher Newton (1964) observed that women from societies that generated shame around sexuality generally experienced more painful childbirth.
Evidence shows pleasurable birth experiences are characterised by sexual, physical sensations with no accompanying erotic ideation in regards to the fetus, and yet the concept still evokes stigmatisation. Anonymous online forums such as Mumsnet.com show these women to be depicted as ‘perverted’ (Caffrey, 2014). The shame associated with sexual birth experiences is particularly evident within the UK study, where women would use terms such as ‘sensual’ and ‘pleasurable’ without acknowledging the sexual dimensions of these sensations (Caffrey, 2014). Harel's study (2007) additionally showed that with three of the interviewees, there was admission of feeling the need to ‘hold back’ sexually. This discomfort was a result of the presence of others at the birth, shame and lack of privacy (Harel, 2007).
The desexualisation of birth and subsequent stigma around sexual birth experiences leads mothers who do not find their birth traumatic or painful to question whether something is wrong within them (Caffrey, 2014). Women express shame around sharing their positive birth stories, with fear that it would devalue the experiences of women who did not enjoy their birth (Caffrey, 2014). On the contrary, it is suggested that sharing may also give women power (Hotelling, 2009) if their experiences are normalised and understood within current culture. This highlights the potential of the midwife to validate women's feelings through open communication, normalising what appears to be a physiologically sound and natural phenomenon.
The power of antenatal education for midwives and mothers
Most healthy childbearing women want a positive birth experience (Downe et al, 2018) and therefore a midwife's role extends beyond just improving clinical outcomes but to provide holistic, woman-centered care (National Maternity Review, 2016). Enabling positive experiences for women requires healthcare professionals to recognise and be sensitive to the relationship between sexuality and birth. Often women are reluctant to share with midwives their experiences of sexual pleasure during labour and birth (Harel, 2007), and close parallels between pleasure and pain within birthing behaviour can lead midwives to potentially miss cases. Without discussion within education channels to childbirth professionals such as midwives (Mayberry and Daniel, 2016), it becomes impossible to implement the concept of sexuality as a positive facilitator of birth into practice.
Sexuality in pregnancy is a repressed subject within midwifery training generally, despite evidence of the significant changes that occur to a woman's sexuality and her relationship with partners (Foux, 2008; Drozdowskyj et al, 2020). Healthcare significantly influences how sexuality is perceived and defined, ensuring women feel they are ‘normal’, with professionals acting as a key route to the transmission of such values to women (Nelson, 2009). It is within the scope of practice for a midwife to therefore address and validate concerns women have regarding their sexuality, to provide holistic healthcare, supporting positive relationships between couples (Drozdowskyj et al, 2020). Women hope that healthcare professions will initiate discussions around sexuality, demonstrating permission to air personal concerns (Nelson, 2009). Further training and understanding of the complexity of sexuality is therefore needed for midwives to develop confidence in illustrating its significance to women.
Despite this, at present, the only reference made to a woman's sexual wellbeing in her pregnancy within antenatal guidelines surround the safety of sexual intercourse, enquiring about sexual trauma, and undertaking clinical tests for sexually transmitted infections (NICE, 2008). Sex within midwifery practice therefore remains clinical and disconnected from the woman's identity, omitting the concept of pleasure and passion within birth. In addition to the lack of formal midwifery education regarding the connections between sexuality and birth experience, the practitioner's own lack of confidence or views regarding discussing sexuality may prevent effective communication (Foux, 2008; Nelson, 2009).
The midwife plays a key role in the intimacy of the birth setting and should therefore continuously reflect on her own beliefs and attitudes regarding the relationship between sexuality and birth, taking into account that care and information should also be culturally appropriate (NICE, 2008). Barriers such as cultural attitude, hospital policy and lack of evidence-based research may limit the midwife's ability to aid sexual birth experiences, but with improved education and awareness, it is suggested that midwives have the ability to be influential in assisting change around this (Mayberry and Daniel, 2016).
Evidence also suggests the potential of antenatal education for prospective parents. When reviewing both studies by Harel (2007) and Caffrey (2014), the education of the women interviewed appeared to influence their openness to engage with their sexuality within the intrapartum period. Women reported that the inclusion of childbirth as a positive, physiological and potentially ecstatic event within antenatal education was, or would have been, beneficial in supporting their experiences (Caffrey, 2014). Most of the women recognised that sexuality and pleasure were part of birth, and actively made attempts to incorporate them, with women claiming the inclusion of intimacy improved the birth progress. The use of nipple or clitoral stimulation as an alternative therapy also warrants further consideration and study, based on the anecdotal reports by women who utilised it as positive, effective pain relief.
Conclusion
A basic understanding of the relationship between birth and sex enables us to understand the natural parallels expressed by women when describing the ecstatic feelings generated during childbirth and those during sexual intercourse. Recognising the physiology behind the hormonal cycle, anatomical parallels and shared birthing and sexual behaviours, supports anecdotal reports by women, validating their experiences that are otherwise generally stigmatised.
Why birth is experienced as ecstatic for some and paradoxically painful for others has been demonstrated to be dependent on a multitude of factors, with further research still required. Emerging similarities between the neurochemistry and neurophysiology of the pain and pleasure systems (Leknes and Tracey, 2008; Moccia et al, 2018) help us to understand the relationship, and evidence suggests that through increasing a woman's sense of wellbeing, we can reduce pain sensation (Arms, 1994). Sensory, homeostatic and cultural influences that bias the perception of pain also show the importance of reducing fear around birth and facilitating calm and empowering environments.
Considering this, it is possible to understand how engagement with sexuality during labour functions as an effective, alternative method of analgesia (Mayberry and Daniel, 2016). Studies suggest engaging in acts of intimacy increases oxytocin production, reducing the perception of pain (Whipple and Komisaruk, 1988; Khajehei and Doherty, 2012). However, current social and cultural elements that discourage sexual expression, as well as a lack of privacy and threat of social ostracisation, may inhibit this from being possible.
It is clear the sexuality of birth is greatly affected by the atmosphere it takes place in with research depicting the optimal birthing environment to parallel that for sexual activity (Buckley, 2010); typically, the home environment. Orgasmic birth experiences are also shown to be greatly reduced in women whose labours are medicated with exogenous opiates and epidurals (Gaskin, 2003), suggesting that an unmedicated birth is a key factor in its prevalence. In order to achieve ecstatic sensation, it is essential for midwives to minimise stimulation of the mother's neocortex by environmental factors where possible, allowing women to follow uninhibited behaviours.
Recognising the sexual dimensions of birth will help midwives and other professionals caring for labouring women to appreciate the need for sensitivity in maintaining a suitable birthing environment (Buckley, 2010). By providing holistic and personalised care that recognises the sexual dimensions of birth, midwives have the potential to be fundamental in the facilitation of pleasurable birth experiences. It is also paramount that midwives feel confident to provide open discussion and education for women in order to validate their experiences and enable the provision of effective sexual healthcare. This calls for an effective incorporation of this into midwifery education and general awareness by healthcare professionals and women to focus on inclusion of passion and pleasure within birth.
Key points
- By reviewing the endocrinological and physiological parallels between birth and sex, we are able to define which areas in maternity care may reduce or increase the likelihood of positive, pleasurable birth experiences
- Qualitative evidence suggests women's experiences of orgasmic or ecstatic birth are greatly influenced by their choice of birthing environment, analgesia and the attitudes of their birth attendants
- Intimacy with partners or herself in the birthing context may act as an alternative mode of analgesia for some women, increasing oxytocin production and reducing pain sensation
- Understanding the sexual dimensions of birth allows midwives to support and validate pleasurable birth sensations that are otherwise stigmatised and misunderstood. This is suggested to be achieved through incorporation of the relationship into midwifery education, as well as antenatal education for women
CPD reflective questions
- How do you feel your relationship to sexuality may affect the care you provide to women?
- Do you feel education around female sexuality may aid your ability to present sound and relevant information to women and their partners, to facilitate pleasure within the birthing context?
- How may the acknowledgment of orgasmic and ecstatic birth experiences by healthcare professionals influence midwifery care overall?
- Do you feel that your culture encourages mothers to be empowered by their sexuality or ashamed around their changing bodies and sexual needs?