‘The modern approach to birth is so focused on delivering the baby that it has lost sight of the mother. The result is a right old mess’
Dr Rachel Reed - Midwife, Researcher and Author
Obstetric violence part 4 - Why is it happening and what are the solutions?
How we got here in the first place is a far bigger story that stretches many years into the past, along the red thread of our ancestors until we get to the point where matriarchal societies and goddess worship were replaced with patriarchy, one of the only realms patriarchy didn’t interfere with for quite some time was birth. Until they did. Until it was monetised, commodified and pathologised for so many years that we forgot how birth was supposed to be.
But to do that story justice I need to save it for another series so I can delve deep into her-story.
For now, I will conclude this 4 part series with some key reasons as to why we are in this mess from a 2024 perspective, and focus on solutions.
LEGISLATION
Research has shown out of the Royal College of Obstetrics and Gynaecology guidelines only 8% were based on the highest level of medical evidence and 40% on the lowest or non at all1. Despite this, women are regularly coerced into procedures they do not want or need which can result in traumatic birth experiences.
The fact that hospital policy is often written up by lawyers may shed some light as to way these things happen. Last year obstetrics made up 64% of NHS negligence pay outs. Maternity staff must be living in constant fear of being sued, and generally they will be sued for what they did not do, not what they did do. This is where we see defensive practice, and explains the sky-high rate of c-sections.
Unfortunately families do not tend to be aware that most guidelines are not based upon good evidence, and often go along with whatever the experts recommend. I know more than one friend who was told ‘your baby is huge, they must not get any bigger, we must induce you now’. The induction has been ‘horrific’ (my friends words) and resulted in a c-section. The baby was born teeny tiny, and absolutely no need for their birth to have been robbed from them in such a way. Had they known to question the guidelines or had they known how inaccurate third trimester scans are then perhaps they would have had a chance to make a different decision.
Maternity services are obsessed with inductions which have sky rocketed in the last decade. Apparently induction is supposed to reduce the chance of still birth. However data does not back that up. Still birth has not gone down with the huge increase in the number of inductions being performed. But birth trauma is increasing, c-sections are increasing, postpartum haemorrhage is increasing. There are a whole host of risks associated with inductions such as infections and bleeding after delivery, low fatal heart rate and increased chance of further intervention, not to mention the effect on the mother having her labour artificially started with synthetic oxytocin. When natural oxytocin is bypassed it can have negative results, physically, psychologically and spiritually.
This hamster wheel of intervention goes round and round with very few people questioning it. The hospital policy written up by lawyers suggests induction as a solution for almost anything these days, and no one seems to want to talk about the problems that the induction caused in the first place!
Dr Sara Wickham who has been researching inductions for 30 years has plenty of resources on this topic and an amazing book called ‘in your own time’. A book that I recommend as vital reading during pregnancy or even before conception.
Wickham is concerned about the number of women being coerced into inductions because of a perceived problem with minuscule risk, but the likelihood of long term consequences to mum and baby from the induction often outweigh those risks.
Common sense is simply not being used.
Dr David Hayes speaking at the Obstetric Dilemmas symposium in 2023 said ‘I knew we weren’t doing anything to support women, but we were doing a lot of things to support a medical - legal bureaucracy’
And Melanie the midwife who hosts the Great Birth Rebellion Podcast states that ‘Institutionalised birth as it is currently organised is inherently unethical; midwives and doctors are expected to place allegiance to hospital policy or cultural practices over respect for the wishes and needs of women’
It is not just present day healthcare professionals who are trying to change the system, back in 1976 obstetrician Frederick Leboyer who was born in 1918 published a book called birth without violence, he hoped the book would radically change what was being done in hospitals and in the book he quotes a passage from the Tao Te Ching;
In the pursuit of learning, every day something is acquired.
In the pursuit of Tao, every day something is dropped.
Less and less is done.
Until non action is achieved.
When nothing is done, nothing is left undone.
The world is ruled by letting things take their course.
It cannot be ruled by interfering.
Lao Tzu
Now, I’m not suggesting we’re all going to turn into Lao Tzu overnight, but it is worth reflecting on ancient wisdom, these words were written over 2,000 years ago and seem so very relevant today.
I had my own experience with hospital policy during my first pregnancy, I was told I ‘had’ to see a consultant when I had reached 42 weeks pregnant. It is policy to induce women at 42 weeks, to be honest these days they’re trying to induce women at 39 weeks, but anyway, I had refused and this meant that my midwifes needed to pass me over to the consultant. The doctor explained why I needed to have an induction. He did not give me any of the risks of an induction, so I proceeded to tell him. He looked at me in the eyes and said ‘You are right, but, I still need you to sign this paper to say you have gone against my advice’.
He knew that a blanket induction policy for all ‘overdue’ babies was not necessarily something that would be helpful to me as an individual, but he was doing what his role required of him to avoid a lawsuit if something had gone wrong. Ultimately it was my body, my decision and I had my baby at home in the pool 5 days later without any need for medical intervention. I shudder when I think what could have happened if I had not done any research and agreed to the induction. I would have been on the labour ward, with strangers, under bright lights, confined to a bed with continuous monitoring and unable to move. The very thought of labouring like that makes me feel terrified. Thank goodness I felt able to say no to the doctor and was able to labour at home where I felt safe.
Burnout, trauma and disassociation within the maternity system
Maternity healthcare providers are really suffering, and covid made this situation even worse. Between 18-33% of obstetricians have PTSD with Midwives experiencing similar rates. In comparison rates of PTSD in the general public are around 8%. If a third of the workforce are arriving at work burned out, emotionally exhausted and struggling with empathy this is going to have an impact on those in their care.
Trauma therapist Krysta Dancy (2019) states that when our brains are operating in a trauma response it means that we are no longer responding to the picture in front of us. Meaning that doctors who are traumatised from previous experiences take this with them into the next birth.
This results in yet more defensive practice - which is generally when a birth is medicalised unnecessarily to protect the hospital from being sued, but it could also be said that defensive practice happens to protect the nervous system of the doctor/nurse/midwife.
Those of us who are not healthcare professionals can’t really imagine what it must be like to see the death or serious injury of someone we felt responsible for. It is understandable that they start fearing every pregnant women in their care could become a statistic, even if the actual probability of that is really low. They may have a ‘not on my watch’ attitude and start intervening when not necessary in order to protect themselves.
The issue is that those very interventions can lead to problems for mum and baby. The health care provider is unlikely to ever see the downstream effect of the trauma the induction or unnecessary c-section caused. This is because their job ends when the baby is born. They are not the ones who sit with a broken woman 6 weeks postpartum suffering flash backs from a birth that was completely out of her control. The obstetricians job is to get the baby out alive and move onto the next.
The truth is that healthcare professionals will witness mothers and babies in critical conditions or even dying. They work insane hours and simply do not have the time or the resources to regulate their nervous systems in between shifts. They are carrying traumatic events with them, and we’re seeing the negative results play out in the form of over medicalisation because the more they ‘did’ will look better in court if something goes wrong.
Legislation, trauma and burnout all combine to create a very hostile environment for anyone wanting to have a more natural experience, and genuine woman centred support.
A need for control over women’s bodies
I have a lot of empathy for those working within the medical system, they do a really difficult job and they do save lives. So I wasn’t sure wether to include this bit, I didn’t want to seem cruel or ungrateful to those living a life in service of others. But I reminded myself of the trauma playing out daily in maternity wards and decided to go there, because these things need calling out. There seems to be an issue within the medical industry of authoritarianism and sexism. I believe this is systemic in maternal care and is an attitude that can be applicable to both male and female HCP’s.
In her book informed is best Professor Amy Brown discusses two types of sexism, benevolent and hostile. I found these descriptions interesting because I recognise both of these in the stories I hear daily from women who are despairing at their treatment within the NHS and in other countries.
Benevolant sexism
If she is seen to be challenging the belief that she is weak, or be overly powerful and have an opinion of her own, the benevolent sexist can get a little angry. The message is ‘conform and you will be cherished and supported, break the rules and you will be punished’. Those high in benevolent sexism like rules being applied to women, particularly rules that restrict their movement, freedom or ability to speak out. They particularly like it when these rules can be imposed as a way of ‘protecting’ women for ‘their own good’.2
Hostile sexism
Generally centred around the belief that women are less than men, disliking and distrusting them and scorning anything about them that is symbolic of being overtly feminine. Those high in hostile sexism become angry when women break the ‘rules’ around pregnancy. They really like the idea of there being rules controlling what women can and can’t do during pregnancy and believe that women should be punished if they break them. What Is telling is its not linked to how risky the behaviours were. It was simply about punishing naughty, out of control women’3
The above examples of sexism link with authoritarian traits, one study showed medical students scored the highest in authoritarian traits against other subjects.
We can see how this plays out in maternity wards.
Someone who scores highly in authoritarian or sexist traits are not going to like women having choices such as;
Having an option on where to give birth
Being able to make autonomous decisions about whether to receive antenatal care or not
Choosing to go against medical advice (baring in mind that the majority of hospital policies are not evidenced based anyway)
The list goes on.
And this power dynamic plays out daily.
Care provider preference
Pit to distress
I hear of this story more in the U.S but I imagine it probably plays out in other countries too. This is when the obstetrician has decided he would like to do a c-section because he wants to go home for whatever reason, so he instructs the nurse ‘pit to distress4’, meaning that the nurse up’s to Pitocin to such a point that baby shows signs of distress so the obstetrician can say ‘oh dear, baby is having trouble, lets get them out now’
Induction for beds
Plenty of whistleblower midwives are speaking out on podcasts about this. Inducing women so that they can manage beds. I also recommend looking at induction rates at your local hospital over the Christmas period. There is always a huge spike before and after Christmas so they can manage the number of women over the holidays.
‘This is the way its always been done’
In part 2 I looked at Kimberleys non consensual episiotomy. This was done despite evidence now showing that episiotomies are not the best option in most situations. The doctor was quite elderly, he did episiotomies as standard. That used to be a thing, so he just carried on doing it, despite new evidence. It wasn’t just Kimberley this happened to.
A study by Van Der Pill et al found shockingly high numbers of first time mothers who were given episiotomies without consent. Figures from around the world show out of all the women who had episiotomies this many were performed without consent - 25% Australia, 35% Norway, 46% Finland, 47% Ireland, 68% in Belgium!
Financial -
OK , So maybe I am being a bit cynical with this one… but, plenty of companies are making money from these interventions. Imagine the hit pharmaceutical companies would take if women just started birthing at home. They would lose millions, possibly billions overnight, so yes I imagine it probably is a factor. When we remember that many women are coerced against their will to accept interventions the whole thing looks a bit creepy.
What are the solutions?
Informed consent and communication are key in reducing birth trauma.
Dr Elizabeth Newham says ‘The systems that are in place antagonise or don’t support normal physiological birth processes, they work against them’
This is the reality.
In order for women to make informed decisions about where to birth they need to know
that a hospital setting is working against physiology. That is important information. A study involving over 55,000 women showed that 72% wanted a natural birth4. A home birth is the most likely environment to accommodate this.
Education around home birth safety is important since there is still a stigma around this with people believing that hospital birth is safer. Professor Hannah Dahlen looked at studies involving 500,000 women which showed that home birth is equally safe to hospital birth and leads to better perinatal outcomes5. She said ‘is it time to ask whether facility based birth is safe for low risk women and their babies’6.
There needs to be more training in physiological birth within the maternity system, because not everyone will be happy to labour at home, and they deserve the option to have an undisturbed birth in a hospital setting. Competent and knowledgable staff should be able to facilitate this. Former NHS midwife Kemi Johnson has spoken out on podcasts saying that she never once witnessed an undisturbed physiological birth on a labour ward in all her years of practice. It is a big problem.
Our medical professionals deserve better care, they cannot operate at 100% if they are completely exhausted. The 2018 Poppy programme ran over a duration of 6 months, which included accessible trauma therapists and safe physical space for down regulation.
This resulted in significantly higher job satisfaction with a 12% decrease in stress related absenteeism and 34% decrease in those wanting to leave midwifery.
If this could be rolled out for obstetricians and midwives everywhere it could really help. When providers are cared for it will trickle down to those in their care and should ultimately reduce trauma among new mums.
We need to see honest language being used. Every day I see women post in social media forums desperately upset because their doctor has told them that their baby will die if they do not have an induction. Passive aggressively saying ‘You don’t want your baby to die do you?’. This is unacceptable. Especially when the risk is usually around 1 or 2%. What the doctor should be saying is ‘There is a 98% chance that everything will be fine and a very small risk of still birth, but we can induce you now, here are the benefits of the induction and here are the risks, I will give you some time to think it over’. This is how truly informed decisions are made.
Using highly emotive language and twisting facts just to get pregnant women to agree to whatever the hospital policy happens to be is abusive. Our minds cannot think straight when we are running off emotion and this can lead to irrational decisions that women spend their lives regretting. It is time to change the narrative. Stop infantilising women and let them decide for themselves.
The fact that the majority of RCOG guidelines are not based on solid evidence needs to be general knowledge. This should end the notion that we cannot question those in authority. We can and we must.
We cannot change the system over night, if ever, so we absolutely need to start speaking up and start taking self responsibility for our birth experiences. When we outsource responsibility we have to be aware that our care providers will be looking out for worst case scenarios, and practice defensive medicine with more and more interventions. Some women will want interventions, but for those of us who prefer hands off undisturbed physiological births, these types of experiences are currently all but extinct within medical systems.
I am a week late hitting submit on this as I recover from mastitis which has consigned me to my bed with an infection that manifested as headaches, flu like symptoms that made every bone in my body hurt and breastfeeding was excruciating. Motherhood will throw us hurdles, and sometimes brings us to our knees. This time in our lives requires us to be as strong as possible. How we emerge on the other side of birth sets us up to deal with these hurdles, and is one of the reasons I am so passionate about this.
Birth matters.
I reckon it’s about time we take birth back from the patriarchal structures that stole it from us.
Thanks for being here. Hit subscribe for bi-weekly articles on our rights and rites.
Anna
References
1royal-college-of-obstetricians-and-gynaecologists-guidelines-how-evidence-based-are-they%20(3).pdf
2Informed is best by Amy Brown p41
3Informed is best by Amy Brown p43
4https://www.leventhal-law.com/blog/pit-to-distress-is-medical-malpractice/
5https://www.sciencedirect.com/science/article/abs/pii/S1877575609000020
6https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30142-7/fulltext