Emma Ashworth discusses how language can be used to support informed decision making
The language around birth has changed over the years, with ‘choice’ now being the way that women are supposed to retain control over their bodies and their births. Unfortunately, in reality ‘choice’ is not a choice for many women. Even the NMC has joined in on this rhetoric with their often repeated phrase, ‘We support choice, but it has to be a safe choice’. Who defines safety and what does choice mean if choices are limited?
AIMS often states that we should ditch the word ‘choice’, which implies a menu, and, as we have seen, items on a menu can be withdrawn. The word decision implies agency and would therefore be a more appropriate term. But how do we make our decisions? How are we to retain control of our bodies when language is used to undermine and coerce us, and to limit our options – often without the health carer being aware of this. Examples of this are ‘which hospital would you like to choose to give birth in’ (not offering other places of birth), ‘would you like us to try to turn your [breech] baby, or would you prefer to book a section?’ (not offering support for a vaginal birth) and ‘do you want vitamin k orally or by injection?’ (an assumption that it’s being given and no option for it not to be given).
This coercion starts during pregnancy, in antenatal meetings with the midwife. What generally happens is that the midwife tells us what they’re going to do:
‘I’ll just do your bloods now’
So lie on the bed and we’ll have a listen in’
We’ll book your scans then’
If you are a midwife and you’re reading this, please be honest and think for a moment. When was the last time that, instead of saying, ‘I’ll just do your bloods’, you said, ‘One of the things that we offer to you in pregnancy is blood tests. I’ll just go through with you what these tests are so that you can tell me whether or not you want them. The decisions are always yours to make and you can decline or accept any or all of the tests.’?
All of the above phrases put the decision making and control in the hands of the midwife. It is the midwife who is looking after the woman – which is quite appropriate – but she is also, usually quite inadvertently, undermining the woman’s control of her body and her pregnancy and taking the control upon herself.
Similar issues arise with women being undermining women at the start of labour. Telling a woman ‘you’re not in labour yet’ because she’s not reached a magic dilation point, when she’s in need of support and may be in significant pain, is confusing, scary and absolutely the antithesis of the role of a midwife to be with woman. The woman might be afraid: ‘If this isn’t labour, how bad is it going to get?’ Or she might be angry: ‘I AM in labour! Why won’t they listen?’ Neither of these emotions are conducive to a straightforward birth, and neither help women to trust midwives once they’re permitted over the threshold of the hospital.
Coercion may be heard during labour. How often do these phrases get repeated?
‘Here’s your room. Just get yourself into your things and pop up on the bed’
‘I’ll just examine you now’
‘I’m just going to break your waters – is that ok?’
Let’s look at these in more detail. Getting women onto the bed is so often talked about as a problem and yet still happens, every minute of every day. The bed immediately becomes the centre of attention. The woman is expected to comply, and, thanks to cultural norms, assumes that being on the bed is where she ‘is supposed’ to be. She will often lie down, as this is what we normally do when we get onto a bed. She will immediately be stepping away from the path of active labour, because her pain levels are likely to rise when lying down, her labour might slow down, and the idea of getting up may be more than she can consider – even if she’s encouraged to do so. Not only does she have to overcome her physical discomfort, but she also has to have a hugely powerful cultural barrier broken down – she has to understand that we don’t HAVE to labour and/or birth on a bed, and be confident that she will be supported to do otherwise.
Consider instead what happens when hospital midwives say, ‘Here’s your room. This is your space – feel free to explore and look around. Labour often feels better if you’re more upright rather than lying down. Remember, this is your personal birthing space, so just lean on whatever you want to, or sit, or stand, or even, if you wish, lie down – it’s entirely up to you. If you want some suggestions of what might feel good, let me know. Here’s how to use the lighting – often it feels good to have it lowered but you’re in control of this – change it how you want, when you want.’ Women who have wonderful midwives like this can hear this message, ‘This is my space and I am OK to look at things and move around within it. I am not confined to the bed, but I can use it if I want to. I have some control over this space and while it’s all new, it’s not solely the realm of the hospital. I have some control and that makes me feel more safe and secure.’ According to research on birth trauma,1 feeling out of control is more likely to lead to birth trauma, and feeling in control is more likely to lead to a positive birth experience, so ensuring that the woman is the leader of her birth from the very moment she enters her birth room is more likely to ensure that she exits it having had a good birth.
‘I’m just going to examine you’
‘I’m just going to break your waters’
The phrase ‘I’m just’, or similar ones such as ‘I need to’ or ‘So what we’ll do now’ are not requests, and they’re not asking for permission. Adding ‘is that OK’ is not giving the woman the space to provide informed consent. We’re British! We don’t say ‘actually, this is not OK’ very often, even when it’s very much not OK. Women often don’t realise that vaginal examinations are optional – and yet when else can we put our fingers inside someone else’s vagina without them properly consenting? We cannot walk up to any other stranger and say, ‘I’m just going to put my fingers inside you now.’ Why do midwives and doctors think they can with labouring women?
AIMS truly recognises the horrific pressure that there is on health staff to perform tasks according to guidelines and in a certain timescale. We understand that if midwives and doctors were to take the time to explain to women in their care the pros and cons of vaginal examinations, or breaking their waters, or any other intervention in birth, they will very quickly find that they are being pulled aside by their line managers. But, what’s the alternative? The alternative is that women are being inadvertently assaulted by the people who are caring for them. Without complete and proper consent, the default is that these interventions, no matter how well intended, are, in law, assault. Women need and deserve care givers who recognise this and who themselves are not prepared to be bullied into assaulting women, and midwives need service managers to support them to support women.
‘Everything seems fine, but I just need to get a quick trace, for the sake of your baby.’
‘We don’t want anything to happen to your baby.’
Even women who are firmly making their own decisions in their pregnancy can be shocked at how they can be coerced in labour. The physiological changes which happen during birth leave women vulnerable to the use of language, meaning that coercive phrases such as ‘it’s for the sake of your baby’ can be hugely powerful as a method of making women do what the health worker wants them to do.
In situations where there are real concerns women need to be given information in a calm manner in order to be able to fully understand the situation and to be able make clear informed decisions without feeling threatened. Scaring women into accepting tests or intervention is never acceptable, and the effects of this unkind and manipulative language can stay with a women for a lifetime. Birth trauma is often more about what was said and done to a women than an unavoidably difficult birth. Making women feel unsupported or vulnerable can lead to births slowing down or stopping, and trauma to the woman who thinks that something might be wrong. This is not just in labour. A very frequent complaint to AIMS is from women whose obstetrician has informed them that they must consent to an induction because otherwise they are putting their baby at risk of dying due to ‘post dates’, high BMI, and even being high risk due to a previous premature birth – with this pregnancy now at term. It is very common for us to receive calls or emails from extremely distressed women who had felt completely confident in their bodies and their births, only to be utterly undermined by such statements, and left in a state of utter confusion. They’ve felt patronised, ignored and dismissed, and they feel that the doctor somehow thinks that he or she is going to be more affected by the tragic loss of a baby than the parents themselves. Telling a woman that the most precious thing in her life may die if she does not conform to a guideline is simply cruel and utterly wrong.
As already mentioned, AIMS recognises the way that midwives are put under horrific pressure to comply. Peer to peer and top down bullying is anecdotally very common in midwifery. Midwives have reported hearing phrases from their colleagues such as ‘You’re brave, doing that...’, ‘Oh here she comes with her pinards and a cloth to bite down on’ and ‘I hope you’ve got your excuses ready for matron’.
Midwives and doctors go into their professions to care for people. The environment that they work in can change how they interact with all of those around them, their peers and those in their care. However, our actions remain our own responsibility. We recognise how hard it is to do, but AIMS very much appreciates and values those who stand firm against the pressure and the person who talks kindly to others. Find like-minded people – they may not even be in the same Trust as you – but they are there (ARM is a great place to start). Be the person you want to be, and the person you want others to be.
No matter how wonderful each midwife is, they’re still fighting against a culture steeped in patriarchy and the false assumption that ‘patients’ (a word that just does not belong in maternity) should do what the doctors say. How often do we hear women telling other women, ‘they won’t allow you to...’, ‘I can’t believe they let you...’, ‘oh, that’s brave/unusual’. There’s a reason why the AIMS book Am I Allowed is our best-selling book. This is your body, your baby, your choice. Those words have power – don’t let them be taken away.
Let’s look towards a day when Am I Allowed is only spoken by health professionals asking permission of women, instead of women who are trying to get the support they need to birth as they want. When ‘I can't believe they let you’ is a statement of outrage between health professionals about their behaviour to women, and not about a woman who has had to stand her ground to get what she needed.
The only person who speaks the words that you say is you, and the words you say have power beyond anything that most of us can imagine. Use them well.
Emma is an AIMS Trustee, doula and breastfeeding counsellor
1. Greenfield M, Jomeen J and Glover L (2016) What is traumatic birth. British Journal of Midwifery,Vol 24: Issue 4: Pages 254-267.
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