By Shane Ridley
Earlier this year one of our Committee members, Shane Ridley, circulated some thoughts on being assertive and compiled a guide to help people think through the issues. It encouraged a flurry of debate, from which the following thoughts emerged:
Informed consent is not a matter of 'choice', it is about understanding what the problems are, or discussing the options available and then making a decision that is best for one's self or one's baby. Informed consent should be about encouraging women to be assertive; many women are doing so, but in order for their assertiveness to make a difference their views need to be respected and if they are not women need to be able to walk away (difficult when in labour).
A real, and barely acknowledged problem, is that women who are normally confident and assertive in their everyday lives (business owners, executives, university lecturers, senior nurses, doctors, media people etc) simply cannot be assertive when they are in labour and giving birth - or even in late pregnancy when they have recently had a baby. A situation that often arises from deep seated problems from childhood, perhaps related to her upbringing, previous abuse, or her personality. So what chance is there for the woman who cannot be assertive in her everyday life? Many women, having been coerced or bullied, assertive or not, end up feeling guilty that they have failed themselves and their babies because they did not strongly refuse to comply (or their refusals were overridden).
Another aspect of this problem is that normally assertive or even mildly questioning behaviour is increasingly interpreted as aggression or threatening behaviour (as Alice Charlwood found when she took part in a workshop on birth - see page 17). Far too many health professionals are aggressive - they may not shout or scream - but they certainly intimidate and undermine1. They are bullies and they too need to learn to be assertive.
When women have one to one care with someone with whom they have been able to have an assertive relationship which means respecting each other's views, abuse is less likely to occur; as a respected midwife once commented "It is difficult to abuse someone your know and have cared for over the last six months". Having developed a relationship with the parents the professional would then be with them providing support, and able to act as their advocate should they require the skill of another health professional during pregnancy, birth and the postnatal period. While women fail to receive this kind of care the opportunity for bullying and abuse increases. Being assertive is not always easy, and for some it is very difficult indeed, but the following piece by Shane Ridley is intended to provide a basis for thinking through the problem and, one hopes, a basis for dealing with difficult situations.
"It means being honest with yourself and with others; and it is about respecting yourself and others. When you are self-confident and your behaviour is assertive you are open to others and their views even though they maybe different from your own. You are able to express yourself clearly and communicate effectively". Anni Townsend, Developing Assertiveness, (Routledge, 1991).
We can all be assertive in certain situations, but what we need to learn is the ability to be assertive in all areas of our lives. This means having some understanding of where we need to be assertive. Pregnancy and parenthood bring many extra pressures, changing hormones, relationship shifts - a time when we can feel less empowered than usual, so we need to boost our feelings of self-worth. This list is likely to ring bells with you if you are having any difficulty being heard about how you have your baby. This is what being assertive is all about.
Do not muddle being assertive with being aggressive or passive.
Often confused with assertiveness, it is not at all the same. An aggressor uses humiliation, intimidation and body language to manipulate their victim. I bet you can think of situations where you have been at the mercy of an aggressive person! Or are you aggressive - do simple requests end in conflict and argument, do you shout a lot, are you a road rager, do you manipulate people?
When a person is passive they will want to appear to be agreeing with people, so as not to upset them. They will follow instructions, even if deep inside, they do not agree. Have you shrunk into your passive shell? Are you angry inside, unable to communicate what you want? Do people speak over your head, are you invisible?
Here's a little test. How many of these statements do you agree with?
If you agree with any of these, your assertiveness skills need a boost. This is where you should be, to be truly assertive -
I'm OK You're OK I'm not OK You're OK I'm OK You're not OK I'm not OK You're not OK
You might have come across this box before (Thomas Harris, 1967), but if not this is the explanation:
I feel OK, I've said what I wanted to say, I've told you how I feel, I am content with the result. I am assertive.
You feel OK too, you've listened to me, you know how I feel, I've listened to you, I know how you feel, you are content with the r e s u l t .
I'm OK, you're not OK
I might be feeling fine about the result, but I've left you feeling bad. I have disregarded your point of view and judge myself to have more power and rights. I am aggressive.
I'm not OK, you're OK
You might be feeling fine about the result, but you've left me feeling bad. I might think that you are more important, have more right to your opinion and therefore I allow you to control the situation. I am passive.
I'm not OK, you're not OK = conflict.
The answer is staring at you when you look in the mirror! Next time you are alone in the house, go to your quiet place, stand up straight and say "I am a very important person", say it again louder, and again and again! Then whenever you look in the mirror tell yourself - loudly if you are on your own, in your head if you are in company. Assertiveness encourages us to find a sense of self, centres on our belief in our right to express opinions, ask for help, and disagree with others.
If you ever have an opportunity to go on a course - take it up as it is a skill which, once learnt, will never leave you. If every child at school were taught it, along with the teachers, I do believe we would have less behaviour problems. I'm getting sidetracked...
If you cannot go on a course, here are some ideas to start practising at home. The list is geared towards your pregnancy, but can be adapted for all life situations.
Try to keep calm - one of the things I carry everywhere I go is Rescue Remedy (available from the chemist). It is a Bach Flower remedy for anxiety, anger or stress. Good for going to the dentist, interviews, toddlers tantrums (for you and the toddler!) etc. etc. Once you mention it you find it is one of those things lots of people know about and would never be without. This can lead you to homeopathy, brilliant in pregnancy - I'm getting sidetracked again.
"Go placidly amid the noise and the haste and remember what peace there may be in silence. As far as possible be on good terms with all persons. Speak your truth quietly and clearly; and listen to others, even the dull and the ignorant; they too have their story. Avoid loud and aggressive persons, they are vexatious to the spirit... And whatever your labours and aspirations, in the noisy confusion of life keep peace with your soul. With all its sham, drudgery and broken dreams, it is still a beautiful world. Be cheerful. Strive to be happy." Desiderata, Max Ehrmann 1927.
I was amazed at the reactions this article provoked within the committee - everyone had a story to tell about their experiences and a comment about the advice (not all positive). But above all we realised that women need more assistance in this area. This article is just an opener - we shall be working on more ideas - as one committee member said
"If we want humanitarian services then campaigning groups like AIMS can create a role model. Learning to be honest about our feelings and exploring the unmet or met needs behind feelings enables compassionate communication and therefore, connection, even in conflict."
Please write to us with your thoughts, experiences and ideas. Remember that many midwives and professionals suffer a similar lack of assertiveness as some pregnant women.
There are lots of websites and books about assertiveness, but I started with a book called "A woman in your own right" by Anne Dickson (1982) and "I'm OK - You're OK" by Thomas Harris (1967).
As we know only too well from our postbag, and Shane points out, successful, confident women seldom manage to be assertive in labour, even when they are being manoeuvred out of adopting the position they know is best for their progress. We also have a couple of case histories where expensive doulas, who had been expected to provide support, were also ineffective, as they did not wish to antagonise staff. And assertiveness can fail, even in home births, as we know. Husbands and birth partners are often helpful - but can blame themselves, or are blamed, when they fail. Maybe we should run classes for the partners, with practising scenarios (like that described by Alice page 17) to show them how to deal with it. A birth partner needs to be clued up as to what to do, and how to do it, when the woman's mind, body and spirit are taken up with getting the baby out, and staff are insisting on implementation of an unnecessary protocol.
We would be most interested in your views and experiences - email: email@example.com
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email firstname.lastname@example.org or ring 0300 365 0663.
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