The best maternal positions for childbirth are rarely utilized in United States hospitals. In fact, Rebecca Dekker, PhD, RN, APRN, reports that approximately 92 percent of women in our country push in a back-lying position rather than science-backed postures such as squatting.

This persists because physicians are indoctrinated into a ritualized birthing system as residents, and most rarely see women in upright positions for birth. My husband, a high-risk obstetrician, is one of these. “I never thought much about women being on their backs. If you see it over and over again, and people are training you do it, it becomes the expectation,” he said.

It wasn’t until I was forced onto my back for the birth of our fourth child that he began think about birth positions. I’d delivered sitting up or on my side before, and I found being put on my back without medical reason to be physically excruciating and emotionally humiliating.

Once this happened, I began to research what I already knew instinctively—that back-lying birth isn’t optimal. Here’s why:

It’s the least effective position for childbirth.

Being placed on your back actually narrows the pelvic outlet and makes getting the baby out harder. Even in the Merriam-Webster definition of “lithotomy position” (on back, legs in stirrups) it states, “this remains the most commonly used birth position although decades of research demonstrate its severe physiological detriments.”

Upright positions work with gravity to help bring the baby down. Squatting on hands and knees positions are most effective at increasing the pelvic outlet, potentially up to 30 percent.

It can make the second stage take longer.

That’s right – longer. In one study, women with a walking epidural who were put in a recumbent position pushed an average of 22 minutes longer than women who sat up. 

Back-lying birth may increase the likelihood of episiotomy.

And not just episiotomy, it may also increase the need for the a vacuum delivery, the use of forceps, and may increase the likeliness that your baby will have abnormal fetal heart rate patterns, which is the second most common reason cited for a primary C-section.

The World Health Organization discourages recumbent positions.

Especially for women delivering without drugs. Without cultural influences, women in labor will move about freely, and prefer upright positions for pushing. Women instinctively know the best positions to give birth because it’s an involuntary process.

Other industrialized nations use stirrups far less often.

In 2010, Britain’s most senior obstetrician said this dated practice is “physiologically inappropriate” and that he “doesn’t approve of it at all.” 

Lithotomy position contradicts best practices.

Britain’s National Institute for Clinical Excellence (NICE) says sitting, standing, squatting or kneeling is better for birth. 

Fathers also prefer when women are in upright positions for delivery.

In one Swedish study fathers with a partner in an upright birth position were more likely to have a positive birth experience and reported feeling more comfortable, powerful, and engaged during the birth.

Back-lying positions make it easier for your provider but not for you.

This dated practice was started in about 1663 because King Louis XIV of France wanted to witness the arrival of his child, and putting the mother on her back made this easier for him. It continued for the convenience of the man-midwife or physician who might want to use forceps. Today, it’s done for the same reason – convenience for the medical personnel, but not for you.

Current best practices recommend upright positions.

Obstetric textbooks recommend upright positions for delivery, especially for first time mothers, instead of recumbent positions.

Putting women on their backs is not a medical necessity.

Obstetrics and gynecology residents, and labor and delivery nurses, train in an apprenticeship manner and learn to put women in horizontal positions because that’s what they are taught. Research-backed recommendations are often hard to put into practice – old habits die hard.

Many women find this position embarrassing and humiliating.

I sure did. In fact, I’ve yet to meet any woman who would prefer to be on her back in stirrups, exposed for numerous people, for an extended time. Even for quick Pap smears, stirrup use has been shown to make women feel less comfortable, more vulnerable, and more exposed. 

Unless you seek out a progressive obstetrician, or aim to see a midwife, you’ll likely be put on your back when you deliver your baby. To avoid this, I recommend interviewing providers about their experience with various birth positions so that you can take advantage of what position works best for you – sitting, squatting, standing or kneeling. Switch to another clinician if you don’t get the response you’re seeking.

It’s up to us – the expectant mothers – to change this practice, because obstetricians are too comfortable to make the change it for us.