Give Birth Like a Feminist
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.