Why Do Women Give Birth on Their Backs?

For most of human history, women gave birth kneeling, squatting, sitting or standing, and lying flat is a fairly recent habit.¹ It spread mainly because it suits the person catching the baby, not because it helps the birth. Health organizations now recommend letting each woman choose her own position, including upright ones, whether or not she has an epidural.² For women without an epidural, upright positions tend to bring a somewhat shorter pushing stage and fewer forceps or vacuum births, along with a few trade-offs.

It Is Easier for the People Delivering the Baby

In one review, about 68% of women gave birth flat on their backs and 23% semi-sitting, with only 4% upright and 1% on hands and knees.³ The nurses in that review all named convenience for doctors and staff as the reason the back position is used most.⁴ Midwives say lying back lets them watch the birth closely, judge whether a cut is needed, and act fast if something goes wrong.⁵ A doctor using forceps has to crouch or squat low to see properly, because a standard delivery table can’t be raised high enough.⁶

You may hear staff call this the lithotomy position, which means lying back with your legs raised and often held in supports. Semi-sitting is similar, except the bed is raised so you lean back at an angle.

Unless there is a medical reason, you can ask whether the bed can be raised behind you or whether another position is possible. Some beds drop away at the foot end or have raised backs, and knowing what yours can do helps you ask specific questions.

A clear view helps staff spot bleeding or a baby in trouble quickly, and in emergencies or forceps births, being on your back really is needed. The problem is using it by default for low-risk births that don’t call for it. A fair question is whether a position is being suggested because your birth needs it or simply because it is the routine.

Training, staffing and equipment keep the habit going. Some midwives were taught only the back position in school and say it is the only one they know.⁷ Many others learned different positions only in theory and don’t feel confident helping a woman birth that way.⁸ When staff are short, the back position lets one midwife handle several births in a row, while squatting risks the baby falling if no one is right there.⁹ Wards may also lack birthing stools, balls or pools, and staff may not know how to set modern beds for other positions.¹⁰ In hospitals with dirty shared floors, squatting or kneeling on the floor can raise infection worries.¹¹

How Lying Back Changes the Space in Your Pelvis

Scans show that squatting or being on hands and knees widens the lower opening of the pelvis compared with lying on your back.¹² A kneeling squat can widen the middle and lower pelvis by up to about 1 cm.¹³ In pregnant women, the width between the pelvic bones grew from about 12.6 cm lying back to 14.5 cm in a kneeling squat.¹⁴ The upper entrance of the pelvis is slightly larger lying back, so the benefit is for the later, pushing part of birth.¹⁵

A centimeter matters because a baby’s head fits the pelvis closely, so small gains can ease its turn and descent.

Lying back presses on the tailbone, which can stop it moving out of the way as the baby comes down. The tailbone and the bone just above it, the sacrum, can tilt backward a little as the baby descends, adding room at the bottom of the pelvis. When you lie on your back, your body weight pins these bones against the bed. Positions where nothing holds that area down, such as kneeling, hands and knees, or leaning forward, free the tailbone.¹⁶

What Upright Positions Do for Pushing and Birth

The pushing stage is the time from full opening of the cervix to the birth. Positions that free the tailbone shorten pushing by about 21 minutes on average.¹⁷ For first-time mothers, upright and free-choice positions came out best at shortening pushing compared with lying back with legs raised.¹⁸ Without an epidural, upright positions also lower the chance of an instrumental birth, meaning one that needs forceps or a vacuum.¹⁹

“Upright” covers standing, squatting, kneeling, sitting on a stool or birth chair, and hands and knees. Side-lying isn’t upright but also avoids lying flat. A free position simply means changing as your body tells you.

On your back, you push partly uphill against gravity, while upright positions let the baby’s weight help press downward. Many people find that kneeling or on hands and knees they feel the urge to push more clearly and can let their body lead. Leaning forward over a bed back or a partner’s shoulders takes weight off the tailbone while still letting you rest between contractions.

There are trade-offs. Upright positions slightly raise the chance of losing more than 500 ml of blood.²⁰ They may also slightly raise second-degree tears, which go into the muscle and need stitches.²¹

Some of the extra measured blood may reflect blood pooling visibly under an upright mother, where it is easier to collect and see. Staff manage bleeding the same way whatever your position. If you plan to birth upright, ask your midwife how they watch for it.

Tears, Cuts and Your Perineum

When all upright positions are pooled, tears and cuts come out about the same as lying back.²² Looking at individual positions, squatting looked lowest-risk for second-degree and severe tears, and hands and knees for episiotomy, a cut to widen the vaginal opening.²³ Women birthing sitting had far fewer of these cuts than those lying back.²⁴

Tears are graded by depth. A first-degree tear involves only skin, may need no stitches, and often heals alone within days. A second-degree tear reaches the muscle and is repaired with stitches, usually after numbing; tenderness while sitting or walking commonly lasts some weeks. Third- and fourth-degree tears reach the muscle around the anus and need repair by a trained doctor, often in an operating room, with careful follow-up afterward.

Findings differ because position is only one factor. Baby size, pushing speed and staff skill matter too. Controlled, slower pushing helps protect the perineum in any position.

Your midwife may offer warm compresses on the perineum during pushing to help protect it. Telling your team in advance that you’d like guidance on when to push and when to pause lets them plan with you.

Lying Flat Can Press on Major Blood Vessels

In late pregnancy, lying flat lets the heavy womb press on the large vein and artery running down the back of the belly.²⁵ Less blood then returns to the heart, and the heart pumps less.²⁶ Some women feel faint, dizzy or sick lying flat as a result.

The vein affected carries blood from your legs and lower body back toward your heart, and it is soft and easy to squeeze. Even a slight tilt or propping up shifts the womb’s weight off these vessels, which is why semi-sitting and side-lying largely avoid the problem.

You might notice dizziness, nausea, a racing heart or a sudden sweat on your back, and these can be mistaken for labor discomfort or nerves. They usually ease within moments of turning onto your side. Some women have no symptoms at all, so feeling fine on your back doesn’t prove blood flow is unaffected. If you do feel faint, tell staff and roll onto your left side. They can tilt you or place a wedge under one hip.

The baby can be affected too. In one study of laboring women, some showed heart-rate dips in their babies only when lying flat, and the dips went away on their side.²⁷ Without an epidural, upright positions roughly halved abnormal heart-rate patterns compared with lying back.²⁸ Babies’ admissions to intensive care weren’t clearly different, though.²⁹

If You Have an Epidural

With an epidural, upright and lying positions showed no clear difference in forceps, vacuum or caesarean births.³⁰ One review did find fewer babies born with low cord blood acid levels, a sign of stress, in upright positions.³¹ So the WHO recommends that women with epidurals also choose their position, including upright.³²

Older, heavier epidurals could leave the legs too numb to move or bear weight. Low-dose types numb the legs less, so many people can still feel and shift them.³³ How much movement you keep depends on the dose, and staff will check your leg strength before you try to change position.

Several positions work with numb legs: side-lying with a peanut ball between the knees, sitting upright in bed, or kneeling over the raised bed back. Staff can help you turn every so often, which also eases pressure.

It helps to ask in advance which type your hospital offers, because that decides how much you can move afterward. Ask whether your hospital uses a low-dose or walking epidural, whether you can change position once it is placed, and whether staff will help you change regularly or use tools like a peanut ball. If you hope to stay upright, mention it to the anesthetist when the epidural is being placed.

Did Louis XIV Really Start It

A popular story says Louis XIV wanted to watch his mistress give birth and so had her lie back.³⁴ Louis didn’t require or invent the practice, though; the doctor François Mauriceau was the bigger influence.³⁵ Royal habits may still have nudged fashion somewhat.³⁶ And the back position was far from universal elsewhere: in a 1961 survey, only 14 of 76 traditional cultures used back-lying positions.³⁷

Births were traditionally attended by midwives, often in the woman’s home, in whatever position she chose. As doctors, usually men, took over many births, they worked in settings and with habits that favored a patient lying on a bed. The bed made it easier to examine and act on the woman, and lying back suited tools like forceps, so the setup came to shape the position. The habit spread as doctors taught students to deliver on the back, births moved into hospitals, and equipment was designed around it.

How to Choose Your Own Birth Position

Women who picked their own birth position rated their satisfaction higher than those told which to use.³⁸ Freedom to move in labor is also tied to feeling more in control.³⁹ Yet hospitals still deny about 60% of women that freedom.⁴⁰ The WHO recommends encouraging low-risk women to move and stay upright in labor.⁴¹

A hospital tour or prenatal visit is the time to ask:

Do staff routinely support upright or hands-and-knees births?
Do you have birth stools, balls, pools or beds that convert?
Can I move freely and eat lightly during labor?
How is monitoring done if I’m upright?

In a birth plan, list positions you’d like to try rather than one fixed choice, and say you’d like to move freely unless a medical reason arises. Have your partner remind staff during labor.

Lying back may sometimes be needed. Forceps, vacuum or emergency situations may require it, and staff may ask you to lie back briefly for checks. You can return to your chosen position afterward.

Practice helps. Try squatting, kneeling over a birth ball or leaning on a wall to learn what feels comfortable. Your partner can learn how to support you in each one, including holding you under the arms in a squat. A childbirth class or a midwife can show you how to adapt these positions to the bed and equipment in your hospital.

Water is another option. Births in water weren’t linked to more infection and had slightly less heavy bleeding, but cord tearing was more likely.⁴²

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