GIVE BIRTH LIKE A FEMINIST
Your Body. Your Baby. Your Choices.
Milli Hill

Copyright

HQ

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First published in Great Britain by HQ,

an imprint of HarperCollinsPublishers Ltd 2019

Copyright © Milli Hill 2019

Milli Hill asserts the moral right to be identified as the author of this work.

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Source ISBN: 9780008313104

Ebook Edition © 2019 ISBN: 9780008313111

Version: 2019-07-26

Contents

Cover

Title Page

Copyright

Introduction

Chapter 1

‘Am I Allowed?’: The Birth Room Power Imbalance

Chapter 2

Birth: the Land that Feminism Forgot?

Chapter 3

When Women’s Bodies Became Men’s Business: A History of Birth

Chapter 4

Loose Women

Chapter 5

Women’s Bodies: Unfit for Purpose?

Chapter 6

Birth and Culture: ‘Fish can’t see water’

Chapter 7

Birth Rights are Women’s Rights are Human Rights

Stand and Deliver

Resources

Footnotes

Endnotes

Bibliography

Index

Acknowledgements

About the Author

About the Publisher

Introduction

Birth is a feminist issue. And it’s the feminist issue nobody’s talking about. This book aims to start that conversation.

As I’ve gone through the process of writing this book, I’ve had a few moments where I’ve wondered, why me? My inner critic (don’t try to tell me you haven’t got one of those) has said to me, ‘Milli? Do you really want to open this particular can of worms? As if talking about childbirth wasn’t treacherous enough, now you want to drop the F-bomb?! Are you nuts? That is literally the worst combination of topics. You are going to get burned at the stake – well, metaphorically speaking, at least.’ My inner critic is such a gas.

It’s true, it’s not always easy to talk about childbirth, and it’s not always easy to raise feminist issues. People can even argue about what feminism actually is, but to me it’s simple: feminism just means noticing when women are getting a raw deal, and taking action. And this is where the problem lies with childbirth. Not enough people are noticing that women are getting a raw deal, and not enough people are taking action. We’ve become blinkered to the massive imbalance of power in the birth room, and somehow come to accept that birth is inherently unpleasant and undignified, or even traumatic, degrading and violating. ‘That’s just how it is!’ Well I want this book to tell you it doesn’t have to be that way, and as feminists we must no longer tolerate this state of affairs.

Feminism doesn’t have to be complicated, and it doesn’t have to be exclusive. Giving birth like a feminist doesn’t mean giving birth a certain way, just as doing anything else – career, relationships, parenting – ‘like a feminist’ doesn’t require a one-size-fits-all approach. You can give birth like a feminist in any setting and in any way, from elective caesarean in a private hospital to freebirth in the ocean. All that’s required is that you have somehow moved from a passive place where you view birth as something that happens to you and over which you have no control, to a place of understanding that you may get a raw deal in this experience if you don’t wake up and get yourself into the driving seat. Essentially: take charge, take control, and make conscious choices.

When I speak at mainstream maternity events, I am often shocked by the fact that telling women and their partners that they have rights and choices in the birth room so often seems to come as a revelation. Many people have no sense of themselves as autonomous or powerful in their labour and birth, nor do they feel that there is anything they can do or not do to influence the way their birth unfolds. They are often misinformed and, to compound this, their belief that they have little or no agency then prevents them from seeking out much information. What is the point in learning about your options against a backdrop in which the phrase ‘not allowed’ is used with such alarming frequency? Most pregnant couples believe that the majority of choices are out of their hands. In practical terms this means that, on a daily basis, fingers enter the vaginas of women who do not know they can decline. How can this be acceptable? Even the most progressive of maternity conversations emphasises ‘informed consent’, with the unspoken assumption that consent, not ‘decision making’, or possibly even ‘informed refusal’, is the goal. Maternity professionals will speak of how they ‘consent’ women – using it as a verb, ‘I am just going to go and consent her’, as if the professional is the active one in the exchange and the women herself is passive. It’s time to challenge a system that perpetuates this myth of unquestioning co-operation and female powerlessness.

When you raise a complaint about a female experience, you quite often get quickly reminded of how unusual, niche or rare the problem is, and just how good so many women have it. This focus-shifting is epitomised so well by the hashtag #notallmen – used to remind women just how many good, well-rounded men there are in the world when they try to highlight any issue from mansplaining to rape. ‘#notallmen are rapists. #notallmen have sexist attitudes. #notallmen beat their wives, remember!’ Hang on, the women say, we don’t want to talk about the large percentage of wonderful men who respect women – we want to talk about the other bunch, who don’t. But in the diversion, the point has already been diluted, making the aggressor seem like the victim in the process. This diversionary tactic happens in conversations about birth, too. Attempts to complain about anything from lack of consent, to women not being properly listened to in labour, to institutionalised misogyny and racism in maternity care, are so often met with protests from health workers of ‘It’s not like that where I work!’ or ‘Not all midwives/obstetricians are like that, it’s important not to make sweeping statements’, etc. So, before we get started on our journey through this book, I want to stress that my focus throughout is not on individuals, but on the systems in which they operate. Maternity care is a system that needs to be challenged, built by and within another system that needs to be challenged – patriarchy. Please don’t divert attention from this vital issue if you feel that you personally are working in a way that fully respects women as autonomous, or if you received gold-standard care in your own pregnancy. This is indeed wonderful, but it’s not really what we are all here to talk about.

Likewise, there can sometimes be protests that we should be doing more to celebrate the wonderful men – and in the same way the wonderful maternity care providers – who are ‘getting it right’. It’s true, there are some brilliant midwives, doctors, obstetric units and organisations out there who are providing the most fantastic, refreshing, woman-centred, personalised maternity care – and yes, praise is a good thing, and yes, some of them are in this book. But do we really need to repeatedly celebrate those who are simply providing what women need and deserve? Do men who treat women with respect need a great big pat on the back? No – they are simply behaving normally, with the required, standard levels of kindness and compassion. There should not have to be medals for this, and for the same reasons I have not devoted endless pages of this book to good, decent, rights-based maternity care. Listening to women, caring for them as individuals, and respecting them as the key decision maker in the birth room should cease to be seen as a shining beacon in the darkness and start to be viewed as the baseline norm.

Currently, we are not getting birth right. This matters primarily because birth is a key human experience that will be remembered in great detail by a woman, and her partner, for the rest of their lives. In this book I have tried to ask some difficult questions about the kind of births women are currently experiencing vs. the kind of births that may be possible or desired. These are not easy conversations to have, not least because all women are different and will want and prioritise different things. Added to this, there is a weight of emotion brought to the discussion by those women who have already given birth and had traumatic or disempowering experiences. In spite of the complexity of the topic and the difficult feelings that discussing it evokes, I sincerely hope that this book will pull women together to work on this problem by truly listening to each other and in the true feminist spirit of solidarity. We owe it to those who are yet to give birth to ensure that we all collectively approve of the direction that the birth experience is taking.

Intervention rates in childbirth are rising rapidly, and we should all be concerned about this. This is not just my personal viewpoint. Leading bodies such as the World Health Organisation have expressed concern that the medicalisation of childbirth, with its focus on how to monitor, measure and control birth, has left the question of how women actually feel about their births completely off the agenda, potentially robbing them of a life-enhancing experience.[1] The world’s most prestigious medical journal, The Lancet, has drawn attention to the ‘too much too soon’ approach to birth, most often found in high-income countries, in which treatments that were originally designed to manage complications are now overused, missing an opportunity for women to feel strong and capable.[2] You will notice that in this book I have given plenty of attention to the issues around ‘natural’ or ‘physiological’ birth, because I do feel that this is a key topic for feminist focus. In writing about natural birth, I have often had the sense that I am ‘championing the underdog’. Because we have to accept that, currently, natural birth – in which a woman has a baby without any pharmacological input such as induction, augmentation or drugs to expel the placenta – is very rare. Rarer still are what I call ‘hands-off’ births, in which women, rather than being ‘managed’, rely on their own instinct, follow their body’s lead, and are not guided into certain positions or told when and how to push. Women who have their baby in this way, feeling totally confident in the loving support (and, if necessary, medical help) that they know is in place in the background, but left to give birth entirely under their own steam, will most often talk of the experience in evangelical terms, as life-changing moments in which they felt sexual, sensual, strong, vital and powerful. You can’t help but wonder when you hear their stories how much the world might change if more women were getting this transformative power boost as they crossed the threshold to motherhood. Instead, it’s becoming much more ‘normal’ to have a birth in which you feel unsupported, disempowered and traumatised. I therefore feel it’s vital that we have a conversation about the value to women of this type of ‘straightforward’, ‘physiological’ or ‘natural’ type of birth experience, which is currently on the brink of extinction.

We also need to talk about those women who don’t want or cannot have straightforward vaginal births. There is literally not one single birth scenario in which increasing empathy for the woman, listening to her voice, respecting her decisions, and honouring that this is an extraordinary day in her life will not be valid. There is literally not one single type of birth that we cannot improve upon. The best way to find out more about this is again to listen to women. I learned so much about what women want in birth from talking to those who have experienced caesarean, and in particular, caesarean under general anaesthetic – often the most difficult birth experience to process and recover from. From them I learned that the smallest of gestures can make the biggest and most life-changing differences. Taking a few moments to photograph the newborn on their mother’s chest, for example, even if she is still unconscious, will create something she will treasure for a lifetime, a tangible antidote to her trauma. Women repeat again and again how much it means to them to know that their hands were among the first to touch their baby, even if they were not ‘there’ to experience it. Every small gesture matters, and we can always do better.

Two radical ideas underpin this book. Firstly, birth is a really important experience in a woman’s life and it’s time to stop telling women that it’s ‘just one day’ in which they ‘leave their dignity at the door’ because a ‘healthy baby is all that matters’. These are old-fashioned ideas, riddled with disrespect for women, for their autonomy, and for their feelings as sentient humans, that have no place in the twenty-first century. This book will try to unpick these ideas by looking at some of the history of birth, at various feminist perspectives, at the links between birth, female sexuality and power, and at the current culture of fear and disempowerment that continues to prop up these faded ideologies. Simultaneously, the book will try to replace these outdated perspectives with new considerations of women’s rights in childbirth, their bodily integrity, in particular through the lens of #metoo, and take a fresh look at what we might find, both literally and figuratively, in a birth room built with women’s needs in mind.

The second radical suggestion that this book will make is that pregnant women should be elevated to the role of key decision maker and most powerful person in the birth room. I can tell you from a decade of talking to women about their maternity care that, while there may be frequent reassurances that this is already the case, in reality it tends to make people uneasy. We see this most clearly when women try to go against the flow, birth outside of guidelines or refuse to consent to or accept the standard protocol or approach. These women, and often too, the midwives or doulas who support their choice ‘no matter what’, will often meet huge resistance, and risk sanctions or even punishment, as we will see in several stories in this book. We need a shift in consciousness, that moves to trusting women to make the right choices for themselves and for their baby. We need an acceptance that the image of a wayward, misinformed, irresponsible or even ‘mad’ woman, who does not have the best interests of her baby at heart, is a damaging and misogynist stereotype, used to justify the control of women, and rarely to be found in reality. In this book you will find several references to ‘freebirth’ – where women choose not to have any medical professionals attend them but simply give birth by themselves. I have to be honest with you and say that I personally would never choose to birth without medical back-up. However, I totally and utterly support another woman’s decision to make this choice. Do you? Because I believe that the key to birth freedom, for all of us, lies in supporting women in choices that we would not make ourselves, or even choices that we just feel are plain ‘wrong’. We need to trust women. Ironically, if we manage to move to this place, we may suddenly find that the numbers of women who wish to freebirth or birth outside the system, begins to decline. Increasing numbers of women, quite understandably, don’t want to birth in a system that doesn’t listen to them, respect them or trust them.

Whether you are reading this book as a pregnant woman, a health care provider, or just as a person who cares about women’s issues, I hope it switches on a light for you. First and foremost I hope that birth is suddenly illuminated as a feminist issue for you in a way that, perhaps, it never has been before. I hope it gets you thinking about the ways in which birth matters, about women’s power, agency and autonomy in birth and about what we could be doing differently or better. I hope you are excited or inspired by some of the things you read in these pages and, equally, I am sure that there will be parts that you fervently disagree with, that are hard to hear, or that even make you angry. That’s OK. As I keep telling my adorable inner critic, there will be many different reactions to this book, but ultimately all of them, ‘good’ and ‘bad’, will be much-needed voices, adding to the dialogue about birth as a feminist issue and moving it forwards. And this is essential if we wish to create a future in which women get the positive experiences of birth that they so desperately want, the medical help they truly need, and the power, respect and autonomy they so absolutely deserve. Let’s start the conversation.

Chapter 1
‘Am I Allowed?’: The Birth Room Power Imbalance

The most common way people give up their power is by thinking they don’t have any.

Alice Walker[1]

The year is 1975. A woman in a hospital nightgown, shaky on her feet, is wandering the corridor outside the labour ward, using the wall to support her. It’s 3 a.m. She is looking for something she has lost: her baby.

On the previous day several things happened to her that were ‘routine’. When I say ‘routine’, what I really mean is that nobody asked her permission. She was induced because she was past her due date. Her pubic hair was shaved off. She was given an enema. The opioid pethidine was injected into her thigh shortly before delivery. And her perfectly healthy baby was given to her and her husband to hold for a while, before being taken off to the hospital nursery for the night. She did not actively consent to any of this. It was just ‘how it was done’.

Ushered back to bed by the stern but kindly matron, my mother never questioned her experiences of birth until, several decades later, she began to hear a new narrative from the baby they had taken to the nursery – me. In the midst of my own pregnancy journeys, I started to ask questions. ‘How far past your due date were you?’ ‘Why did they shave women – was there any evidence to support this practice?’ ‘Did you ask for the pethidine?’, ‘Did they give me formula in the nursery?’

‘I don’t know. You didn’t really ask questions then.’

‘Why didn’t you just tell them you wanted to keep your baby with you?’

‘Well … they just didn’t let you do that I suppose. It just wasn’t allowed.’

‘They did not let me’, ‘I was not allowed’ … you would think these two phrases would be confined to the history books. And yet thirty-two years later, they were to become part of the fabric of my own first daughter’s birth story, when I was ‘not allowed’ a home birth but instead ‘had to’ be induced because I was past my expected due date, and then ‘had to’ have a forceps delivery, because current policy ‘did not let me’ spend longer than two hours in the pushing stage. There were countless other small incidents during my pregnancy, labour and birth in which what was about to happen to me was presented as ‘policy’ or ‘procedure’. The professionals I met were kind and caring, but I did not feel like I had been given a choice.

As a new mother, I contemplated all of this as I sat on my stitches and nursed my newborn in the long, isolated hours so typical of modern motherhood. I wondered – as an educated woman with a reputation for being ‘opinionated’, ‘persistent’, even ‘nasty’ (depending on the viewpoint of the observer) – how had this happened to me? I had laboured, as I had wanted to, free and naked, in a nest of blankets and cushions on the hospital floor. I had groaned and chanted, unfettered by drugs. I had gone to the abyss and fought my demons, as many labouring women need to do. And as I lay on that floor I had connected with my inner wild woman, with my maternal lineage, and with all the women who had been on this epic journey to meet their babies before me.

But somehow, I had been woken from this deep, almost hallucinatory trance, and moved from this place. A man had come and told me my time was up. I had been taken to the bed. I had been made to put on a shirt and cover my breasts. My feet had been placed in stirrups. I had said no to all this, but I had been told I ‘must’.

At the moment of birth, I called out, in almost sexual tones, ‘Oh, yes!’, as my daughter’s body finally slipped free. It’s true, it did feel like the most perfect, ecstatic release, but the way I vocalised it was quite conscious and deliberate. It was a clear message. I wanted the doctor to know that he had not taken this pleasure from me. I had been sanitised, covered up, conventionalised, conformed: this declaration of pleasure was my final act of rebellion.

The memory of this rather strangely timed two-finger salute to my obstetrician is evidence to me, as I look back on that day just over a decade later, that even in that moment, I already knew I’d been hoodwinked. Even though I had gone into the hospital with an academic understanding of many of the feminist issues that surround modern birth, and with the desire to avoid unnecessary intervention, I had somehow ended up with my feet in stirrups. It almost felt like I had become a living metaphor: the wild woman tamed, the naked woman clothed, the renegade woman cut, the mad woman put firmly back in the attic. No wonder I made that final rebel yell.

The Language of Permission

In the months and years that followed I began to listen to other women’s birth stories with a keen ear, waiting to hear for the tipping point where they had either triumphed or, as I had, slipped beneath the waves. In every story from across the Western world I heard the same words over and over: ‘They did not let me’, and ‘I was not allowed’. I heard it so much so that I gave this phenomenon its own special name, ‘The Language of Permission’.

‘I had to have a vaginal exam, as soon as I arrived at the hospital, to check if I was in labour.’

‘I wanted to have a water birth, but I was not allowed to use the birth centre[fn1] because of my BMI, so I had to be on labour ward.’

‘Because I was trying for a VBAC,[fn2] I was not allowed to eat or drink in labour, in case I ended up having another caesarean.’

‘My partner wanted to come with me for that part, but he was not allowed.’

‘They don’t let you have skin to skin with your baby after a caesarean in my hospital.’

‘They told me not to push yet even though I was desperate to.’

… and so it went on.

I began to wonder how these phrases were tripping so readily off our tongues as women of the twenty-first century. We would not accept being restricted in this way in our relationships or marriages, in our educational choices, or in our career paths. Why, when it came to giving birth – arguably a pretty significant moment in a woman’s life – were we using such passive language, casting ourselves as the ‘permission seekers’, rather than the ‘permission givers’?

The answer to why we have this imbalance of power, I’ve discovered, is complex, and emotional, but, if you put it in a big pot and simmer it for a long time, it boils down to a few interconnected essentials:

 Fear of birth is at an all-time high

 Confusion over the rights of the fetus can cause ‘risk’ to trump ‘autonomy’

 And finally, we live in a patriarchy.

Let’s start with the fear. In the twenty-first-century birth room, everyone – women, partners, midwives and doctors alike – is, either consciously or unconsciously, terrified of birth. This fear, which a hundred years ago may have taken the form of low-level anxiety or healthy respect, has transmogrified in recent decades into full-scale panic. Where birth was once a large stray dog that you generally expect to be friendly but approach with caution, it now seems to have evolved into a many-headed monster-hound, rumoured to be loose on the moor, with occasional sightings reported in hushed tones. Like death, birth has become something we’ve lost touch with, that no longer takes place in our communities and that we therefore rarely see or hear. Women go to the hospital and come back with a baby, and what happens in the intervening day or two remains a somewhat terrifying mystery. If we do see birth, it’s quite likely to be a representation on TV, which, as we’ll explore in Chapter 6, may be a long way from accurate.

In all areas of life, fear can make prisoners of us, and birth is no different. Our fear may shape our behaviour, our expectations, and, in turn, our actual reality. In fear, we may not prepare for birth, believing it to be ‘unpredictable’, or we may decline to ask questions, feeling that we are powerless. In modern maternity care, medical professionals and parents-to-be alike are often found erring on the side of caution, and this defensive behaviour can be at the expense of personal freedom. Which brings us to the overlapping concern of point two, the safety of the unborn child, another key player in the birth room power imbalance. Modern maternity care is rightly focused on birth outcomes, but a good outcome is most often measured not in terms of the woman, her feelings, her experience, and her postnatal mental health, but on the idea of the ‘healthy baby’ – indeed, women are frequently told that this is all that matters.

Of course, for most of us, the welfare of our baby is the most important aspect of the birth experience, but it’s interesting how this idea that it is all that matters has really started to trip off the tongue in the last few decades. It has become a mantra, and hidden beneath it is a rather dark, unspoken message: women do not matter. In a power dynamic in which you are given the message – however subtle – that your needs and feelings are of secondary importance, it can be difficult to challenge those who are perceived to be in authority, or even to voice your discomfort. New mothers who have had what feminist Naomi Wolf calls ‘ordinary bad births’ – or even suffered severe trauma – are told repeatedly to ‘focus on their healthy baby’, as this is ‘what really matters’, and while this may be well-meant reassurance, to many it carries the subtext, ‘Be quiet about your bad birth now please’, or, worse still, ‘Aren’t you grateful for your baby – don’t you love them?’

There is also an assumption that ‘safety’ and ‘health’ begin and end with simply having a pulse. However, as many women who have had what may look from the outside like fairly straightforward births will reiterate, feeling that you are safe can be very subjective, and being healthy is more complicated that simply looking OK on the surface. Feelings of trauma, sadness, shame, guilt, powerlessness, violation, and regret pervade the postnatal experience and reach far into the future mental and emotional well-being of women, and by default their relationships not just with themselves, but with their partners and children too. Statistics vary, but traumatic birth in the UK alone is estimated to affect nearly one in three women a year,[2] with many of those – between 4 per cent and 18 per cent – going on to develop PTSD.[3] Still others may not necessarily raise their hand to feeling full-blown trauma, but, if you ask them about their birth story, will tell you of a catalogue of missed opportunities to treat them with kindness, respect or tenderness, and sometimes atrocious treatment that they would never have felt they had the right to complain about.

During pregnancy itself, women are also reminded that the pinnacle of their birth expectations should be a healthy baby, most often at times when they show signs of having done their research and thus being keen to take an active role in the decision making. ‘Birth plans’ are a crucible for this phenomenon – a woman who goes so far as to outline on paper what she would like to happen to her in labour will be discouraged, at best, or even openly mocked, as we saw in November 2017 when a group of doctors caused outrage on Twitter when they joked that, ‘the length of the birth plan directly correlates to the length of the caesarean incision’, and that laminated birth plans were only useful if the woman had a massive haemorrhage.

Bloody difficult women

Indeed, ‘laminated’ birth plans (which, in reality, I am yet to come across) seem to stand as a metaphor for a really organised and strong-minded woman who misguidedly thinks she can have any power in the birth room. In his bestselling memoir, This is Going to Hurt,[4] former obstetrician Adam Kay recollects a woman with a ‘nine page birth plan, in full colour and laminated’, who has abandoned it – ‘hypnotherapy has given way to gas and air has given way to an epidural’ – and is now headed for surgery due to ‘failure to progress’. This, he says, does not surprise him: ‘Two centuries of obstetricians have found no way of predicting the course of a labour, but a certain denomination of floaty-dressed mother seems to think she can manage it easily’, is his summary.

Such attitudes pervade modern maternity care. I hear them embedded in women’s birth stories daily, but if you don’t believe me, you only need to look at the media reaction to celebrity births to find more of the same. My first ever paid gig as a journalist was to write about how the press were bullying Kate Middleton about her plans for a natural labour and hypnobirthing, and we’ve seen similar mockery of Meghan Markle in the run-up to the birth of her first baby. ‘A doula and a willow tree,’ a leading obstetrician apparently joked, ‘let’s see how that goes!’[5] The willow tree, like the floaty dress, is an attempt to poke fun at ‘earth mothers’ who want everything to be ‘natural’, and neatly portrays Meghan as demanding enough to want a particular kind of tree at her birth. It’s all intended as humour, but underneath the surface is the rather chilling idea that a kind of satisfaction or sense of triumph might be gained from seeing a woman’s ideal hopes for her birth go to the wall.

In Ireland, the Eighth Amendment – which gives the pregnant woman and the fetus equal rights in law–has recently been repealed, but the legacy of hundreds of years of blurred lines between Church and State mean that women’s rights in birth still have a long way to go. Here, midwives in Dublin reliably inform me, a woman with a birth plan and strong ideas about what she wants is commonly referred to as ‘a difficult woman’ by her care team. Indeed, in early 2018 an obstetrician from a Dublin maternity unit, Dr Aoife O’Malley, described women who make birth plans as ‘middle-class birthzillas’, adding that her audience of fellow birth workers would ‘know the women because we’ve all had them’ who ‘think they are the only woman who’s ever given birth and they certainly think they are the only woman giving birth in the labour ward that day’[6].

Selfish, opinionated, controlling and difficult: women can often be treated like wayward children when they try to create this grown-up document. Lawyer and board member of Human Rights in Childbirth, Bashi Hazard, has described the birth plan as ‘the closest expression of informed consent that a woman can offer her caregiver prior to commencing labour’. Hazard also reminds us that the medical institutions where we birth will always have a birth plan themselves; ‘one driven purely by care providers and hospital protocols without discussion with the woman’.[7] An intelligent consideration of birth plans reveals that they are a fantastic opportunity for women to consider their many birth options and open a meaningful dialogue with their care providers about their choices. Why would anyone find this problematic? one wonders.

There is even controversy about the label ‘birth plan’ itself, with some birth professionals arguing that they shouldn’t be called ‘plans’ at all, because this gives them too rigid a feel in a situation where it is important always to be flexible. ‘Women need to go with the flow in labour’, we are often told, as if we have the mindset of 5-year-olds. ‘Preferences’ is the most oft-suggested alternative, but it’s interesting to consider why the word ‘plan’ is the source of such anxiety, in a world where women can make plans in other areas of their lives and be considered perfectly capable of adaptability, contingency or, indeed, dealing with the emotional fallout of disappointment itself. Why must we present our needs and wishes in childbirth in the style of Oliver Twist, holding out our empty bowl tentatively and apologetically, when in fact we have the legal and moral entitlement to take the lead in every single one of our childbirth choices? Imagine if business people or our politicians spoke about their ‘shortand long-term preferences’ – we would quickly lose confidence in their strength and leadership. Indeed, the very hospitals we give birth in have ‘policies’ and ‘protocols’, and nobody is asking them to tone that language down.

Regardless of what a woman decides to call her birth plan, she can expect to receive subtle discouragement at every turn, because birth is ‘unpredictable’, and you ‘can’t really plan for it anyway’. She will be urged to ‘go with the flow’, rather than try to ‘control’ what happens to her in labour: but whose ‘flow’? As midwife and academic Dr Elizabeth Newnham puts it, ‘Going with the flow is fine, as long as it’s the physiological flow, not the institutional flow.’[8] Debby Gould and Melissa Bruijn, founders of the Australian birth trauma organisation BirthTalk agree: ‘Most women’s interpretation of “going with the flow” is “to put ourselves in the hands of our health carers, and accept the interventions they suggest as inevitable, unquestionable and in our best interests”. Every week we talk with women whose birth plan was to “go with the flow”. And now they are contacting us for support after a traumatic birth.’[9]

Encouragement to take a passive role in birth is everywhere, but if a woman does push ahead and make a birth plan she may find the cultural prediction that it’s ‘pointless’ coming true: in a 2016 survey from Positive Birth Movement and Channel Mum, nearly 75 per cent of respondents said that they made a birth plan, but only half of this group said that their birth plan was read by professionals, and 42 per cent said that their plan was not adhered to.[10] In some cases, plans simply have to change: you cannot have a home water birth if you develop placenta praevia, for example, but women understand these situations and when they complain about their birth plans being disregarded, this is not the kind of example they are giving. Rather, they talk about plans not being read due to a hospital shift change or because they are ‘too long’, or aspects of their plan which could have held in almost any situation, such as optimal clamping, minimal talking in their birth space, or keeping their placenta, not being observed, or being told at the last minute that what they are requesting is not possible, or even not allowed.

MAKING A BIRTH PLAN LIKE A FEMINIST

There is a point in making a birth plan

Don’t let anyone tell you otherwise. There are also ways that you can approach making that plan that will make it a valid and useful document. Firstly, know that you matter. What you want matters. You are important and your needs are important. This is your body, and your birth.

Knowledge is power

The process of making a plan will in itself educate you on your options and get you thinking about what YOU want – that’s a reason to make one right there.

Shoot for the moon but also consider the stars

Just as you plan to party on the beach but know where the nearest cafe is if it rains, you should also think about birth plans in this way. Make a Plan A that sums up your hopes for your ideal birth. Don’t be afraid to have a strong vision of what you want – with birth, as with all other areas of your life, a strong vision can help you reach your goal – but it’s not a guarantee. So, once you’ve got that vision, make contingency plans – a Plan B (and maybe a C or D). Think about what you might want if birth deviates in any way from Plan A. Consider as many eventualities as you can.

Ask for what you want even if it is not what others want

Only one person can have this baby, and that’s you. Because of this, you absolutely get to call the shots on how and where you want it to happen. This is about you, and what you need. If you think your mum being in the room will make you feel loved and safe, great. If you think it will make you feel self-conscious and anxious – she’s barred. If you want a certain type of birth – be that a home birth or a caesarean – but family members don’t agree, show them the evidence behind your choice, and stick to your guns. It’s your party.

A birth plan is not ‘all or nothing’

There are some parts of a plan that should only go out the window in exceptional circumstances. For example, if you want skin-to-skin contact immediately after your baby is born, or optimal clamping, this should be available in almost every circumstance. Make sure you are clear with your partner and your care providers that, even if your birth veers a long way off track, there are still some choices that you want to be honoured, no matter what.

Make a full plan for caesarean, whether you hope to have one or not

There are lots of choices that you can make if your birth takes place in the operating theatre. Learn about ‘woman-centred caesarean’ and think about what might be important to you in a surgical birth. Then make a full caesarean plan.

Make a postnatal plan

Think about what you want the first hour after birth to be like and lay out what is important to you in that time as part of your plan. You may also like to make a separate postnatal plan too, with a clear idea of how you are going to navigate the first few weeks with your baby, and a list of useful numbers for help and support with feeding.

Get it read, get it signed!

Make sure that everyone involved in your birth reads your birth plan in advance of your labour. Your partner, doula, and any other birth supporters need to have a clear idea of what you want on the day. Discuss your plan in advance with health care providers especially if you have specific needs or requests that deviate from the norm. Ask them to record details of conversations and decisions you have made in your notes and to sign your birth plan. These discussions will help your care providers to demonstrate that they have fulfilled their obligation to have a balanced and individual discussion with you about your personal circumstances and risk factors, and you can demonstrate that you have understood the information given to you and that your wishes have been documented. Your birth plan will not have legal status, but it is still evidence that your views and preferences have been discussed and noted.

In the worst of cases, birth plans – and the questions to care providers that usually accompany them – can be interpreted as a sign of lack of care or ill will towards the unborn child, of being a ‘bad mother’, because of course, as a woman is repeatedly told, what happens in the birth is unimportant, as long as there is a healthy baby at the end of it. ‘I wanted to know more about why they wanted to induce me, but in the end the doctor just said, “You’ve waited a long time for this baby, haven’t you?” ’, Laura from the UK told me. ‘He was questioning my desire to be a mother, he was questioning how much I cared about my baby, and even how much I wanted them to live. It was a horrible moment but at that point I decided to comply with the hospital’s wishes.’

Some birth workers refer to this practice as ‘playing the dead baby card’,[11] and it is certainly a dimension of the current fear-based climate that can be very effective in silencing a woman who is trying to argue her right to make her own choices about her body. Michelle Quashie, a mum of four from London, recalls her obstetrician similarly ‘shroud waving’ when she was determined to have her third baby via VBAC: ‘He asked me, in quite a dramatic tone, “What is more important to you, a natural birth, or being a mother to your other children?” and as he did so he looked very pointedly at my husband as if to say, “take charge of her”.’ Michelle’s story is reminiscent of the remarks of Irish obstetrician Dr Donal O’Sullivan who caused controversy when he said during a radio interview in 1996 that, if a woman wanted a home birth, her husband ought to put a harness on her and drive her to hospital like cattle.[12]

A part of me, even then, could not tolerate passivity, but I identified that part with the ‘unwomanly’ and in becoming a mother I was trying to affirm myself as a ‘womanly woman’. If passivity was required, I would conform myself to the expectation.

Adrienne Rich, Of Woman Born[13]

Telling women not to try to plan birth but instead to focus on the end result carries the underlying message that a woman in labour must ultimately sacrifice herself – her hopes, needs, desires, dignity or even her life – in order to save her baby. This is interesting, because, although you might assume most women would happily give their lives for their unborn if they had to, this is not always the case. If you ask pregnant women – and their partners – this rather unpleasant question, ‘You can only save one, who do you save?’ they will almost overwhelmingly tell you, ‘the woman’. And yet, for historical, moral and religious reasons that we will explore later in this book, maternity care can often be clouded by the notion that the safety of the baby always takes precedence.

Safety first?

In some notable cases, we can gain a window (albeit one we would rather not have) into what happens when total priority is given to the life of the baby over the wishes of the mother. In April 2014 I was privileged to speak[14] – via an interpreter – to Adelir Carmen Lemos de Góes, a 29-year-old Brazilian woman who, when expecting her third baby after two caesareans, had researched VBAC and become interested in giving birth naturally, with the help of a doula. In early labour, she attended the hospital for a check-up only to be told that her baby was in the breech (bottom down rather than head down) position. Doctors demanded she stay and have her baby by caesarean, but she signed papers to discharge herself, and left, saying she would return when her contractions were five minutes apart.

Later that night, her labour intensifying, she was picking out a dress to wear to the hospital when she saw headlights outside the windows of her house. After overhearing incredulous expressions from her husband and doula, she told me, she decided to go outside herself. ‘There I was confronted by a justice officer, who stood up in front of me and said that I had to be transported to the hospital mandated by a court order that he had in his hands.’

Doctors had that afternoon obtained a court order for a compulsory caesarean.

‘The whole discussion was so surreal, everything was so unbelievable and we were just trying to understand. There were about nine policemen and they were all trying to make my husband get back … and just take me away.’ Adelir, by now experiencing strong contractions, agreed to go with them: ‘I couldn’t refuse – it was either do what the court order said or be handcuffed. And I was so scared – frightened with my whole body … having chills in my whole body.’

Adelir was driven to the nearest hospital and, although she was 9 cm dilated and nearly ready to push, her baby was born by caesarean as the court order dictated. Her husband was not allowed to be with her and she did not see him until six hours later. ‘Everything had happened so suddenly and I felt pretty much robbed and kidnapped,’ she told me.

Adelir’s story is extreme, made more shocking, perhaps, by the fact that there was no question over her ‘capacity’ – she was felt to be of sound mind, but simply judged to be ‘wrong’ in her decision to try to birth naturally. Interestingly, when I discussed Adelir’s story at the time with others, two questions repeatedly arose: ‘What were the risks of the VBAC then?’ and, ‘How about this breech thing, didn’t that make it more dangerous?’ Questions like this miss the point: by trying to judge the rightness or wrongness of her decision, we fall into the same trap as the Brazilian authorities – declaring that a grey zone exists in which a pregnant woman can be compelled to make the decision that others judge is best for her, regardless of what she would choose for herself. As human rights barrister and founder of UK charity Birthrights Elizabeth Prochaska put it to me at the time of Adelir’s story:

‘Risk might sound appealingly scientific and rational, but it is not. When it is used to compel women to receive medical interventions, it is an expression of violent patriarchy, pure and simple. Would a Brazilian court order a man to undergo an invasive kidney transplant to save his dying child? No. Only women’s bodies are treated as public objects subject to the whims of the medical profession backed by the coercive power of the state.’

Some may feel that a pregnant woman should not have the right to make a decision that puts her baby ‘at risk’, but, unfortunately, as unpleasant as it may sound, the unborn child can never and should never be considered to have any rights – and as soon as we put so much as a toe in this water, we begin to stray into a place in which a woman can be taken from her house by the police and compelled to undergo major surgery against her wishes. There is a creeping nature to such a mindset – once we begin to make provision for the occasions when doctors or the state may overrule a pregnant woman with full mental capacity, we are on a very slippery slope indeed. Instead, the point needs to be made clear, often over and over again, that we have to trust women to be the ultimate decision maker in birth, no matter what. This is enshrined in law, and in global principles of human rights, that I will outline in more detail in Chapter 7.

For now, let me simply share the words of the UK Court of Appeal in a case known as MB, in 1997, which could not put it more clearly:

‘A competent woman, who has the capacity to decide, may, for religious reasons, other reasons, for rational or irrational reasons or for no reason at all, choose not to have medical intervention, even though the consequence may be the death or serious handicap of the child she bears, or her own death.’[15]

That sounds pretty definitive – and yet more than twenty years on, women are still asking ‘Am I allowed?’ in their birth space. The reason this power imbalance continues to pervade, and indeed the roots of everything this chapter has already laid out, can be found in the fact that we live in a patriarchy.[fn3] With the hashtag #metoo snowballing on social media in late 2017, a sudden uprising of women has collectively been saying, ‘Keep your hands off us from now on, unless WE say so.’ A vital and public conversation has been started about women’s bodily autonomy, consent, and the power imbalance and patriarchal structures that, for too long, have been enabling men to behave in ways that make women feel everything on the spectrum between mildly uncomfortable and downright violated. We now need to turn the #metoo spotlight on the experience of childbirth.

#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

Language Used | Why it’s wrong | Alternatives
Delivered | Pizzas are delivered, babies are born. And if they are delivered, it’s the woman who delivers them, nobody else! | Gave birth Caught e.g. ‘Dad caught the baby’
Am I allowed? They did not let me | Women have the moral and legal right to make decisions about their birth. They cannot be compelled to make certain choices, nor should they have options denied to them. If anyone does any ‘allowing’, it’s the woman. | I am allowed
Failure to progress | Nobody ‘fails’ at birth | Slow labour
Only three centimetres | Using negative language to describe the progress of labour can make some women feel discouraged, at a time when they need to be positive. | Three centimetres already, that’s great!
My induction in room 3 | Reducing women to the intervention they are experiencing or the type of birth, etc. dehumanises them. Saying ‘my’ implies possession. | Say her name
Trial of scar | Used to describe a VBAC. Will there be a judge in a wig? | VBAC or just ‘birth’
Good girl | It’s infantilising. Is this Saint Trinians? | Fantastic, that’s really helpful, thanks
I consented her | Consent is actively given by the woman, not obtained while she remains passive. | She gave her consent
I just need to get your consent | Decisions should be made by the woman after full information is given and she should be made aware that she can decline or consent. | These are your choices … the benefits and risks are … would you like more information before you decide what you wish to do?
I’m just going to … | This assumes consent has been given | I would recommend that we do x,y,z. The alternatives are … etc.
She says Mum says | The woman is an individual with a name. | Use her name

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]

It’s very important to be clear that the vast majority of medical staff do not knowingly perpetrate obstetric violence. This is because, as academics and experts in obstetric violence Sara Cohen Shabot[32] and Keshet Korem point out, obstetric violence is ‘structural’ not ‘behavioural’: ‘the staff merely perpetuate the violence of the existing structure’.[33] In other words, this way of behaving towards labouring women is not only institutionalised but also held up and perpetuated by our culture, and, like other gender-based violence and abuse, accepted as normal and allowed to go unchallenged. Health care workers will almost certainly not be aware of how their behaviours towards women are experienced, unless we find our voices and tell them. We also need to challenge the ‘small’ attitudes and actions that underpin obstetric violence. ‘Locker room banter’ is not rape, but it does normalise misogyny and, by extension, violence against women. Likewise jokes that mock or degrade labouring women help to prop up a system in which disrespect and abuse take place, and we should therefore continue to challenge them just as we challenge all other ‘everyday sexism’. Every single denial of a woman’s autonomy and power in the birth room, great or small, is part of the same problem. Call it out.

Interestingly, and also in common with other forms of violence against women, it is often the woman who is left carrying the blame and shame in the aftermath. Just as the woman who has been attacked may feel that the clothes she wore or the route she took home at the end of the night may have contributed to her violation, women traumatised by birth will spend the days, weeks or even years afterwards going over the events in fine detail and asking, ‘What could I have done differently?’ And, just as men are rarely asked to reflect on what they could do to reduce violence against women there is similarly considerably less postnatal analysis – and often none at all – done by the individuals, institutions and systems that inflict birth trauma. Women are left with the shameful reflection that they ‘should not have got their hopes up’, ‘should not have made a birth plan’, or ‘should have just gone with the flow’ and these messages are consistently reinforced in popular culture. Those who try to take control of their births, and antenatal courses and teachers who encourage them to believe they can do so, are consistently derided and mocked. ‘Yes,’ the woman thinks to herself, ‘I was totally unrealistic to think I could have a positive experience of birth, and that is why I now feel so awful. It is my fault I feel this way.’ This is victim-blaming, pure and simple.

‘Can I hold her now?’ Who owns the baby?

In 2018 research into skin-to-skin contact after caesarean, academics observed the mother’s body was perceived to be divided after the birth, with obstetricians ‘owning’ the bottom half, anaesthetists ‘owning’ the top half, and midwives ‘owning’ the baby.[34] Mothers may wish to hold their newborns desperately, but in both caesarean and vaginal births, the first hands to touch the baby are often not the woman who birthed them, and she may have to wait to hold them. Often, in a vaginal birth, the moments directly before the birth will have been strictly controlled by the professionals, too, with the woman being told when and how to push, or even instructed not to push at all until given permission. And the imbalanced power dynamic does not end with the arrival of the baby. One question I have been asked many times by pregnant women is ‘What do I do if I want to keep my placenta? Am I allowed?’ It’s fascinating to me that women are uncertain about this, when clearly the placenta belongs to them and came from their own body, just like the baby. This permission-seeking speaks volumes about the dynamics of power in birth and about the background against which we see the violation of women and their bodies being normalised on a daily basis. Just as the baby was once whisked off to the hospital nursery without so much as a by your leave, the placenta (in many cultures considered a meaningful or even sacred organ) is often disposed of without question or consent. Most women aren’t bothered by this but that isn’t really the point – the point is that, among those who are bothered, there is an uncertainty about ownership, and, on occasion, a violation of their rights to keep the placenta or at least be consulted about their wishes.

Similarly, the cutting of the umbilical cord has become almost symbolic of power and ownership in the birth room. Midwife Amanda Burleigh has campaigned for fifteen years for ‘optimal cord clamping’, sometimes called ‘delayed cord clamping’.

‘We know that there is plenty of evidence to support the health benefits of delayed clamping and it has been a NICE guideline since 2014,’ she told me. ‘However, in spite of myself and a number of others campaigning for clinicians to wait just a few minutes, some are still cutting the cord immediately which is not recommended and research shows can cause harm.’

Indeed, in a survey by the Positive Birth Movement[35] of parents whose babies were born in the UK between 2015 and 2017, nearly a third stated that their baby’s cord was cut less than a minute after the birth, with one in five stating the cord was cut immediately. Arguably, cutting the cord too early with no clinical reason could be described as an act of obstetric violence, and yet it clearly continues to happen in UK birth rooms and globally – why? Some say it’s just because change takes a while and ‘that’s the way it’s always been done’, others suggest that in a time-pressed world, it can be difficult to pause. I wonder. Could it be there is something about the moment of birth that is so powerful, that somehow there is an unconscious need to lay claim to the cutting of the cord and holding of the baby (perhaps the ultimate ‘prize’)? It is certainly very interesting to look at the behaviour of birth attendants in the first hour of life, and notice just how much disturbance can take place to the mother–baby bond and interaction.

It seems as if the moment the baby arrives the focus on the mother is lost. It becomes about the staff’s interactions with the baby. The doctor who insisted on delivering my baby cut the cord, announced the gender and held her aloft like a hunting trophy. She illustrated her take on who was relevant in the room and who wasn’t. My husband and I did not feature, let alone the baby.

Hannah Carter, UK

A poignant ventouse delivery – it’s a mum I saw in infertility clinic at the very start of this job. I feel like holding the baby aloft like Simba and blasting out my best ‘Circle of Life’.

Adam Kay, This is Going to Hurt[36]

I have called the first hour after the birth the ‘Hour of Power’. I call it this for two reasons: partly because it’s a time when, ideally, a woman should be feeling pretty triumphant, and partly because it’s a ‘supercharged’ time in which a new human begins their first experiences of the world, and a woman and family meet that human for the first time. It’s magical, and, just like birth, we should be thinking about what we can put in place to make this time special and memorable for everyone involved, and what our plan B is if this doesn’t work out.[fn4] Ideally, the time should be calm and undisturbed – as pioneering obstetrician Michel Odent puts it, ‘don’t wake the mother’.[37] During this time a complex set of hormonal and biological processes take place that affect bonding, lactation, the colonisation of the baby’s skin and gut flora, and the baby’s adaptation to the world of breathing, gravity and thermo-regulation, to name just a few. Of primary importance is the hormonal dance during which the mother falls in love with her newborn; if left to their own devices, this will take place with mother and baby in skin-to-skin contact, quietly meeting one another’s gaze. It’s very unusual to see this unique time unfold naturally without interruption, however, and not just in Western culture, but globally – where everything from a belief that colostrum is bewitched to bathing, eye drops, suctioning the nose, swaddling or ear-piercing disrupt the golden time between parent and child.

The Hour of Power is not always experienced as empowering. In the time immediately following the birth, women most often readily accept that professionals have important checks to do that must take precedence over what is often an overwhelming and even physically felt need to hold their babies. The question ‘Can I hold her now?’ can be heard in birth rooms globally, as the mother seeks permission to have her newborn returned to her. Odent has an interesting theory about why, with our early clamping, washing, wiping, weighing, and bewitched colostrum, nobody can seem to leave mothers and babies in peace. The disruption of bonding has an evolutionary advantage, he argues, creating tougher humans and better warriors: ‘The greater the social need for aggression and an ability to destroy life, the more intrusive the rituals and beliefs are in the period surrounding birth.’[38] Whether or not Odent is right, it’s certainly true that Westerners value ‘independence’ in their children, and that the link between parenting and personality is well established. In disrupting the Hour of Power, our cultural values – that efficiency and tick boxes matter more than relationships and connection – are certainly being upheld. Furthermore, if Odent is right, we’re upholding the patriarchy, too, laying the foundations for a new generation of aggressors and destroyers, who will in their turn cut, clamp, separate and generally disrupt the oxytocic peace. Whichever way you look at it, Odent sums it up well when he says, ‘reconsidering our attitudes during this short period of time shakes the very foundations of our cultures’.

Love from a distance: life in the NICU

The early attachment of woman and baby is also low on the list of priorities when a baby is born prematurely. Common practice is for the baby to be taken to a special unit and placed in an incubator, with only a few pioneering neonatal units in the world doing things differently. In Uppsala, Sweden, Dr Uwe Ewald and colleagues encourage ‘kangaroo care’,[39] whereby the separation of the baby from their parent is kept to a minimum. His state-of-the-art unit places babies in skin-to-skin contact on the chests of their carers, out of the incubator and in bed or often in slings, with mobile monitors in the parent’s pocket. However, in Dr Ewald’s experience, parents will often detect issues several seconds ahead of the monitor. Ewald’s work is inspired by a focus on the rights of the child not to be separated from their parents, an understanding of early infant attachment – ‘Bonding is a bit more than just holding a finger,’ he points out – and an empathy for the experience of both the baby and the parents and the anguish of separation they may be feeling.

Dr Ewald’s way of thinking is highly unusual, however, and the majority of parents whose babies are in the NICU will be apart from them and will often feel the need to ask, ‘Am I allowed?’ ‘At the start we didn’t realise that we were actually able to touch her,’ said one mother. ‘Nobody told us we were allowed and we thought it was just the nurses who could. We didn’t hold her either because we didn’t realise we could.’ ‘I did not feel like she belonged to me,’ said another NICU mother, while another commented, ‘I felt like I was cluttering the place up because I hung out there so much.’[40]

Donna Booth, who founded the New Zealand organisation NUMB (Neonatal Unity for Mothers and Babies) after her own experience, told me of how the imbalanced power dynamic of the NICU made her feel assaulted. ‘My baby was born by caesarean and I had a general anaesthetic that I did not want. This was the first assault. The second assault happened when I was in recovery and NICU staff kept sending messages insisting on having my child’s name given to them to write in the notes and on the incubator – but I wanted to be the one to name this child when I recovered. The third assault was when I finally got to the NICU in a wheelchair and the nurse (probably thinking she was being welcoming and helpful) introduced me to my baby, taking the hat off the baby and telling me the hair colour and remarking on the fingers and toes. I wanted with all of my heart and soul to be the one to discover these things myself, to reclaim this time, to marvel in the gorgeousness of my perfect child; but she stole that from me. There were further assaults. Mothers like me who want to be with their babies are a challenge for the NICU. “Parents can visit any time” does not mean you can stay for twenty-four hours a day without some sort of resistance, punishment or even being positioned as somehow not right in the head.’

‘Re-centering me as the decision maker’: love and loss

Attitudes and practices like these of Donna’s NICU staff are usually well meant, but often so deeply ingrained that they are beyond everyday awareness and rarely analysed or reconsidered. They are another part of our ‘allowed/not allowed’ birth culture. We know that, most often, health professionals have their patient’s best interests, and in particular safety, uppermost in their minds. To a clinician, everybody getting out of birth alive is the greatest priority. They have been trained to view every aspect of the experience through the framework of safety and risk, and this can sometimes be the justification for the over-medicalisation of birth or even for treatment lacking in empathy or compassion: ‘There simply wasn’t time.’ It’s interesting, therefore, to look at what happens to women when these safety concerns are completely removed, in that terrible scenario of baby loss.

‘Attitudes to stillbirth have improved a lot in recent times,’ Mel Scott, from the charity Finley’s Footprints, tells me. ‘Up until the past decade or so, babies who had died tended to be whisked off immediately or after just a few minutes. I still get messages from mums who lost their baby twenty years ago, who didn’t see them, hold them, name them, and don’t know where they are buried. And they have never forgotten, never got over it, and always regret not having that time. Although there have been some great improvements, it’s still the case that most parents don’t realise they have choices they can make about how they welcome their baby, or how they spend their time together, or where their baby goes.’

Natalie Lennard, whose son Evan was stillborn in 2013, had to fight for permission to give birth to him at home, even though he had a condition – Potter’s Syndrome – that meant there was absolutely nothing a hospital could have done to save him.[41] Hospital protocol was to end the pregnancy via an in-utero injection and induce the birth under epidural – choosing not to do this was a highly unusual and counter-cultural choice. With the support of Virginia Howes, an independent midwife, Natalie finally got permission to birth at home, at term, a triumphant and positive experience for her in spite of her loss: ‘His nose, ankles and wrists were squashed from having no fluid around him in the womb but otherwise he was my simply perfect baby. How could I have ever wanted him whisked away, cleaned and wrapped? No way, holding his bloody birthy beautiful body in my arms was the best part of all!’ Natalie is passionate that it was the support she received from her midwife that made truly informed choice possible; she was ‘the only character who stood alone from any party, and kept re-centring me as the decision-maker’.

Natalie goes on to say, ‘I joined a group on Facebook for Potter’s Syndrome and every few months a new woman joins from somewhere in the world, whose baby will have been diagnosed with exactly what Evan had, and sometimes she terminates within a couple of days because in their words, the “doctor thought it best”. Those women were never even given a choice, they probably didn’t think they had one. It would have been hard enough for me even with my own determination, but these women have no one to play the role of angelic devil’s advocate … Virginia’s attitude is nothing short of revolutionary, the future of all health care.’

Currently, a revolutionary attitude, and, if possible, a ‘Virginia’ for back-up, is required all round if you want to birth your baby, from your body, where you want, and how you want. Elective caesarean? This might require persistence: a report from the charity Birthrights in August 2018[42] highlighted that, in spite of UK NICE guidelines supporting a woman’s right to choose and be supported in this option, 15 per cent of trusts have an explicitly stated policy not to offer it, while a further 47 per cent were unclear as to whether a woman requesting a surgical birth would actually get one. The reasons for elective or maternal request caesarean are complex,[43] but in many cases requesting surgery is an attempt to take control over bodily autonomy, often after a previous birth experience where this was felt to be completely lost: ‘I chose an elective for both physical and psychological reasons,’ the journalist Natasha Pearlman writes. ‘The thought of surgery terrified me, to be honest, but not as much as giving birth naturally again.’[44] Autonomy is also a factor for women who have a history of sexual abuse: ‘I chose caesarean because it felt like, in terms of my history, it would be safer, more predictable. I didn’t want anything to happen, in particular involving physical touch, where I might feel out of control as I felt this would be very triggering,’ Lindsay, who had elective surgery in Australia for both her babies, told me. Maternal request caesarean forces us to ask questions about why some women would rather have major surgery than experience modern childbirth, and until at least some of those questions are addressed and resolved, there should be no barriers for the small percentage of women who request a birth in theatre.

Opting out: freebirth

Freebirth, the choice to labour and give birth without a midwife or any other health professional present, may seem as far away from elective caesarean as it’s possible to get, but, in fact, as is so often the case with opposite ends of the spectrum, they have much in common. Blogger and doula Jenny Wren has described freebirth as a ‘feminist statement … because it is the radical notion that the woman takes priority over the baby’.[45] Several studies have been carried out into women’s motivation to freebirth,[46] finding that negative experiences of maternity care are a driving factor in many cases, with one study published in the journal BMC Pregnancy and Childbirth concluding:

The UK based midwifery philosophy of woman-centred care that tailors care to individual needs is not always carried out, leaving women to feel disillusioned, unsafe and opting out of any form of professionalised care for their births. Maternity services need to provide support for women who have experienced a previous traumatic birth. Midwives also need to help restore relationships with women, and co-create birth plans that enable women to be active agents in their birthing decisions even if they challenge normative practices. The fact that women choose to freebirth in order to create a calm, quiet birthing space that is free from clinical interruptions and that enhances the physiology of labour, should be a key consideration.[47]

Women’s actual stories of freebirth support these findings. I share two here in their entirety because I think they speak volumes not just about the choice to freebirth – which only a tiny minority of women make – but about the imbalance of power and overall lack of true listening that this chapter is essentially about, and that a much wider group of women are coming across in their maternity experience.

The first is from Megan, who gave birth in the south of England. Both her births took place between 2009 and 2019.

I have had two lovely home births. During my first birth I got the impression the NHS midwives that attended didn’t want to be there. It was a busy night on the ward, I was asked to come into the hospital for a VE (vaginal exam), but I declined, I didn’t want any VEs due to testing positive for Group B strep, and knowing they would increase the risk of infection and possibly rupture my waters prematurely which is another risk factor. I also have a fear of hospitals ever since witnessing the substandard care my sister experienced during her first birth. My informed choice was not respected and when the midwives did arrive at my home I was coerced into having an unwanted VE because they threatened that they couldn’t stay unless they knew I was in established labour. My contractions were 3 minutes apart lasting 2 minutes by this point. It was quite clear to anyone watching that I was in established labour. I was 7 cm upon checking.

I was later told, during pushing, I had to get out of the pool for an episiotomy because baby was in distress and not moving down (he was having heart rate decelerations). They had me semi-reclined in the pool and were coaching me to do horrible chin-on-chest pushing. I asked to try one more thing first, I listened to my body, got myself into an upright squat and pushed my baby’s head out on the next contraction with ease and no tearing. The next contraction brought the rest of his body out and he was perfect, alert, and peacefully looking up at us both.

I was then pestered for the next 30 minutes to keep checking his cord to see if they could cut it yet (I wanted to ‘wait for white’), and then once it was cut, it was more pestering about having the injection to bring the placenta out. Again I declined 2–3 times. I ended up having it tugged out of me by the cord. I had no idea how dangerous that was! There were great parts of my birth too, I wouldn’t call the birth traumatic. But I didn’t feel cared for by the midwives. I felt rushed and coerced into completing their tick list so that they could move on and get back to the hospital.

So during pregnancy two, as I reflected back on this birth I realised that the midwives being there didn’t make me feel safe at all. And safety is important in birth. I wanted an independent midwife who I trusted and had got to know as I did my doula, but I couldn’t afford one. So I wrote a detailed birth plan for the NHS midwives; no VEs, no temps, no BP, no questions, no talking, intermittent monitoring of baby’s heart rate only. Basically I wanted the midwife to sit back and watch me birth my baby, as a safety net in case anything did go wrong.

However, I got a phone call from the supervisor of midwives, who was gravely concerned at my request for a hands-off birth. She actually asked me if I would ‘allow’ the midwives to use oxygen on my baby if they were born not breathing! I could not believe this! How did a request for a hands-off birth get put into the same category as a mother who doesn’t want any medical assistance to her baby should there be complications? After that phone call I was so angry. I lost all trust in the NHS midwives. I decided that I wouldn’t be inviting anyone into my birth space until I knew the birth was imminent. As it turned out I had a virtually pain-free birth and no transition signs, I went from mild regular contractions to pushing contractions and my baby being born within 15 minutes with just me, my boyfriend, our three-year-old son and my doula present. She was perfect and healthy thankfully but I am still angry that I was put in that position because of such a rigid checklist system that we call midwifery care.

The second birth story is from Kay Parsons, in Massachusetts, USA, whose babies were born between 2004 and 2014.

I was 19 the first time I gave birth and felt like being young and unmarried really affected how I was treated. From the moment I arrived at the hospital I felt like my autonomy was stripped from me.

I so clearly remember the moment they told me that they thought he may be malpositioned or have his cord wrapped around his neck. I had taken some prenatal yoga classes and wanted to try different positions to give him space to turn or adjust but they ‘wouldn’t allow’ me to. They forced me onto my back so they could monitor his heart rate.

There were so many people rushing in and out of the room. Every time I’d have a contraction, 10 people would run into the room and stare at my belly or at the monitors as though doing so would somehow change the outcome of his heart rate deceleration. Of course it did nothing to help him and made me feel like an animal on display in the zoo!

At one point I had five different people all holding sharp objects wanting to poke or prod me in some way. I couldn’t catch my breath, started to cry, and asked for a moment to just centre myself and breathe and a nurse said to me, ‘Oh honey, you can’t cry now, you have so much more to come!’

In the end he was born by caesarean. The whole experience was so traumatic and brought to the surface past experiences of sexual trauma and the feeling of having no voice, no power, and no right to decide what is best for me or my baby.

When I got pregnant a couple of years later I knew that I would never feel safe having a baby in the hospital again. We hired midwives and had a lovely, but trying and long home birth. Five years later I had another midwife-assisted home birth.

I found that the midwives were all great. I really believe in midwife-assisted home births and have trained to become a midwife myself. But I’ve always struggled with feeling like even midwife-assisted births contain an element of fear and trying to control the outcome.

I’ve found that many home birth midwives are great at supporting women to labour autonomously, follow their intuition, and trust the birthing process. But even the best of midwives change when a woman starts pushing. They rush around and get a bit frantic and have their hands all up in her business. It’s like they are ingrained to need to ‘do something’ perhaps out of fear, perhaps out of excitement, perhaps out of liability. But the energy of the room changes. Things get busy, and rushed. There’s the clanking of instruments and busyness of preparing for the big moment. And I’ve found that their fear becomes palpable to me. Even in my trance of ‘labourland’ I feel pulled out into the mundane of their sense of responsibility for the outcome.

I read an article once about the holistic stages of childbirth that talks about the moment of pause before a baby fully arrives earthside. This quiet moment where the world stands still and they emerge into the world and I longed for that experience.

I didn’t want anyone to rush the moment of emergence. I wanted to birth without the fear that comes with the anticipation of baby’s final arrival. I wanted to savour that moment, in between the worlds, where my baby is not yet fully outside me and yet not completely within me either. So I planned a freebirth with my last baby. Just my husband, me, and two of my dearest friends.

And when she arrived, I had my moment. The whole world stood still. It was just me, her, my husband, and our hands as she made her way earthside. It was the most empowering moment of my life!

But perhaps I placed too many prayers on holding the slowness of that moment. She was a little slow to start breathing normally. It was like she sat in that pause with me for too long and when she started breathing, it was shallow and fast, like she couldn’t quite catch her breath and arrive. We were nervous so we called the paramedics ‘just in case’.

They arrived, and the two male paramedics were obnoxious and a bit freaked out, but this one woman paramedic was amazing. Before ever touching my baby, she knelt down beside me, looked me in the eye, and congratulated me before ever saying another word. She never judged me for birthing at home or birthing alone. She expressed nothing but support for my autonomy and my choices. She held the sacred with me, even if she didn’t know it.

She encouraged me to bring her in and have her evaluated but at that point she was already breathing normally. When she found out she was my fourth baby she laughed and said, ‘Never mind, mama. You got this!’

It was a moment of such deep healing. Of course all of the nightmare scenarios were running through my head, the fear of being judged, disempowered, having my magical moment taken from me again. And instead I was met with utter respect and trust in my knowing of my baby and my body. Somehow it healed, all the way back to that first experience of birth, and all the way forward to every moment of support I will offer another woman. Even in the midst of ‘complications’ this paramedic reminded me that we have the choice, to join mama in the sweetness and the stillness and treat her with respect, autonomy and trust.

Every generation likes to think that they are free, and often, only the clarity of hindsight can reveal just how restricted they actually were. My mother, for example, like many women in the seventies, thought that it was the pinnacle of freedom to have her labour induced, to know what day of the week on which I would be born and make practical arrangements, and to have a kindly midwife look after her newborn while she rested. Looking back on it now, over four decades later, she can more easily see the restrictions placed on her personal freedom that were epitomised when, lost and drug-hazy, she wandered the hospital corridors looking for the baby she knew she had just birthed, but could not find anywhere.

It would be foolish to assume that ‘that was then, this is now’ and that there is nothing happening to women in twenty-first-century maternity care that will not, when we look back on it in another forty years, seem laughable or even barbaric. In fact, you don’t necessarily need twenty–twenty hindsight – you only have to talk to women who are experiencing the current birth system to hear a myriad of restrictions, small and large, that are placed on their freedom, and a range of abuses, small and large, that are happening to them and hiding in plain sight in every maternity ward. When I listen to these stories, the same thought keeps coming back to me – birth needs a feminist revolution! But where is it? Where is feminism?

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