Liberating childbirth: a lecture

This is a new posting of a lecture that I originally gave in 2005. It was published (in a slightly different form) in the AIMS Journal 2005, Vol 17, No. 3. It felt timely to repost.

 It was my first baby.  I had booked a homebirth but had been transferred in for lack of progress and possible mec after 18 hours.  In hospital I had been put on a drip and suffered agonies without any pain relief.  All of a sudden, at the darkest hour I felt it. . . was like a pop inside, my contractions felt different and I felt that maybe this baby was going to be born!  The midwife was summoned (yes it was shared care)  “I think I want to push” I told her.  I was examined>”You are 10 cms but let a doctor check you”.   I was surprised but asked “where is the doctor?, when will he be here?”  “In about 15 minutes came the reply.  I said to the midwife “I have waited 24 hours to have this baby.  I am not waiting any longer.  You are a midwife!  Do your job! “  However I did not say it quite as politely as that.

This little cameo encapsulates much of what I want to say today about what needs to change in the birthing care women receive today.

In this country we do not have woman centred care we have consultant centred care.  Woman centred care is where the care revolves around the woman, her wants needs and foibles.  Care is based on mutual respect and open access to information, the woman speaks directly to the professionals who control her care, and these professionals will refer the woman to specialists if and when this maybe needed.

With consultant centred care a doctor who you may never see or meet dictates the choices you can make for birth. The consultant is at the top the hierarchy, the centre of the wheel.  The service we receive revolves around their interests, wants, needs and foibles.  The needs and wants of the birthing woman are subjugated to him/her.   For example Bradford does not have a birthing pool, not because women don’t want it – they were never asked – but because the consultant does not want it.

Consultants are specialists in abnormal birth, skilled in dealing with the medical problems that may occur in pregnancy and birth and they save lives and we are grateful for that.  However, we do resent the way in which this has been done, taking away our autonomy as women, the professional independence of midwives, and exerting authority over normal birthing which is outside their specialism. 

For example: in Bradford, rather than the experts in normal birth, midwives deciding on the merits of birthing pools as pain relief in normal births, it is the specialist in abnormal birth, the consultants who make the decision.  And so it was that  a senior midwife had to visit me at home and we both had to sign to say that she had told me how bad it was that I should choose warm water for my pain relief.  And so it was that at my second birth 8cm dilated, in transition, one of the midwives spoke up and said:”  “At this moment, I have to ask you to leave the pool as it is not Bradford Trust’s policy to allow you to remain in the pool for the birth.”  I politely refused and proceeded to give birth in the pool unimpeded – but what a farce!  So even though my consultant was not present at my NHS births, he was present in the actions and words of the midwives who were.

So when we women are not the centre of our care, reality is defined, not by us, the birthing woman, but by the (absent) doctor.  And so in my cameo, what carried weight was not my description of what was happening to me, nor the opinion of a trained midwife’s examination, but only the hands of the doctor. Only he could inform me that I was in second stage.  And one of the most shocking things I find about the medical literature is how little medicine thinks to ask the woman! 

And so we have a culture of disbelief which does not consider or validate women’s experience of birth.  It is the doctor who really knows what is going on and so women have stopped believing in their bodies – they can no longer read its messages, and midwives are trained to defer to doctors and machines rather than their own eyes and hands and expertise of normal birth.

It is a phenomena that has its roots in women’s socio-cultural standing through history.  The feminism of the sixties did not challenge it, but we must do to retain our dignity as birthing women, mothers and midwives.

Furthermore, the Historical dominance of the male doctor and the medicalisation of birth has produced a false dichotomy between the welfare of the mother and that of the baby, pitting the welfare of the one against that of the other.  The most common example is to tell the mother that she is putting the baby AT RISK if we do not do as we are told. I have mercifully been spared this experience but so many friends and customers have been threatened with the dreadful risks to their baby of having a homebirth – sometimes after the healthy baby has been born! 

But more insidiously the medical orthodoxy tells women unhappy with their treatment at birth, that they should stop complaining and be grateful for the healthy baby received from their hands.  It took me to my fourth child to make a complaint about the care at my birth.  Their response was of this very kind – as if the birth of a healthy baby was down entirely to them and I did not play any major role. 

What I WANT TO SAY LOUD AND CLEAR is that a healthy mother and baby does not excuse substandard care, lack of respect and unnecessary intervention.  We women want it all – a healthy baby and a good birth and I believe we are entitled to expect it without apology or qualification.  It is not an either a good birth or a healthy baby, it is a both: a healthy baby and a good birth.  What makes a good birth is not an ideal birth but one where we are satisfied that what happened was as right as it could be.  This false dichotomy is a product of our social standing as women, and the centrality of the medical perspective of birth.  And we need to challenge it.

And midwifery.  The midwives who had been so central to my care at home, who had been confident and competent professionals, became invisible under the bright hospital lights.  I remember my GP God Bless her, confronting every doctor who walked into the room with the words:  “I am Dr Eisner, Mrs Weston is my patient and she will want all the interventions explained and discussed with her.”  The midwives said nothing.  Not out of a lack of compassion but because they were not independent professionals in that setting but servants doing as they were told.  And for me as the woman, user, that rendered me both vulnerable and alone because I had no advocate and no protection.

The demise of the independent professional midwife has its roots in the socio-economic, discrimination of women down the centuries and has been documented by greater souls than mine – but I can tell you the contemporary results from a users perspective:

The midwife in hospital and increasingly in the home has become silent and complicit in the mistreatment of birthing women and their partners.  They can act outside their own professional code, their motherly compassion and sometimes downright common sense and medical evidence, in order to fulfil their contract with the consultant led medical hierarchy.  Even the independant minded NHS midwives conspire with the system becoming what my mentor, radical theologian John Vincent calls “the soft underbelly of the oppressive state”, mitigating the cruelty with kind words and ameliorating the rules with subversive practices.  I don’t denounce this care but we do need to recognise its limitations.

Three examples: 

  1. one: my wonderful NHS midwives more than once responded to one of my more outlandish suggestions>”I know, I know, Ina May Gaskin might do it but it is more than my job’s worth”. 
  2. Two.  A senior midwife photocopied the manual on how to handle a natural third stage to attach to my notes because it was likely that I would have a midwife who had not practised a natural third stage.  –  Is that scary or what!  Midwives unable to oversee a normal third stage because they have only been trained in an unproven medical intervention. 
  3. Third.  I find it difficult to forgive the midwives who stood at my rear end at my first birth shouting instructions at me as if I were an animal.  I called that birth my crucifixion: I felt like I gave birth in fear and agony gazing at a white hospital wall and a drip machine.  I was not important enough to be spoken to face to face.

Please be clear.  I am not saying all this to rubbish NHS midwives as individuals, but as a user I need everyone to be clear what are the consequences of midwives complicity in and enslavement to, the current medical system.

So what are we going to do about it?  How can we change the scenario and make that young midwife of my story in to a confident professional.  How can I come to receive the care of a midwife who I can trust not to leave me in the crisis but who will advocate for me and support my birthing.

 

Part III: Tools for change.  Subversion, avoidance and confrontation

 So what are we going to do about it?  How can we change the scenario and make that young midwife of my story in to a confident professional.  How can I come to receive the care of a midwife who I can trust not to leave me in the crisis but who will advocate for me and support my birthing.

 Well first of all the change starts here with me and you.  I need to decide within myself that I do not want to play the game anymore.  I am neither going to be a victim of it or a stakeholder in it.  I am going to be the woman, mother, midwife I am, and be confident and sure of my dignity and worth.  Believe you me as a long time campaigner I have learnt that they can take your job, your financial independence, they can mock and ridicule and demean you but if you know your true worth and stand within that, they ultimately cannot touch you or win out against you.  

So cultivate your soul, your personhood your faith whatever you call it, and stand tall as the woman, mother, midwife you are.

Then we have to start asking Why.  And you will find like Ricardo Semler  – the radical and successful businessman and entrepreneur – that you need to ask the question tow or three times consecutively.  The first time you will get the pat answer, the second time you get a a more carefully constructed explanation, the third time – that is when you start getting a feel for the strength of the underlying argument.  Anyone who has a pre-school child will know what he is on about.

Ricardo says that any policy that cannot stand up to the second or third why should be ditched.  I read his book at Christmas and I am trying it out – I invite you to do the same.  As Whyse women we need to get behind, pat answers, we have always done it this way, custom and practice.  Phrases like: What evidence do you have?  What follow-up research has been done?  Has anyone researched this? Why not? Who did the research? 

We may be powerless to say it to their faces but always ask the question in your mind.  Always be asking yourself ‘why’ – it is the fundamental tool for change.

This maybe so, but  Women who stand tall alone tend to be ignored, ridiculed or shot down.  The medical system picks us off midwife and mother one at a time.  We are defeated birth by birth, woman by woman by the weight of the system.  So as my mother used to cry faced with a buffet to be eaten:  Women of the world unite!  It is time to organise, unionise, and here is how:

There are three ways to work against an oppressive system:

  • Subversion
  • Avoidance and
  • Confrontation

SUBVERSION

Subversion, I would suggest, is what many midwives and mothers practice now.  For example, after my second miscarriage, when I refused my D&C I was put under enormous pressure by the doctors.  In between one of the rounds, I sat on a stool in the laundry room and sobbed – because after all I was a grieving mother – and a nurse came in and put her arms around me and whispered in my ear “Its your body, love, you can do what you want with it.”  For example: it is the midwife who at one of my births said “I should call the ambulance and have you transferred right now but I am not going to.  You are going to have your homebirth.”

Women subvert the system often unconsciously by smiling sweetly and doing their own thing – and calling the midwife too late to do anything about it. . . At the birth of my fourth child, during my labour, we were told that there was no midwife available competent to attend my waterbirth.  When told this my husband smiled and said to the attending midwife “That’s OK I have attended two waterbirths and Jeanie here has attended one – we will tell you what to do.”  Thirty minutes later three mdwives had arrived!

Subversion is the valid defiance of the powerless and I want to encourage it.  Like rabbit burrows and wood worm it can undermine big structures and edifices.  But I doubt whether it will be enough to bring the whole system tumbling down even if it grinds it to a halt.  We need to do more.

AVOIDANCE

Avoidance is another form of opposition.  It is practice by women and midwives alike.  It is where you circumvent or bypass the system altogether.  So you become an independent midwife or you engage and independent midwife, or go to a birthing centre (Do you know a woman was accepted for a local birthing centre but then she got a letter out of the blue at 36 weeks telling her that she was no longer eligible – no reason was given)  or you plan an unassisted birth.  Some women have even left the country in search of the birth they want. 

This action is costly for the protagonists.  Midwives give up security and income and invite the hostile attentions of the medical establishment.  The families who engage independent midwives or birthing centres pay substantial sums – for us fifth time around it represented 15% of our then income.  Unassisted birth invites the hostile attentions of the medical establishment – for how is a woman to give birth without a medic to ensure she does it correctly!

Those of us who have practised avoidance one way or another and have paid handsomely for the privilege will probably say that one way or another it is worth every penny and every sacrifice.  But it can be a difficult road and so we must recognise that it is an important part of the opposition because it is providing an alternative model and practise.  It shows that the alternative is realistic, workable and effective.  Like the radicals and nonconformists of the past we must take courage and be proud.  We have done it because (to coin a phrase) we are worth it.

CONFRONTATION

Confrontation.  Ah this is the difficult one because we are so well conditioned not to make a fuss and to do as we are told.  And of course we cannot win because if we are nice nobody listens but if we get angry we are dismissed as emotional neurotic bitter women.  Sadly the feminism of the last century has not overturned these cultural norms particularly in the maternity services.  But I want to say to you now that silence is complicity and doing nothing for change is actively supporting the status quo.  Ultimately to bring about change we must confront the beast and bring it down.

My husband is an archaeologist and he says that ancient human hunters knew that they could not kill large prey like bison and mammoth with one shot of their little arrows.  So what they did was make arrows that did not kill but made very messy wounds.  They aimed arrow after arrow at the beast making such a bloody mess that the beast finally bled to death.  We may not be strong enough to bring the beast down with one shot but if we fire arrow after arrow at our prey, aiming to make as big a mess as we can with our puny arrows, it will finally fall bleeding from a thousand wounds. It is not a pleasant picture but it illustrates the tactic very well.

There is a problem in that for women like myself the moment of confrontation happens at our weakest moment on enemy ground.  And so I would say we need to organise, we women do not just need advice we need advocacy.  We need someone at the consultation acting as a witness, if necessary a spokesperson and advocate.  There is precedence for this in many areas of advice work.   We need someone strong enough to help us say no when we want to say no.

Midwives have told me about the bullying and the bullying culture, the fragmentation, the lack of cohesion.  Unfortunately this is not uncommon for an oppressed group.  It reminds me of some advice the late veteran MP Tony Banks once gave to a new MP  – your opponents sit opposite you, your enemies sit behind you”.  Oh that I had had that piece of advice when I worked for the church!  I suspect that if you work for change some of your toughest and most hurtful opposition will come from colleagues.  Be prepared for that and start thinking of ways to deal with it.  Here are a few of my ideas I am sure we can come up with more:

My experience of working with deprived groups in Britain is that what you need in a particular place is just a few people getting together and organising, for change to happen.  But we also need groups of midwives at local and district level deciding not to play the bullies game and supporting one another, and supporting one another in pressing for change and combating and withstanding the bullying.  And we need a network of women and midwives who will turn up and be there to support midwives and women being taken to the cleaners for their good practice.

And midwives need a union not a royal College.  You need a union, a NASUWT, a NUT an AMICUS, a union with a track record of sticking up for its members through thin and thinner, and who campaign vigerously for change.  You don’t have such union representation at the moment and you are suffering for the lack of it.  Some one or some persons need to put their hand up and sort out a union or two to campaign and protect midwives.  Don’t even bother to pay your subs to any association that does not have a good reputation for standing up for its members because you will be wasting your money and your good faith if you do.

And what else, well we need groups of parents to band together for letter writing sessions to challenge  current Trust policy and change legislation.  We need groups who will band together to do some high profile direct action and publicity stunts.   A vicar and a 60 year old woman hit the headlines and raised the issues of council tax for being willing to go to prison.  And I am telling you they were being backed by a strong organised union, they had their supporters in court with them.  And imagine a babysit in.  Imagine a squat in.  Imagine an impromptu NHS nativity play.  A Midwife ducking! What about a t-shirt group producing T-shirts.  Confrontation can be fun too – and needs to be to relieve the tension.

To conclude:

And so to bring about the change we want we must repeatedly ask the question ‘why’ and not accept the pat answers, and we must be subversive, and we can practice avoidance and set up independent structures . . . .but ultimately ultimately we must confront the beast.

And we need to be determined, cunning, fun.

We need to band together to organise and unionise,

 to write letters and demonstrate

And we need to educate, educate, educate.

Talk to our daughters, sisters, mothers

Talk to our sons, and husbands and brothers (after all they have 50% of the vote)

And we need to fearlessly claim our heritage to birth and bring to birth,

To be the women, the mothers, the midwives we are

We need to campaign as determinedly and creatively as we give birth

Because our daughters are worth it

                                                            – and so are we.

 

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