Chapter of the book “Giving Birth” (Parir. El poder del parto) by Ibone Olza.
Translated to English by Sinead Byrne. www.foreignrights.prhge.com/
According to some sources, when a woman in Sparta (Ancient Greece) hadn’t gone into labour after nine months, other women would go to her house to berate her almost violently. They would hurl all the grievances in her face that they had kept to themselves during the pregnancy and the heated exchange usually triggered the onset of labour in the hours or days that followed, thereby avoiding the risks of a prolonged pregnancy. So, the Spanish term poner a parir (literally ‘to put to birth’ but used figuratively to indicate severe verbal abuse) may date back to the Spartan aim of rebuking a woman so strongly as to send her into labour . If this telling of history is true, it means that they were already aware of two important factors then: the risks associated with a postdates pregnancy and the effect that intense emotion can have on a pregnant woman at full term, to the point of being able to bring on the birth process.
The Real Academia Española (RAE) Spanish dictionary defines poner a parir as ‘to harshly criticise or insult’ somebody, which is interesting because it suggests that according to popular wisdom, inducing labour is something negative and painful; and with negative connotations like this, the problem with the way in which many births are assisted is made very clear.
The truth is that, in light of understanding the fine balance of neurohormonal mechanisms and complex sequence of events involved in birth, as well as an awareness of how much we still don’t know; to consider forcing the process seems absurd and dangerous to me – something that should only have to be done in exceptional circumstances, when there is a genuine medical problem. Nevertheless, this is still being done to women in most maternity units in Spain. They are ‘put to birth’ – and induction is only part of the problem. In lots of hospitals, birthing women are still placed into highly uncomfortable positions, they are put into wheelchairs or examination chairs, they are stripped down, they are put on drips, their pubic hair is shaved, they are told what they can and cannot do, they are forbidden from eating or even drinking, they are isolated in rooms alone, and they are hoisted on obstetric tables that are difficult to get down from by themselves.
Added to this, childbirth practitioners seemingly ‘do’ the births. In the hospitals I worked in, expressions such as ‘I did her delivery’ were regularly used. Or even worse, ‘I delivered that woman’. This sort of language is revealing and illustrates the extent to which women are robbed of the primary role in birth – along with their wellbeing, in many cases. Legions of mothers come out of the birth process with injuries and with no conception even of their lost opportunity to instead feel empowered and stronger. New motherhood can be very challenging and distressing following a debilitating birth and is often marked by problems with breastfeeding and bonding, depression or another mental disorder postpartum. So, this journey becomes a mammoth undertaking; rather than the easy, enjoyable and straightforward path it might be.
The problem with birth care is global. Firstly, mothers are still dying due to a lack of adequate or sufficient care in the birth process. There are an estimated 830 deaths every day, worldwide, due to preventable causes related to pregnancy or birth; with 99% of these occurring in developing countries .Secondly, medicalisation and excessive intervention in childbirth mean that in wealthier countries, increasingly fewer mothers are emerging unharmed by birth – without stitches, cuts or wounds to the perineum or abdomen. Many enter the delivery room sound in body and mind, only to leave operated–on, wounded or suffering serious physical or psychiatric effects for years to come. Some women also die. In the United States, maternal mortality in birth is rising to a worrying extent. Between 1987 and 2011, the number of maternal deaths doubled per 100,000 live births ,which is partly attributable to the disproportionately high numbers of caesarean deliveries there (with one in every three mothers having a baby this way).
Elevated caesarean rates are the most visible aspect of the birth care crisis. Ideally, they should only be performed when strictly necessary for medical reasons because they represent major abdominal surgery that can result in significant and sometimes permanent complications, disability, or even death – particularly if carried out in settings lacking facilities or the capacity to operate safely and handle complex surgery. The World Health Organisation (WHO) acknowledges that the current caesarean section rates worldwide are alarming and show no sign of dropping off. In 2014, the WHO carried out a systematic review of available studies in order to identify, critically evaluate and synthesise the correlation between caesarean rates and maternal, perinatal and neonatal outcomes (Betran et al., 2015).
A committee of international experts then convened in Geneva to assess the data from 8–9 October, 2014. Their findings included that ‘at population level, CS [caesarean section] rates higher than 10% were not associated with reductions in maternal and newborn mortality rates’ (Betran et al., 2016).
However, the WHO research did not take into account the psychological or social aspects of birth and delivery – only maternal and neonatal mortality. As caesarean mortality is less frequent in developed countries, the experts also recommended that future studies evaluate the consequences of caesareans for maternal and perinatal morbidity in the short and long term; including the psychological aspects of the mother–child relationship, the mother’s mental health, women’s ability to successfully initiate breastfeeding, and paediatric outcomes.
The figures speak for themselves. At least one in every five women worldwide have a baby by caesarean (which is a cautious estimate and the figure is probably higher). Between 1990 and 2014, global caesarean rates rose from 6.7% to 19.1%, which represents an increase of 12.4% in absolute terms (Betran et al., 2016). In Latin America, 40.5% of all births are by caesarean section and in some private clinics, more than 90% of babies are delivered by caesarean. In certain countries, like Egypt, the caesarean rates in the given time period have risen from 4.6% to 51.8% (Betran et al., 2016). The rates have gone from 4.5% to 27.8% in North Africa, while they have scarcely changed in sub–Saharan Africa (increasing from 2.3% to just 3.5%).
This inequality is also part of the problem. In some settings, it is likely that many women still have no access to a caesarean when needed, which led the WHO to point out that
every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate’(Betran et al., 2016). Furthermore, the WHO proposed use of the Robson criteria (that allow women to be classified into groups to facilitate reviewing reasons for caesarean section), so that meaningful comparison of the rates can be made across countries despite the disparity that still exists in the way that caesarean and birth data are recorded, which makes comparative analysis hugely difficult.
Obviously, such high caesarean rates cannot be explained by medical reasons alone. Social and cultural factors, maternal and practitioner fears, women’s life circumstances, etc. also have to be included in the analysis. The WHO has been criticising the excessive medicalisation of care in delivery and birth for years (Johanson, Newburn, & Macfarlane, 2002), though in their recent statements they have been citing abuse and maltreatment in childbirth as a global problem (Lukasse et al., 2015) – an issue that has begun to be censured under the concept of obstetric violence (Sadler et al., 2016).
The definition provided by the Oxford English Dictionary for ‘medicalise’ is to ‘treat (something) as a medical problem, especially without justification’ and offers ‘medicalised motherhood’ as an example for the term in use, which is very telling. Birth is not an illness, but is dealt with as such. In hospitals in the Western world, labouring women are treated like time bombs about to explode. The medical model approaches the entire childbirth process as if pregnancy were a condition to be cured as soon as possible by extracting the baby, or the so–called foetus.
The course of medicalised birth can begin on the first ultrasound scan in pregnancy. Sometimes doctors actually contradict women regarding the date of conception and generally move the mythical ‘estimated due date’ (EDD) forward by a week (rarely backwards), on the basis of the size of the embryonic sac in the first weeks of pregnancy, for example. One consequence of this is that many labours are induced in late pregnancy because the women are supposedly ‘overdue’, when they could still have another week or two of contented gestation left. Women are also sometimes induced at week 37, in the belief that the baby is ‘not growing enough’, although this is not proven to be beneficial or risk–free either (Bond et al., 2015).
Induction rates are one of the most obvious indicators of the medicalisation of birth, though quite often the fact that labour was brought on early is not even recorded. Or worse still, the mother herself doesn’t realise that the painful vaginal examination carried out during her final obstetric appointment was actually intended to kickstart labour. What is known as the Hamilton Manoeuvre (or membrane sweep), which involves inserting a finger into the vagina as far as the neck of the uterus and then rotating it in an effort to separate the membranes of the amniotic sac from the uterus wall, might be enough to initiate labour when already imminent. But, incredibly, in many cases this is carried out without even asking the mother’s consent or informing her of the associated risks.
Once labour begins, every second of the baby’s heart rate is usually monitored electronically, though there is ample scientific evidence to show that this is not only pointless but also very dangerous in low–risk births (Bailey, 2009). In 2009, the US Preventive Task Force (a prestigious, independent group of experts in evidence–based medicine) recommended against the use of continuous monitoring in low–risk births (Bailey, 2009). A recent Cochrane review found that electronic monitoring of the foetal heart rate, when compared with intermittent auscultation on hospital arrival, increases the risk of caesarean section by approximately 20% with no evidence of benefit (Devane et al., 2017). Before and after monitoring, numerous digital vaginal examinations are usually performed, which considerably increases the risk of serious infections for both the baby and mother, often leading to newborns having to spend their first few days in a neonatal intensive care unit.
The widespread belief that vaginal exams must be carried out to assess progress in labour, even when their effectiveness has not been demonstrated, is noteworthy. In a Cochrane review of vaginal examinations carried out on women in labour, the authors concluded:
It is surprising that there is such a widespread use of this intervention without good evidence of effectiveness, particularly considering the sensitivity of the procedure for the women receiving it, and the potential for adverse consequences in some settings. The effectiveness of the use and timing of routine vaginal examinations in labour […] should be the focus of new research as a matter of urgency.(Downe, Gyte, Dahlen, & Singata, 2013)
The epidural anaesthetic is routinely offered to pregnant women in hospitals, as if it were a panacea. I have even heard anaesthetists telling pregnant women during information talks that in epidural–assisted births, babies suffer less and are ‘better oxygenated’ than in births without it – which is clearly false. The epidural is invariably associated with the use of synthetic oxytocin that accelerates contractions very painfully, actually endangering the supply of oxygen to the baby, and this indiscriminate use of synthetic oxytocin seems to me to be one of the most serious problems in birth care at present. Furthermore, although the anaesthetic can be administered in a way that allows women to continue moving about freely (commonly known as the ‘walking epidural’); many hospitals do not provide this option so that, following administration of an epidural, women are confined to bed or an obstetric table (still being placed in absurd positions) for the remainder of the birth process.
Many doctors who assist birth are convinced of the extreme danger associated with the process. Some will have never seen a birth without medical interventions or, for example, a vaginal breech birth. On the contrary, the majority of births seen or assisted by them will have been highly medicalised and therefore complicated to a greater or lesser extent. But how might they be shown that most of these complications are a direct result of the interventions that they have made?
The use of synthetic oxytocin, for example, can lead to total saturation of uterine oxytocin receptors, so that the uterus becomes non–responsive to the drug and stops contracting, which can cause massive or catastrophic haemorrhaging. Nonetheless, it is so strongly accepted that oxytocin be given to augment uterine contractions that most obstetricians are unaware or deny that its use is the very cause of the incredibly serious, massive postpartum haemorrhaging that they have all witnessed (Belghiti et al., 2011). The same can be said of other grave complications. For example, babies suffering a lack of oxygen in birth with resultant damage, due to the brutal contractions sometimes caused by synthetic oxytocin or because the mother is fixed in a position that restricts blood supply to the uterus. Though, as I mentioned before, many obstetricians believe that such serious complications are inherent in birth and they are incapable of understanding how their routine interventions actually cause the problems.
The medicalisation of childbirth is correlated with severe complications caused by medical intervention (Belghiti et al., 2011; Johanson et al., 2002) and if practitioners don’t have a place of support where they can address this causative aspect of care, they can spiral into increasing medicalisation as their sole defence strategy. So, there is a domino–effect whereby birth is perceived as this highly dangerous event, a ticking bomb about to go off; while practitioners remain unaware that the stream of unnecessary interventions actually cause complications, giving rise to further intervention, risk and pain.
Of course, from this point of view the mother’s satisfaction with her experience would seem insignificant when compared to the risk of ‘life or death’. For example, when obstetricians hear that a mother has had a good home birth, assisted by a midwife, they usually consider that ‘she has been very lucky’. They specifically base their criticism and advice against home births on the supposed dangerousness of the birth process. They don’t even bother to read up on the many studies that show that home births appear to be safer for healthy women than hospital births under particular conditions: most importantly, when assisted by a good midwife and only when the mother does not suffer from any serious condition and can get to a hospital in reasonable time in the event of complication (Blix, Huitfeldt, Oian, Straume, & Kumle, 2012). This scientific evidence underpins, for example, guidance provided by the National Institute for Health and Care Excellence (NICE) in Britain, which recommends home birth as the safest and therefore preferential option for women who have given birth before.
The American anthropologist, Robbie Davis-Floyd has studied the existing phenomenon whereby many ‘technocratic’ practices surrounding hospital birth are not supported by scientific evidence. If they have no ‘physiological’ basis, how can their development and ongoing use be explained – especially when we know that there is no evidence to justify them? Because they have a cultural basis, according to this expert (Davis-Floyd, 1994) . Present–day birth care cannot be understood without knowing something of its history and without an examination of the existing cultural and social context.
It’s a long story as to how we arrived at the current situation and difficult to analyse the extent of the problem in birth care. There is an entire social, cultural and historical context
behind the issue and there are many questions to be asked when we review the figures for caesareans, inductions, episiotomies, newborns requiring hospital care, etc. For example, does the female body really have that much difficulty in giving birth and is birth as difficult as we are given to believe? Could it be that current birth care is more dangerous than birth itself? Also, to what extent does the fact that giving birth is an exclusively female act influence the existing medical model of care, which is so often tinged with cruelty? For certain, there is a gender bias underlying the birth care model at present, which needs to be made visible and analysed so as to improve care practices and make them safer and more acceptable – not just for mothers and their families, but also for practitioners.
THE OBSTETRIC DILEMMA
In addition to questions relating to the medicalistion of birth, it is important to consider whether we women need professional assistance in delivering our babies and to what extent deliveries are complicated by the lack of professional assistance. In other words, how many births would end badly, if they happened spontaneously? It seems to me that if we accept the 10% suggested by the WHO as the percentage of women requiring a surgical intervention, such as caesarean section, for their babies to be born safe and sound (as an act of caution); then the other 90% should represent women who have no need of intervention in delivery. However, the opposite is generally the case, which suggests that although we don’t have data on how many women are assisted in giving birth intervention–free, that percentage is probably very low.
Although it seems like a rhetorical question, we might begin by looking at whether we women need to be accompanied in childbirth and to be assisted in delivery. To put this in context, it’s interesting to observe how other mammals have their offspring.
For non–human primates and almost all mammals, birth is generally a solitary event. Exceptions include the calving of an elephant, whereby the members of the herd encircle the mother elephant, protecting her until she has successfully delivered her calf. Among primates, diurnal species such as monkeys tend to have their young at night; while lower–primate diurnal species like prosimians (lemurs, for example) usually do so by day.
Delivery is more difficult for small primates than it is for large ones. Neonatal death is not uncommon for the smallest primates due to cephalopelvic disproportion, whereby the neonate’s head remains stuck in the mother’s pelvis. Female monkeys usually seek out isolation for birth – quite often in trees, protecting them from terrestrial predators. Other monkeys may witness the birth process at a distance, but do not assist the mother or infant. Monkeys generally give birth in a squatting position and the newborn offspring are able to cling onto the mother with their hands.
The reason most often given in defence of the need for birth assistance is what is termed the ‘obstetric dilemma’, referring to the narrowness of the female pelvis in proportion to the relatively enormous human infant’s head. Champions of this argument point out that without birth assistance, many women and/or babies would die in the process, with this pelvic narrowness potentially resulting in the baby’s head becoming absolutely stuck in the birth canal. Human pelvic narrowness is attributed to bipedalism, as it’s thought that when our ancestors began to walk upright, the pelvis naturally narrowed – thereby creating the conflict in birth with babies’ heads being too large, in relative terms.
Birth in the human species is usually attended by others. According to researchers into what is known as ‘evolutionary obstetrics’, assisted birth came about with bipedalism and is therefore as old as human ancestry itself (Rosenberg, K. & Trevathan, 2002). The baby generally emerges facing in the opposite direction from the mother and most women seek to give birth in a squatting or seated position, which is notable since the diameter of the pelvic opening increases by 30% in the squatting position. A survey of 159 cultures for which positions in delivery were given showed that there were: 47 seated, 44 kneeling, 26 squatting, 17 semi-reclined or in a hammock, 16 lying down and 9 standing. It seems that giving birth in an upright position (squatting, seated or standing) is ideal and limits complications, according to some studies. Giving birth in a squatting position is most common in cultures in which women carry out many of their daily activities (like cooking, childcare and cleaning) in that position.
As far as can be seen, women traditionally tend to seek assistance from other women who are childbirth experts. The study authors suggest that this is a consequence of the different mechanisms in birth, in turn resulting from the anatomical differences between human and non-human primates. In view of the authors, assistance is a human adaption due to the typical presentation of a baby in birth, facing in the opposite direction from the mother – making it difficult for her to reach down to the baby, clean it and remove the umbilical cord. In another survey across 296 cultural groups, ethnographers found only 24 in which delivery does take place unassisted, but only following a previous birth (Trevathan, 1987). In all other groups surveyed, births are always assisted.
Assisted birth does seem to be a universal phenomenon and human birth is a social, rather than a solitary event (Rosenberg, K. R. & Trevathan, 2001). Perhaps this is because the high level of oxytocin that a woman releases in birth also affects those attending (as a hormone strongly associated with bonding, love and intimacy). Or, perhaps nature has a way of knowing that those present will somehow become bonded with the baby due to arrive. The fact that several people witness these first moments of a baby’s life and bond with it in one way or another may have real social logic in terms of sharing its care. If women in most societies seek the assistance of female experts, at least for their first births, it’s probably because they need it to ensure a safe delivery. But in considering the kind of help offered by the original community experts, it’s very likely that a key aspect of that assistance was to provide emotional support, so that the woman felt safe and secure to focus on her body and the birth.
It seems that we mothers need birth assistance to maintain neurohormonal balance and ensure maximum oxytocin levels, both to promote the most effective contractions for delivery and a loving bond between mother and baby after birth. In this regard, the main task of birth attendants should be to look after the maternal psychological state as an effective way of preventing complications.
Nevertheless, the debate on the obstetric dilemma does not appear to be closed. One recent study claims that the pelvis is not as narrow as has been thought (Warrener, Lewton, Pontzer, & Lieberman, 2015). A further study proposes that caesareans will change the evolution of mankind by enabling the safe birth of babies that, in previous times, would have died by getting stuck in the birth canal due to their relatively large heads (Mitteroecker, Huttegger, Fischer, & Pavlicev, 2016). But these theories seem misogynistic and wrong to me, revealing a profound lack of knowledge of the physiology of birth.
HISTORY OF BIRTH CARE: A POWER STRUGGLE
For many centuries (probably thousands of years), births all over the world were assisted solely by midwives. These were female experts who often had a knowledge of herbal medicine and it was traditionally accepted that they had ancestral ties with life and death. In past times, there were two things expected of English midwives: to have the strength and stamina to provide physical resistance and support to the woman in labour, and to be courageous.
The fact that men became involved in birth and ended up managing the process came at great cost. The burning of witches during the European Inquisition mostly involved burning female carers such as midwives and traditional healers and, among other things, launched a bitter struggle for medical power which lasted for nearly four centuries (Ehrenreich & English, 1973).
In her book Get Me Out, Randi Hutter Epstein retraces the history of midwifery and obstetrics (Hutter Epstein, 2010). She looks at examples of the many people who were burned at the stake for ‘crime’ in birth (including midwives, women who asked for pain relief in labour and even men who wished to be present). Some of the examples cited by Hutter Epstein are especially interesting: in 1522, Dr Wert was burned at the stake for having sneaked into a delivery room disguised as a woman; and, in 1591, Eufame Maclayne was burned for asking for pain relief while giving birth to her twins. Hutter Epstein tells us that in the 16th century, medical authorities began to dismantle the reputation of midwives to insinuate themselves into this business only occupied by women to then. The physicians of the era needed to get rid of the knowledgeable women carers and, in doing so, boost their economic power by charging for their attendance at all births. According to the author, it was through the invention of obstetric instruments that birth ceased to be a largely spiritual journey and instead become a medical procedure. Although this change came about in the 16th century, it has persisted into the 21st century. The history of birth care is also the history of women, of the power struggle between doctors and midwives or carers, and of medicine.
This struggle for power in birth care still exists and is still fierce. Nowadays, how births are assisted is very much influenced by those attending. The obstetric or medical model of care differs considerably from the midwifery model. Despite consensus and evidence that normal births are best assisted by midwives and that obstetricians are pathology experts; in practice, in most settings births are assisted by obstetricians with expertise in dealing with complications – which, it is worth repeating, is a potential complication in itself from the outset. Dr Marsden Wagner, who was Director of Women’s and Children’s Health at the WHO, used to say that having an obstetrician attend every birth in case anything goes wrong is as ridiculous as having a paediatric surgeon watch over every two–year-old on a swing in case they get hurt in a fall.
So, who currently holds sway over birth care – obstetricians or midwives? It’s hard to tell whether the medical model and the midwifery one complements each other, or are mutually exclusive. The reality is tremendously complex, but for the moment the power clearly lies in obstetrics.
NEUROBIOLOGY IN BIRTH: A KEY RELATIONSHIP
What makes for a positive birth experience is the same as for making love, namely: intimacy, trust, feeling safe, and respect. As previously discussed, the same hormones are involved in both sexual intercourse and childbirth, and are released in the same way (with the scent, for example, being notable in childbirth).
For the neurohormones to be released in birth, the altered state of consciousness discussed earlier (the birth state) must be facilitated. For this to happen, there needs to be as little interference in the process as possible. If a couple making love receives a phone call and one of them answers it, their intimate connection is suddenly interrupted, and it can take a while to return to the point of climax. Well, the same thing happens in birth. If a woman in labour is interrupted with questions and required to activate her intellect, the labour process is usually stalled. For a smooth birthing process, the neocortex has to be deactivated, which means stopping conscious thought and moving into this altered, more emotional state.
To enable birth neurobiology, it’s understood that labouring women must feel safe, which is provided for through the presence of a caring midwife they have met before (Halldorsdottir & Karlsdottir, 1996). Knowing the midwife who’s attending and is offering continuous support lessens the need for pain relief (Leap, Sandall, Buckland, & Huber, 2010). Furthermore, women in labour have to know what’s happening, how the labour is advancing, and that their partner is present. It’s important that they have a sense of being in control of themselves and their circumstances. When this is the case, they feel strong and unafraid. On the contrary, if they don’t have this support, they can feel very vulnerable. Understanding and empathy, feeling cared for and supported, and not feeling alone are all primordial prerequisites for a positive birth experience. Women themselves express the importance of having a good relationship with their midwife (‘to be able to express myself freely with her, without feeling shy’) and that only people they trust be present during the intimate experience of giving birth(Halldorsdottir & Karlsdottir, 1996) . In summary: they must have a relationship of trust with the practitioner assisting them, who is a person known and familiar to them, having met before; they should not feel threatened, stressed or judged; and they should be able to be themselves, as they are through sexual intimacy.
Most people would be unable to have sexual relations in front of strangers dressed as doctors, or in an aseptic operating theatre under a surgical light and with monitors in the vagina… Likewise, it is almost impossible to have a good birth experience surrounded by strangers in a delivery room under a blinding operating light and being unable to move freely.
The mother’s stress about feeling exposed in front of strangers is more than enough to arrest the process or even cause the baby to begin to suffer. Consuelo Ruiz Vélez-Frías a highly experienced midwife who assisted in thousands of natural births during Franco’s dictatorship, used to sum this up none too romantically in saying, ‘giving birth is like having a shit – it’s a physiological act’. Nobody could defecate lying down with their legs in the air and surrounded by strangers.
Women certainly need to have a connection with the person assisting them in birth. For this reason, it makes no sense to be assisted by a stranger that would probably cause a complication, in fact. As the expert doula, Penny Simkin, observes:
Labour progresses well when the mother feels safe, cared for and respected; when she is able to move about and be freely active, in a vertical position; and, when her pain is managed safely and adequately. Wellbeing is further increased by the presence of her partner or loved ones, with competent and confident professionals and doulas, and in a comfortable space to give birth that is heated and well-equipped. If the woman feels embarrassed, inhibited, ridiculed, vulnerable, incompetent, alone, judged, insecure, restricted, constrained, ignored, disrespected or insignificant; a psychobiological reaction takes place, which interferes with effective progression of labour .
This theory on the parallel between loving or intimate relations and the birth process has been repeatedly put forward by natural–birth advocates(Odent, 1982). In these contexts, it is especially understood that the altered state of consciousness particular to giving birth needs to be respected and that the most important thing is to not disturb the woman in this. On the contrary, in more medicalised birth care settings, such as large hospitals, the importance of facilitating the neurohormonal state of a physiological birth is usually dismissed or ignored.
But regard should be shown for the ambience of sexual intimacy in which the woman can listen to her body, express herself and move with complete freedom, without inhibitions, given that ‘every mother and baby is likely to benefit from additional support for physiologic childbearing’(Buckley, 2015).
Notwithstanding this, even less attention has been paid to what happens on the other side of the coin, in terms of the effect that birth care and dealing with this aspect of people’s sexuality has on practitioners. What is birth assistance like for them? How is this unique professional relationship with women and how should it be? What is it like to work within the intimate and sexual space of women and their partners? How does their profession affect their personal lives?
To assist birth well it’s important to be comfortable with the labouring woman’s demonstration of sexuality. A thorough understanding of physiology is also vital, to care for her properly and to recognise when there is a problem. The most important traits for midwives would probably be intuition, empathy and the ability to connect with the woman in labour – in addition to their invaluable technical and scientific knowledge.
As Penny Simkin points out, working with a woman in labour requires being open and receptive. It’s important to be observant of how the woman is doing and feeling – of her affective state – but also of one’s own. To be able to deal with the emotions of labouring women demands a certain degree of personal work on the part of practitioners. Practitioners must work on their own feelings to be able to attend to the emotional needs of others, which can be a source of stress in health care settings.
Empathy is the ability to take on the feelings of others and to feel what they feel. The work of midwives involves a high degree of mutuality and reciprocity that can go far beyond empathy. It’s the emotional availability of the midwife that favours the likelihood of the woman
having a good birth experience (Hunter, 2002; Lundgren & Dahlberg, 2002). But for exactly that reason, if anything goes wrong, it’s also devastating for the midwife. To assist a birth well, one has to be invested in the process, though this can be incredibly difficult or impossible in certain clinical settings.
SUFFERING AND TRAUMA OF CHILDBIRTH PRACTITIONERS
The exhaustion and suffering of midwives is enormous. The vast majority of them originally entered the profession on a vocational basis, to care for mothers as best as possible. But all too often they find that this is nearly impossible, given the awful conditions and huge demands of their working environments. As one midwife pointed out in an anonymous letter published in a British newspaper:
I cannot care for each woman individually when I have so many under my care. I find it nearly impossible to give safe, high-quality care to women and their babies when I have so many others to care for. I cannot always be compassionate and kind when I am hungry and tired from not being relieved by another member of staff. This is personally devastating, as it is caring for women, giving safe and high-quality care and being compassionate that first inspired me to be a midwife.
The reality of my work is that I am often left exhausted, frustrated and dissatisfied so that I am not able to do the good job that I know I am capable of doing […]
I am extremely upset that my only solution seems to be to resign as a midwife and leave a job that I love and I know I am good at […] I cannot work like this any longer – exhausted, frustrated and in fear .
Mavis Kirkham, a British professor and midwife, has outlined and analysed the difficulties faced by British midwives, the fact that the majority of them choose to work a shorter day (not to mind children or elderly parents, but to look after themselves and cope with the stress of their work), and the fact that so many leave the profession. ‘It’s almost miraculous that so many midwives work so hard to care for women in a system that neither values midwifery nor motherhood’, according to this very experienced midwife . Kirkham adds that some even opt to become doulas after many years of midwifery, which is curious.
Obstetricians don’t have it easy either. In the current context of preventive medicine, many suffer tremendous stress when something goes wrong in birth and some consequently decide to leave obstetrics, dedicating themselves only to gynaecology (Ghetti, Chang, & Gosman, 2009; Mollart, Skinner, Newing, & Foureur, 2013). Obstetricians are the most in-demand professionals and it’s important to point out that they currently receive more requests to not perform a caesarean than to do one unnecessarily, for example. Quite frequently, when a baby suffers damage in birth, obstetricians deny responsibility to indemnify themselves against the costs of the baby’s future care, which is not generally covered by social security or the presently inadequate welfare system for people with disabilities or dependencies, in Spain and in many other countries.
Added to the strain of the social context promoting defensive medicine are the working conditions endured by many clinicians and midwives, which leave much to desire. Hospitals do not safeguard the wellbeing of their employees. A great number of gynaecologists and midwives are hugely stressed during their own pregnancies because of managers or colleagues who treat them with very little empathy while they are expecting.
Childbirth professionals can also be traumatised by the dehumanised nature of their work. They can feel impotent or unable to intervene to avert trauma. In a qualitative study carried out by Cheryl Beck, 26% of obstetric nurses satisfied all the diagnostic indicators for Post-traumatic Stress Disorder (PTSD), having witnessed their patients’ trauma (Beck & Gable, 2012). Being present at what labour and delivery nurses described as abusive deliveries increased their risk of suffering secondary trauma.
The nurses used phrases like ‘the physician violated her’, ‘a perfect delivery became violent’, ‘unnecessary roughness with her perineum’, ‘felt like an accomplice to a crime’ and even ‘I felt like I was watching a rape’ They felt tremendously guilty and said that they had failed their patients by not defending them or question the obstetricians’ actions (Beck & Gable, 2012).
Significant numbers of the midwives, gynaecologists, resident doctors and nurses surveyed in that study eventually opted out of working in maternity units because they could no longer put up with the violent nature of the work. They didn’t feel capable of performing episiotomies or the Kristeller manoeuvre at will, or watching others do them. Those that choose to remain in settings where respect towards women is not a given, continue to suffer with insomnia, irritability and sometimes serious inner conflict. This heightened sensitivity often manifests as a sense of personal failure, of feeling incapable of doing what others are able to do, or feeling cowardly for not daring to leave the job or speaking out when others give ridiculous and potentially detrimental orders. The personal cost is extremely high and to address the issue, the actual extent of violence must be clarified and understood).
The first country to recognise obstetric violence as a legal concept was Venezuela. In Venezuelan legislation, through the Organic Law on the Right of Women to a Life Free of Violence (published 19 March, 2007), obstetric violence is defined as:
The appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones [abusive medicalisation and pathologisation of natural processes], bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women. (Pérez D’Gregorio, 2010)
Article 51 of the Law explains acts that are considered as constituting obstetric violence:
(1) Untimely and ineffective attention [tending] of obstetric emergencies; (2) Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available; (3) Impeding the early attachment of the child with his/her mother without a medical cause […] and blocking the possibility of holding, nursing or breast‐feeding immediately after birth; (4) Altering the natural process of low‐risk delivery by using acceleration techniques, without obtaining voluntary, expressed and informed consent of the woman; (5) Performing delivery via caesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman. (Perez D’Gregorio, 2010)
The concept was subsequently recognised in countries such as Mexico and Argentina, where obstetric violence is also now classed as a criminal offence(Fernández Guillén, 2015). While, in terms of activism, since the creation of the first Obstetric Violence Observatory in Spain, at the end of 2014; other observatories have been established in Chile, France, Italy, Portugal, Argentina and Croatia that are now clustered through an international network that is working towards the eradication of this type of violence .
We might ask ourselves then, how childbirth professionals come to engage in obstetric violence? Indeed, there is no simple answer to that. A key factor is the lack of training and established techniques on how to deal with the psychological, emotional and sexual aspects of birth. Many practitioners haven’t even been taught basic clinical communication skills through their medical or nursing studies, or in obstetrics or midwifery training. In residency, psychological aspects are notable by their absence, especially in relation to the training of future obstetricians. They are not shown the importance of looking after the psychological state of a woman in labour or how the clinician’s emotions (especially fear) can affect the woman about to give birth.
Another factor in the practice of obstetric violence is Burnout Syndrome or being burnt out, which has been recognised and studied for decades now through research into organisational psychology – most commonly experienced by people in caring professions and especially in clinical settings. Practitioners who are burnt out suffer extreme emotional exhaustion, low professional self–esteem and tend to depersonalise their clients or patients (Maslach & Jackson, 1981).
Although it might seem best that those affected by Burnout leave or change their jobs, in the current climate of limited labour mobility, burnt out practitioners usually remain in their positions where their unhappiness often has a contagious effect. Even young and enthusiastic people burn out quite quickly working in a setting where there is no effort made to improve the quality of care or where women’s emotional appeals are sneered at. The mental health of
healthcare professionals is not an indulgence, but vital to take into account for them to be able to work optimally (Fernández Canti, 1995).
In 2013, I participated in a thematic conference on the subject of obstetric violence at the University of Valparaíso, in Chile. Many midwives, students and gynaecologists spoke of being traumatised by the violence they had often found themselves having to engage in. Mention was also made of how interns and resident doctors are sometimes distressed for the same reason. College directors and others responsible for training were present. Everybody listened, lots of people cried, and many spoke out. One midwife described to me the first time that she attended a birth with two fellow students: ‘It was a very violent birth. One of my college mates fainted on the spot’ and ‘in the first few months of rotation in the maternity unit, lots of people gave up or became ill. I suffered irritable bowel syndrome for six months because I actually needed to take benzodiazepines to cope with being there.’
The following year, the midwife Lola Ruiz Berdún and I undertook a preliminary study to investigate awareness of the concept of obstetric violence among childbirth practitioners, as well as any impact this may have had on their professional and personal lives. We conducted a pilot survey consisting of a self-administered, web-based questionnaire containing 11 items that 74 professionals responded anonymously to.
To the question on whether they had ever witnessed obstetric violence in training, 94% responded positively. Furthermore, 80% felt that they had been taught to use or be complicit in obstetric violence and 79% of respondents had felt obliged or pressured to employ violent practices in the labour and delivery room. When asked to describe instances of what they considered as obstetric violence, they gave clear examples of serious and institutionalised violence towards women giving birth and their babies:
Sedating women so they’re quiet and compliant, instrumental deliveries being done so a resident can practise, shouting at women that they’re doing badly and that they’ll end up killing their babies in the process…
Witnessing an unnecessary forceps delivery, done because they [the obstetrician] needed to go for dinner. Preparing a woman for caesarean, for no reason other than wanting to finish before a certain time.
Expressions like, “don’t explain so much to the women”, “the less they know, the better” and “some midwives don’t know how to deliver women”. A male midwife once told me that “you have to take charge of the birth or the woman will get carried away.”
Denying women water or being able to get up and walk around. Being ordered by the midwife to perform episiotomies that are not indicated. […] I once saw a woman’s mouth being covered to stop her from screaming.
Accusing the woman of not wanting to give birth. Telling her that she didn’t know how to push. Refusing her an epidural because when they had offered it before, she turned it down (it was still possible to administer, but the anaesthetist refused).
Women being examined by up to six different people, without any privacy throughout. Births in which more than 15 people have come into the delivery room, each with their own agenda, without paying any real attention to the woman other than to her perineum and vagina.
They teach us that we have to protect ourselves, so if we see any instance of violence, to always exempt ourselves by saying that what happened was in order and never tell the woman the truth or back her version of events.
The personal cost to the practitioner is extremely high. Asked about how they were affected by witnessing such births, those surveyed responded:
I had symptoms of depression after leaving the delivery room traumatised and in tears. A gynaecologist slapped me when I nicely and politely touched his arm and looked him in the eyes as a way of asking him to stop the brutal Kristeller manoeuvre he had been doing on a young woman in labour (for several minutes). The young woman was asking him to stop and he kept going and going. It was like a rape. I still feel like crying and have nightmares about it.
I’ve often gone home in tears and dreamt about previous births. More than anything, I feel extremely guilty for having been, to a greater or lesser extent, indirectly complicit in an act of violence.
Realising that many of the complications that arise are our fault. I know I’m right because the vast majority of births are complicated by the unnecessary procedures that we do.
I’ve never cried more than I did during my midwifery residency – too often because I felt complicit in violence.
A considerable number of respondents mentioned professional impacts such as having had to change their place of work on different occasions, having left the profession or having switched to assisting in home births:
I had to look at other ways of assisting birth and options outside of hospital settings. I now assist home births. […] Quite simply, I had to flee a system that I don’t believe in. […] I stopped working as a midwife.
The most commonly cited effects of their experiences include demotivation, a sense of guilt, feeling powerless, deep sadness and aggression:
It’s been a very painful journey but I now see that the conflict I’ve felt coming from somewhere deep down, says a lot about the pain disguised as false power underlying my profession in midwifery. I now realise how self-deceptive I was in my job, believing that I was some sort of
saviour…such arrogance in the face of life and death. Recognising the deception that shrouded my position has made me more humble and trusting in life, while acknowledging death.
I became irritable, stressed, aggressive and overreactive (in the negative sense) to the slightest request. It affected me family-wise, making my partner feel insecure and causing my children to become afraid of me seeing me so angry with the world.
I am afraid of childbirth, which is why I haven’t become a mother yet.
The majority of practitioners who took part in this study recognised obstetric violence, having witnessed it and having been trained to use it. Although the study was a preliminary one that needs to be replicated, I believe that it indicates the dimension of the problem.
For childbirth professionals, just as for many mothers, their trauma arises not from the need for an emergency caesarean section, but the possibility of serious maternal haemorrhaging or even a baby dying. Their trauma almost always stems from maltreatment, seeing the woman in labour being treated badly, unnecessary interventions being performed, shouting, threats, indifference… In other words, obstetric violence. I have come to the conclusion that for birth care to improve, it’s not enough to produce tons of evidence–based scientific information; what is really needed is a change of mentality, whereby practitioners are cared for, especially regarding their emotional and psychiatric health. Healing spaces must be created to allow or facilitate childbirth professionals to express their pain and to talk about how they had felt in the delivery room; sharing experiences and together seeking a way to prevent and/or heal negative after–effects, so as to break the vicious circle they find themselves in and to put an end violence in the birth process.
It is also vital to understanding the relationship that exists between PTSD in women, maltreatment and the factors that indicate for this type of behaviour in care by practitioners. The high level of deep emotional suffering experienced by a great number of childbirth professionals must be made visible and therapeutically dealt with. Dialogue between women using maternity services and professionals is urgently needed to put an end to obstetric violence.
HEALING PRACTITIONER TRAUMA
The American midwife, Mary Jackson, has spent years studying how the personal aspects of practitioners influence the way in which they assist births. Jackson highlights the importance of practitioners being able to explore what is going on in themselves and being able to review their own birth stories or experiences of childbirth. If not, all of this can surface in every birth they assist, in one way or another. As Jackson explains:
I think primary and step number one is: to do your own work. To always, continually, do your own work. […] If as a midwife, I walk into a birth and I haven’t integrated what happened at the last birth and it was something big that happened and I carry all of that into the next birth, then the worry, the concern, the fear and the constriction is going to be present in my body. I’m going to have a worry that the same thing could happen with the present birth that I’m at instead of seeing it as a new and individual experience and really differentiating between what happened in the last birth from what’s occurring right now (Cerelli, 2013).
Every birth brings an opportunity to heal and repair, not only for the woman in labour and their partner or family, but also for the practitioners attending. Realising this potential does requires a degree of effort, however: to listen to oneself and others; and to trust in life, nature, physiology, or even the mysterious. Says Jackson:
One thing I’d want is the trust from the practitioners – whoever is attending the mothers – that they trust in birth, they trust in women’s abilities to give birth, they trust the baby’s knowing about how to be born. That’s one place that I could see make a huge impact (Cerelli, 2013).
We must create meeting and support spaces for childbirth professionals, where they can listen to each other and talk about their individual pain. I believe that this is the only way that mothers and baby care will improve. Care of practitioners is vital so that they are able, in turn, to care for others and because they usually carry a significant degree of accumulated trauma, invariably hidden deep in their souls.
‘In the ideal NICU [neonatal intensive care unit], psychosocial support of both NICU parents and staff should be goals equal in importance to the health and development of babies’ (Hynan & Hall, 2015). I believe that this citation on the importance of looking after ICU professionals’ psychosocial health is also applicable to childbirth professionals. In the ideal maternity unit, the wellbeing of practitioners should be equally important to that of mothers and babies. A healthy working environment for childbirth practitioners should not just mean that facilities are nice, warm or comfortable for both the women in labour and those assisting them. It should also mean that clinics or hospitals concern themselves with the mental health of their employees and that they look after them through the provision of specialised supervision following difficult circumstances (such as intrapartum death), flexible working hours, and effective care conciliation policies, for example. It must be understood that good birth care, just like terminal care, requires a special commitment that is only possible if attention is paid to the emotions of both women and practitioners.
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 9 https://www.pennysimkin.com
 11 https://vimeo.com/101904692
 The practice of applying manual pressure to the uterine fundus to facilitate and expedite a vaginal delivery, which is now widely recognised as a dangerous manoeuvre that carries the risk of uterine rupture (https://gh.bmj.com/content/3/3/e000906