Give Birth Like a Feminist

‘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.