Liberating childbirth

AIMS Journal 2005, Vol 17, No 3

Ruth Sharples Weston gave a rousing speech at the Birmingham conference that had everyone on their feet and clapping by the end. We print the text in full here, as her views from a mother's perspective embody much of what AIMS campaigns for on a daily basis.

I am a trained theologian specialising in liberation theology. I have also been a practitioner of my subject being involved in church and community work and grassroots organising for nearly 15 years.

Three years ago on impulse I took over the only Yorkshire Birthing Pool Hire company 8 weeks before the birth of my fourth child. We are in the process of setting up a Birthing Your Way social enterprise. My family and I live on a council estate in Bradford, West Yorkshire.

The following is a reflection on my personal experience, and so I will begin with a piece of it.

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

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

Women-centred versus Consultant-centred care

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

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

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

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

So when we women are not the centre of our care reality is defined not by us, the birthing woman, but by the (absent) doctor. And so in my cameo, what carried weight was not my description of what was happening to me, nor the opinion of a trained midwife's examination, but the hands of the doctor. Only he could inform me that I was in second stage. And one of the most shocking things I find about the medical literature is how little medicine thinks to ask the woman! validate women's experience of birth. It is the doctor who really knows what is going on and so women have stopped believing in their bodies, they can no longer read its messages, and midwives are trained to defer to doctors and machines rather than their own eyes and hands and expertise of normal birth.

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

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

No More Excuses

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

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

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

The demise of the independent skilled midwife

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

Three examples:

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

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

Change the Scenario

So what are we going to do about it? How can we change the scenario and make that young midwife of my story in to a confident professional and me as a birthing woman, the subject and centre of care?

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

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

There are three ways to work against an oppressive system:

• Subversion
• Avoidance and
• Confrontation

Subversion

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

Women subvert the system often unconsciously by smiling sweetly and doing their own thing - and calling the midwife too late to do anything about it. At the birth of my fourth child, during my labour, we were told that there was no midwife available competent to attend my waterbirth. When told this my husband smiled at the midwife present and said "That's OK I have attended two waterbirths and Jeanie here has attended one - we will tell you what to do." Thirty minutes later three midwives had arrived! Subversion is the valid defiance of the powerless, and I want to encourage it. Like rabbit burrows and wood worm it can undermine big structures and edifices. But I doubt whether it will be enough to bring the whole system tumbling down even if it grinds it to a halt. Subversion can undermine without effecting change or offering an alternative. We need to do more.

Avoidance

Avoidance is another form of opposition. It is practised by women and midwives alike. It is where you circumvent or bypass the system altogether. So you become an independent midwife or you engage an independent midwife, or go to a birthing centre or plan an unassisted birth. Some women have even left the country in search of the birth they want.

This action is costly for the protagonists. Midwives give up security and income and invite the hostile attentions of the medical establishment. The families who engage independent midwives or birthing centres pay substantial sums - for us fifth time around it represented 15% of our then income. Unassisted birth invites the hostile attentions of the medical establishment - for how is a woman to give birth without a medic to ensure she does it correctly! Those of us who have practised avoidance and have paid handsomely for the privilege, will probably say that one way or another it is worth every penny and every sacrifice. But it can be a difficult road, and so we must acknowledge its important role in bringing about change by providing an alternative model and practice. It shows that the alternative is realistic, workable and effective. Like the radicals and nonconformists of the past we must take courage and be proud. We have done it because we are worth it.

Confrontation

Confrontation. Ah! This is the difficult one because we are so well conditioned not to make a fuss and do as we are told. And if we are nice, nobody listens, but if we get angry we are dismissed as emotional neurotic bitter women. If we 'rock the boat' 'they will dig in their heels' but if we don't 'rock the boat' there will be no imperative for change. Sadly the feminism of the last century has not overturned these cultural norms particularly in the maternity services. But I want to say to you now that silence is complicity and doing nothing for change is passively supporting the status quo. Ultimately to bring about change we must confront the beast and bring it down. My husband is an archaeologist and he says that ancient human hunters knew that they could not kill large prey like bison and mammoth with one shot of their little arrows. So what they did was make arrows that did not penetrate to kill but made shallow but very messy wounds, several of these arrows and the beast finally bled to death. We may not be strong enough to bring the beast down with one shot but we need to make sure that our small actions make maximum damage.

There is a problem in that for women like myself the moment of confrontation happens at our weakest moment on enemy ground. And so I would say we need to organise, we women do not just need advice we need advocacy. We need someone at the consultation acting as a witness, and, if necessary, a spokesperson and advocate. There is precedence for this in many areas of social and advice work. Midwives have told me about the bullying culture, the backbiting, the fragmentation. Unfortunately this is not uncommon for an oppressed group but my experience of working with deprived groups in Bradford is that all you need in a particular place is a few people getting together and organising for change to happen. But we also need groups of midwives at local and district level deciding not to play the bullies' game, and supporting one another to withstand the bullying and change the culture. And we need networks of women and midwives who will turn up and be there to support midwives and women being taken to the cleaners for standing up and being counted.

Midwives need a union

And midwives need a union not a Royal College. You need a union, a NASUWT, a NUT an AMICUS, a union with a track record of sticking up for its members through thick and thin, and who campaign vigorously for change. You don't have such union representation at the moment and you are suffering for the lack of it. Someone or some persons need to put their hand up and sort out a union or two to campaign and protect midwives.

And what else, well, we need groups of parents to band together for letter writing sessions to challenge current Trust policy and change legislation. We need groups who will band together to do some high profile direct action and publicity stunts. Look how a vicar and a 60 year old woman have hit the headlines and raised the issues of council tax for being willing to go to prison. And I am telling you they are being backed by a strong organised union. And their supporters would have packed the court. And imagine a baby sit-in. Imagine a squat-in. Imagine an impromptu NHS nativity play. What about a tshirt campaign? Confrontation can be fun too, and keeps us going. And so to bring about the change we want we must be subversive, we can practice avoidance and set up independent structures, but we must ultimately confront the beast.

We need to be determined, cunning, and fun. We need to band together, to organise and unionise, to write letters and demonstrate and we need to educate, educate, educate. Talk to our daughters, sisters, mothers. Talk to our sons, and husbands and brothers (after all they have 50% of the vote). And we need to claim fearlessly our heritage to birth and bring to birth.

To be the women, the mothers, the midwives we are. We need to campaign as determinedly and creatively as we give birth. Because our daughters are worth it. And so are we.