Give Birth Like a Feminist

#metoo: the power of no

Currently we are only just beginning to acknowledge that we have a big, ongoing problem with the way we treat women in our culture, with our collective relationship to their bodies, with our respect for their bodily autonomy, and with consent. We would be foolish to think that women’s experience of maternity care is somehow exempt from this.

Let’s look at vaginal exams (known as VEs). During labour, at regular intervals – usually around every four hours – a midwife or doctor will place fingers inside you and estimate the dilation of your cervix. In this way, the speed with which your body is opening up to allow your baby to be born can be neatly marked on a graph and your progress – or lack of it – can be readily assessed. You may be asked to lie on your back to have the VE, or get out of the birth pool. If there is any kind of ‘hold up’ with your labour, a VE can be a very helpful assessment, but standard practice is to perform VEs routinely, even if labour is patently ‘cracking on’ and there are no concerns for either woman or baby. Some women don’t mind them, some really like knowing their dilation, others find them intrusive, distracting, uncomfortable, or violating. No matter how you feel about them, they are part of a standard package, and you will get them anyway.

The interesting thing about VEs is that they are completely optional – but not a lot of people know this. You would think it would be obvious – of course nobody can put their fingers inside your vagina if you don’t want them to, right? But the majority of women are unaware that they are perfectly entitled to decline. Furthermore, some women report a nagging sense that they are entitled to decline, but are unable to voice their refusal, whereas others do manage to decline but are then either directly or indirectly coerced, for example by being told they cannot be admitted to the ward or use the birth pool unless they comply, or by simply being told they ‘have to’ – which is of course incorrect, as you don’t ‘have to’ allow anything to happen to your body against your wishes. Still others consent to the VE but are told afterwards that the midwife or doctor gave them a ‘sweep’ or broke their waters ‘while they were in there’. Women to whom this happens report finding it extremely violating and yet rarely complain formally about it, perhaps because there is a widespread and unspoken acceptance that maternity care requires you to ‘leave your dignity at the door’ and can at times be violating by its very nature.

Of course, you may actively want a VE, or indeed any other birth intervention. Giving birth like a feminist isn’t about declining everything, it’s about knowing that you can, and the shift in the power dynamic this brings. To use another example, in your sexual relationship, you hopefully know that if you say no to your partner at any point, they will respect your wishes. You may have been with your partner for just a few years, or for decades, and in all that time you might never have said no to them, not once. You might have said yes, yes, YES to everything! But all along, you have known that, if you wanted to say no, you could say it, and be respected. Just think how the power balance of your relationship would change if this fundamental and often unspoken understanding was not in place? And yet this is the exact dynamic in which the majority of Western women give birth.

Good girls

There is a wider issue of compliance to those in ‘white coats’ that can affect all of us and is not purely a women’s issue. Most of us, male and female, have been conditioned to accept without question that ‘doctor knows best’ and to follow their ‘orders’. However, there is something about being female that makes challenging authority of any kind particularly difficult, perhaps because, as young girls looking around us as we grow, most of ‘authority’ is male. Politicians, lawyers, scientists, doctors, artists, philosophers: the default human-on-a-plinth is almost always male, and we grow up looking up to them and, consciously or unconsciously, absorbing maleness as synonymous with ‘leader’. The feminist campaigner Caroline Criado Perez has tackled this head-on, getting the first statue of a woman – Millicent Fawcett – in Parliament Square, along with Jane Austen commemorated on the new £10 note, but even in the twenty-first century, these are notable exceptions – and it’s worth remembering too that Criado Perez has been vilified in the media[16] and even sent death threats for her activism in this area.

As women, the social conditioning of a world dominated by men comes in tandem with consistent messages that compliance makes us more favourable humans. From birth, or even before, our culture encourages us to give girls toys, books and movies that suggest that being a girl has some connection to being passive rather than active, and conformist rather than confrontational. Even if we try to escape this as parents, our daughters will inevitably be given ‘home and beauty’ based toys of mirrors, cleaning equipment and plastic food, and often taught to sit neatly with their legs together, quite literally taking up less space than their male counterparts. Shoes, bags and even duvet sets are targeted at specific genders and carry similar messages: the emblem of the girl is the shy and gentle butterfly, while boys have dinosaurs and sharks as their totem animals. Even the clothes we are socially encouraged to choose for our daughters, and that they in turn are encouraged to choose for themselves, hold them back – and I speak as a mother who has spent many hours in parks watching little girls struggle to navigate climbing frames in a dress, while the boys are already ahead in their more practical and durable fabrics. Perhaps due to this early conditioning, once they hit school age girls are generally better at ‘self-control’ than boys,[17] and hence will be praised more consistently for being ‘good’, which tends to mean, ‘quiet’, ‘still’ and ‘not challenging’.[18]

Believe it or not, although you may not have been referred to as a ‘good girl’ for at least a couple of decades, you may well find the phrase returning to your life if you are pregnant, and even – yes, really – you may hear it loud and clear while you are ‘pushing’ your baby out. In February 2018 medical student Natalie Mobbs, NICE fellow Catherine Williams, and Professor of Maternal Health at the University of Liverpool Andrew Weeks – wrote an opinion piece for the British Medical Journal entitled ‘Humanising Birth’,[19] about the use of language in maternity care. In it they called on health professionals to consider more carefully the words they used to pregnant and labouring women, and alongside several other problematic examples, they called out the phrase ‘good girl’ as disrespectful to women as autonomous adults.

‘While some may mourn the days when the doctor was in charge and their advice was gratefully received and unchallenged, there are now multiple, alternative sources of healthcare advice available to women both before and after consultations. With improved knowledge among women and a renewed recognition of respect for human rights in childbirth, comes an equalisation of status between doctor and woman,’ they wrote, concluding, ‘The role of birth attendant is no longer “owner” of the situation but “facilitator” of the health services.’

LANGUAGE OF MATERNITY CARE TO CALL OUT OR CHALLENGE

Although Mobbs, Williams and Weeks challenged a range of phrases, the UK tabloid press, who, as you can imagine, didn’t like one bit the thought that infantilising and patronising women was off the menu, seized upon ‘good girl’ with a series of headlines in which the use of shouty capitals expressed their outrage. They even reported that midwives were now ‘BANNED’[20] from using the phrase – which is not true, of course – the BMJ article was merely an opinion piece. It’s interesting to ponder the roots of this outrage, and whether they wind their way down deep to what seems to be a cultural vested interest in the existing power imbalance; an underlying need for women in the birth room to continue to be, like the little children on the schoolroom mat, ‘quiet’, ‘still’ and ‘not challenging’. Does birth as we know it rely on our silence and complicity to function, just – as we have seen from #metoo – as the wider world often does?

Being called a ‘good girl’ makes women feel everything from uncomfortable to outraged,[21] and while it may seem like a trivial detail to some, it is representative of paternalistic attitudes that pervade maternity care and come from care-givers of both genders. It reflects a desire to assert power over the birthing woman, who, in order to meet the expectations of her attendants and therefore show herself to be a ‘good girl’, must remain childlike, behave herself and comply. Often, it is when the woman tries to break free of this dynamic and take the role of ‘permission giver’ rather than ‘permission seeker’, that we see a similar kind of outrage to that expressed in the tabloid ‘good girl’ headlines being played out in the birth room itself.

‘I went in with a suspected hind-water leak and the doctor examined me and told me they would give me steroids and antibiotics and admit me overnight,’ Maryellen Stephens told me. ‘I said no, that I would rather have an ultrasound, I was calm but assertive. She immediately began telling me that my baby would die and quoting a study, which I happened to have read myself. When I suggested that the study only involved ten women and wasn’t really good enough evidence to extrapolate to every single birthing woman, she was enraged, and – literally – stamped her foot and stormed out. She returned with the head obstetrician who was much more measured, agreeing to my plan of coming back in the morning for an ultrasound.’ Another mother, Hayley, told me her obstetrician said she was ‘washing her hands of her’, because she wanted to wait to be induced until the next morning. Similarly, Emily, from Southampton, told a tale I’ve heard multiple times: ‘I was told there were not enough midwives available for my home birth, but I refused to go to hospital, knowing that I had a right to have my baby where I wished. When they finally sent two midwives, they consistently tried to find reasons to transfer me and told me my baby might die if I didn’t. I stayed put and everything was fine but it really affected my experience negatively.’

Professional childbirth attendants, known as doulas, present as a supporter to the mother in the birth room and observing rather than taking any kind of active role, often report this phenomenon of women being admonished when they try to assert themselves. Interestingly, they also report how they themselves are silenced when they try to support women’s autonomy. ‘I have witnessed doctors becoming everything from irritated to enraged when a woman “talks back” about her options,’ one UK doula told me. ‘And if a doula expresses a view or backs up her client she will often be told, “I wasn’t talking to you, I was talking to my patient,” or worse, threatened with being reported or removed from the birth room.’ Another confirmed: ‘On one occasion I was told, “Don’t talk for the patient” as the doctor put on their gloves and went ahead with a vaginal exam my client had not consented to. Another time I quoted the NICE guidelines and the doctor snapped, “Well clearly you know my job better than I do.”’ Doulas are often gently – and sometimes harshly – mocked in the same way that birth plans are. In some countries, such as Guatemala, doulas have even been banned from the birth room, just as a notice in a Dublin hospital waiting area apparently proclaims ‘You Do Not Need a Birth Plan!’ Could it be that doulas, just like birth plans, speak up for the mother and her rights in a way that threatens the status quo?

Obstetric violence

‘Shut up, close your mouth and push: there is only one voice in this room, and it is mine’,[22] a doctor told a mother in Illinois in 2008, and, in 2013, his words were echoed in a California birth room when a young woman named Kimberly Turbin[23] gave birth to her first child. Like many twenty-first-century labours, a home movie was made by a family member. A two-time rape survivor, Kimberly had urged her care providers to treat her gently and to explain to her every detail of what was happening. As her baby began to crown, her doctor, who had been sitting on a stool between her legs, announced he was going to perform an episiotomy (a cut to enlarge the vaginal opening). Pleading with him that she wanted more time to push her baby out naturally, Kimberly repeatedly said no. The situation in the birth room became more heated as both the doctor, the nurse, and Kimberly’s own mother all urged her to comply.

On the movie, which has since been viewed over half a million times, Kimberly can be heard begging, ‘No! Why? Why can’t we try?’ as the doctor’s voice becomes more aggressive, telling her, ‘Listen: I am the expert here,’ and mocking her suggestion that she can do it herself, telling her, ‘You can go home and do it. You go to Kentucky.’ Just to clarify, Kimberly was not from Kentucky – he meant it as a slur and an implication of ‘backwardness’.

The doctor then proceeds to perform the episiotomy with twelve audible cuts to her perineum.

It’s harrowing viewing. Perhaps more harrowing is the thought that Kimberly is very much not alone: a survey in 2013 by Childbirth Connection[24] found that 6 out of 10 US episiotomies were performed without consent. What makes Kimberly’s case unusual is not that her body was violated in the name of expertise and safety, but that she had this violation entirely captured on camera and that b) she was determined to fight back. With the help of advocacy organisation Improving Birth, Kimberly went in search of a lawyer to take her case. It’s notable that this in itself took 18 months. ‘It took us a year and a half to find a lawyer, in spite of clear, video evidence of blatant disregard and abuse,’ Dawn Thompson of Improving Birth explained. ‘This should be really concerning for a lot of people! Women are coming to us and talking about coercion, manipulation, abuse – every single day, and some of it is just being accepted because it’s just considered par for the course of giving birth in our current maternity care system.’

‘Many of the lawyers we’ve spoken to are not sure whether a woman giving birth has the right to say “No” to a medical procedure,’ her colleague Cristen Pascucci told me during their search for legal representation. ‘And they don’t see the dollar value in litigating this kind of a case, when they know that, just like them, any jury probably believes that the best outcome of childbirth is a live baby – irrespective of whether the mother has been maimed by her care providers in the process.’

Eventually the case was settled out of court in 2017, amidst wide praise for Kimberly for highlighting the issue of consent and abuse in the birth room. Her attorney, the prominent civil rights lawyer Mark Merrin, called the lawsuit, ‘a big step for women who have been silenced’. It’s easy to see this story as an isolated case, or to conceptualise it as an American problem, but, unfortunately, it’s just one example of a widespread, global issue, referred to as ‘obstetric violence’.

It’s worth saying at this point that the term ‘obstetric violence’, perhaps understandably, tends to push buttons and cause misunderstanding, first and foremost because people mistakenly think that ‘obstetric’ implies it is only perpetrated by obstetricians. In fact, ‘obstetric’ simply means ‘relating to childbirth and the processes associated with it’, and the term therefore covers any violation a woman experiences in the birth setting. The second word in the term – ‘violence’ – also causes confusion. While people are generally able to accept that pushing or hitting or maliciously hurting a person is ‘violence’, when a professional is ‘just doing their job’ and ‘helping the baby to be born safely’, for example by insisting they stay on the bed when they really want to move, it is harder to understand this as a violent act. Nor do we always understand acts of coercion, emotional or psychological abuse, lack of proper consent, misuse of power, or abusive or unkind language as acts of ‘violence’. Indeed, as we have seen in the case of Kimberly Turbin, even when the act is quite clearly aggressive and violent towards the woman, there is a kind of cultural blind spot that allows us, for the most part, to accept it as ‘just what birth is like’.

Kimberly’s case is an extreme example of obstetric violence; there are also many other more subtle ways in which a woman can feel violated during her birth experience, and they are all equally valid. It might be helpful for everyone if obstetric violence were instead called ‘obstetric abuse’ or even ‘birth abuse’, in order for everyone to understand fully just what and who is encompassed by this broad term. However, too much debate around the semantics can evolve into a distraction from the solid fact: this is happening to women, and we need to hear their voices. Perhaps, as Mila Oshin, the director of the Digital Institute for Early Parenthood (DIEP), put it at a Birth Trauma conference I attended in 2018, we need to accept that those who have not experienced obstetric violence are last on the list to decide how it should be named. ‘The term obstetric violence is one that does not necessarily reflect the intentions of others, but I feel entitled to use it in reference to my experience,’ she said.

Thanks to Latin American birth activists, Venezuela is the first country formally to define obstetric violence, making it one of nineteen kinds of punishable violence against women. It’s helpful to read their definition and consider how it applies to our own experiences of maternity care, wherever we may be in the world.

The appropriation of a woman’s body and reproductive processes by health personnel, in the form of dehumanizing treatment, abusive medicalization and pathologization of natural processes, involving a woman’s loss of autonomy and of the capacity to freely make her own decisions about her body and sexuality, which has negative consequences for a woman’s quality of life.[25]

The following list, from Venezuelan law, of what constitutes obstetric violence, is also helpful. They state that it encompasses:

 untimely and ineffective attention to obstetric emergencies

 forcing the woman to give birth in a supine position when the necessary means to perform a vertical delivery are available

 impeding early attachment of the child with his/her mother without a medical cause

 altering the natural process of low-risk labour and birth by using augmentation techniques

 performing caesarean sections when natural childbirth is possible, without obtaining the voluntary, expressed, and informed consent of the woman.[26]

Both action and inaction can be violent, and violating. Neglecting a woman in labour who is asking for pain relief or stating that something is wrong, denying access to a caesarean, or intervening too late,[27] could be considered acts of violence, just as the ‘too much too soon’[28] approach can also be violent, undermining a woman’s autonomy and depriving her of the chance to experience her own bodily capabilities. The World Health Organisation (WHO) has also called for the prevention and elimination of abuse and disrespect during childbirth, and the reduction of unnecessary intervention, stating that, ‘The growing knowledge on how to initiate, accelerate, terminate, regulate, or monitor the physiological process of labour and childbirth has led to an increasing medicalisation of the process. It is now being understood that this approach may undermine a woman’s own capability in giving birth and could negatively impact her experience of what should normally be a positive, life-changing experience.’[29] As Dr Princess Nothemba Simelela, WHO Assistant Director-General for Family, Women, Children and Adolescents, put it in February 2018, ‘A “good birth” goes beyond having a healthy baby.’[30]

Women who say they have experienced obstetric violence normally describe situations where they feel their personhood has been disregarded, their voice has not been heard, they have not been properly informed of what is happening to them, they have not given their consent to a procedure, or they feel that their body boundaries have been transgressed without permission. They often use the language of rape and violation, reflecting the sexual and intimate nature of the birth process. In many cases they feel they have been treated with straightforward cruelty or disrespect, but at times they also express an understanding that the professionals in charge of their care were ‘doing what they had to do’, but that they could have done this in a way that made them feel more involved, informed, and respected: ‘This would not have taken much time but it would have made all the difference to me.’ Often, the health professionals’ superior knowledge is used as a justification for proceeding against the woman’s wishes: as one doctor told his patient, ‘I have delivered hundreds of babies, you have not delivered any’.[31]