Reflections on birthing

AIMS Journal, 2012, Vol 24 No 1

Susannah Sweetman reflects on her experiences

When I became pregnant with Evie, Mal and I had just moved back to Dublin. We had been living in the South of France, and left Toulouse in July, to go to the Caribbean and deliver a yacht back to Ireland. It was a desperately stressful trip, delayed because of problems with the boat, engine trouble, difficulties to the point where we had no option but to leave the Caribbean at the peak of the hurricane season.

My memories of the crossing are that it was in fact quite calm – we were so relieved to get away from the British Virgin Islands, and out to sea. There is something about dropping out of soundings (when it's too deep to gauge the depth) – it's like dropping off the face of the earth, or into an alternative two-dimensional universe. People ask whether it's claustrophobic, being on a boat for that long, in such a small space with three other people, but you'd be surprised: your boundaries shrink, and you don't need that much space. Things become simplified. Time is different at sea, measured out in threeor four-hour watches. Catching fish, cooking, reading, sleeping. There's less talking, and more space between people than one might imagine.

There is very little one can control in the middle of the ocean, so you have to accept the conditions. There's no going back, in September, in the Atlantic. The further north we got, the less likely we were to be hit by really bad weather, so every line of latitude was a cause for quiet celebration, acknowledged with a nod, a toast of coffee cups. We became more relaxed the closer we got to the Azores, and then to Cork. I don't think we ever thought anything terrible would happen, we were all quietly confident, but continued to worry, dutifully, superstitiously, in case something might sneak up behind while we weren't looking. With sailing, all that wind and water, you can never predict what will happen at the end. You can sink half an hour from port, or your anchor can drag when you're moored. Things can go wrong very quickly. You can never let your guard down. We arrived in the Azores almost three weeks after we left St. Maarten, with hurricane Katrina screaming across the Atlantic below us. It took another eight days at sea to get from the Azores back to Cork in very heavy seas and winds. We arrived in Baltimore in the middle of the night, accompanied by dolphins and a pod of comically friendly pilot whales. It was a huge relief to be back in Ireland. We were delighted to be home.

The reason I mention these things about sailing is because, for me, there are parallels with being pregnant. There are no half measures. Once I was pregnant, I was committed to it, and I knew that somehow I would have to come through it, and out the other side. I did worry about things, the birth, the pain, whether I would be any good at it all, but I worried more about how difficult it was to get any straight answers from anyone about it. I recognised warning tones in the antenatal classes and from other women, my mother and my aunts, whispered lines of coded advice here and there, my mother blurting out 'oh, poor you!' before she could stop herself when I told her I was pregnant. But at the same time, I trusted myself. I felt confident. I had always been healthy. I felt strong, I had a supportive partner. I trusted my body. I really believed that I would be able to hold my own. I thought that when push (excuse the pun) came to shove I would be able for it. It was something I tried to hold onto throughout my pregnancy, but it became increasingly difficult.

I have been trying to write down my birth stories, as a frame for what emerged from them. It has been surprisingly difficult to recount my experiences of birth in a chronological way – I can't seem to remember it in that way – the camera jumps. It prioritises unexpected memories. Everything is fragmented. There is no unifying narrative, other than a steadily growing sense that I ought not to be as confident as I was, because anything could go horribly wrong at any moment, and that you aren't out of the woods until ... ever? At least until you're holding the baby. The chronology of what actually happened makes less sense to me than the ebb and flow of certainties and insecurities that accompanied the events. It is only now that I realise that it took my second experience of birth to make sense of my first.

Evie

I looked forward to the first booking appointment so much when I was pregnant with Evie: I was very naive – I think I expected to be made a fuss of, just for the fact of being pregnant. I was so disappointed by it. The atmosphere in the waiting room was dominated by a sense of mutual suspicion between the women over who was next in the queue. I sat opposite a midwife who sat behind a computer screen and fed deeply personal information into a database about me – if I had been under any illusion that I was special before I went in for that first appointment, it ended there. My disappointment (an understatement – disillusion?) turned into anxiety, which over time fed into mistrust of almost everyone I came into contact with – the scan technician, the midwives in the hospital who take your blood pressure before the appointment, the GP, the secretary of the local semi-private clinic, who seemed to have an inflated sense of control and propriety over information that was not hers, the obstetrician and his henchwomen, his registrar. Any information that I got was on a need-to-know basis only. The obstetrician galloped through the appointments. Beyond, the people whose job it was to measure and tick boxes about my size and weight. I felt there was a withholding of information from other sources – between Malachi and I we have eleven aunts: they all have daughters, and lots of the daughters have daughters too. It's a family of women. They wouldn't tell me anything when I was pregnant – I kept trying to read in between the lines, and catch meaning in between their shared glances – I wasn't in the club yet.

The antenatal classes were a series of lectures given by a jocular midwife who laughed her way through anecdotes about bewildered new mothers struggling to cope – with labour pain, with breastfeeding, with a crying baby, with nappies.... I began to feel that the subtext to her telling these tales was to illustrate to us novices that there was nothing new in any of what was happening to us. She had seen it all before, and there was nothing special about any of it. She told us we would 'just know' when to go to hospital. I wasn't so sure I would know. I went into labour at home. Even though I knew it was coming, it was still a shock to think that I would have a baby at the end. I rang the hospital, and the woman I spoke to said that it didn't sound like I was in labour (what, in my voice, made her think that?). I countered with my own mystic 'I just feel like I am' but that wasn't enough – the fact that I was still able to speak meant that I should stay put and ring back. An hour or so later, when I was able to speak in gasped fragments, we went to the hospital. There is something embarrassing about being in that much pain in public. There shouldn't be really, especially in a place where labour pain is part of the process, but it seemed to me that it was made embarrassing by the idea that it wasn't really acceptable to express pain. An older midwife called Mary came to examine me. Up until that point, everything was going well, and then, all of a sudden, she broke my waters during a contraction. I asked her to wait until the contraction was over, and she said 'it's alright, I'm not doing anything' – I remember feeling, thinking – I had never been so bewildered or shocked by the dislocation between what was being said and what was being done – it was like someone pointing at black and saying, insisting it was white – I simply couldn't believe what was happening.

Three or four years previously, my mother had been having chemotherapy, and once when we were talking about it she said, by way of explaining how she coped, 'I just pretend it's happening to someone else'. I pretended it was happening to someone else. I felt that it was the only way I could deal with so much uncontrollable panic. I felt totally dislocated from myself. I felt suffocated. I was so thirsty. They wouldn't give me anything to drink. It was like being tortured. I couldn't believe what was happening. The midwife told me to save my energy for pushing. I had an epidural. Malachi was told to leave. He didn't come back for a long time. I couldn't continue without him being there. Labour stopped. I had oxytocin. It started again. The epidural wore off, but it was too late to have any more pain relief. The midwife was telling me to push and I remember thinking that I thought she must be wrong because I just didn't feel like it, that she would come out anyway, whether I pushed or not. I remember thinking there was something vaguely melodramatic and theatrical about the whole scene, her shouting at me like a racehorse commentator. But I did push, anyway, because I thought maybe the epidural was confusing how I felt and the midwife must know something I didn't. I felt like I was acting. At one point I remember thinking that this was when a woman berates her husband for getting her into this situation – it could have been my next line. I thought that maybe the epidural had dulled my brain. They took a foot each. And then she was born. The umbilical cord was cut. It was like a cut snake. There was a spray of blood on my face and high up onto the wall behind me. Malachi's face was horrified. I don't know where they took Evie. They brought her back then. They shoved her up inside my t-shirt ('skin-to-skin!' someone bellowed) while I had stitches. I asked how many stitches – out of a bizarre sense that I ought to make conversation since no one else was – 'not many' came the reply ('too many' as it happened, an error that wasn't rectified until 9 months later). Everything about her birth was an assault – shock – brash – everything was too bright – too loud – staccato noises in the delivery suite – women screaming in adjacent rooms – midwives barking at us and each other. So that was that. There was something wrong with my head when I was still in the hospital – when I went to register the birth I couldn't remember Malachi's middle name. I couldn't make sense of anything they were saying – I couldn't decipher the meaning from the look on the midwives' faces when I was struggling with breastfeeding – Pity? Sympathy? I remember thinking about autism, and how people who are autistic find it hard to read other people's facial expressions, and that's how I felt. I had my perfect baby – I kept being asked 'was it a normal birth?' – when we were still in hospital, at the two-week check, the six-week check – surely it was not normal to have felt so obliterated? There had been such disparities between what had been said and what had been done, during the birth, and this now continued. On paper it had been a normal birth, healthy baby, healthy mother, nothing to report. I couldn't make sense of it.

I went to a breastfeeding group. When I began to speak to other women – it was only when I began to understand that my experience was a version of normal that things began to make sense – that is, the version of normal that passes for normal – a normal bad experience. At first I thought that a series of unfortunate events had led to me not having a good birth – the wrong people, the wrong time, bad luck, a particularly busy day at the hospital – but it was typical. If anything, Evie's birth hadn't been that bad – I hadn't been induced, I hadn't had a caesarean or a forceps delivery, or a ventouse birth. I hadn't been told that terrible things were wrong with my baby. I hadn't been told to pull myself together, or wasn't I lucky she was born alive. I was struck by how we all told our stories in the same way – there was so much fear and shock in those experiences. When I studied psychology, I was interested in issues around bereavement – when people have been through a bereavement, or any kind of a trauma, they repeat their stories in such a way that they become crystallised, so they can tell them over and over again without it really affecting them any more. It's a coping mechanism: to tell a story is to explain, without having to engage – it becomes a separate, independent entity that can be drawn on, like putting on a CD. They use the same phrases, the same pauses, intonations. Everyone does it. But to really work through something, you have to learn how to express it in a different way, and tell a different story. As the babies grew bigger, we talked less about episiotomies, mastitis, thrush, stitches, scars, blood and guts, and more about teething, sleep, feeding, weight gain. I felt like a birth veteran, along with my friends, my aunts, my mother.

Reuben

To really understand my story of Evie's birth I had to learn how to tell it in a different way. My second pregnancy was dominated by doubt and uncertainty and fear, reflected in my chaotic attempts at organising maternity care. When I became pregnant again, I was terrified – my first thought was 'I'm going to have to go through labour again'. I waited so long to book myself into anywhere that the midwife at the booking appointment asked me whether I would like to see a social worker to discuss why I had decided to conceal my pregnancy, maybe I was in denial about 'my situation' (I hadn't concealed it from anyone: I was paralysed). I thought the Domino Scheme sounded like the thing for me, by then I felt far more informed about models of care – but we were outside the catchment area. I booked myself into the semi-private clinic where I had been before, but I was determined not to be railroaded into anything this time.

I wanted to keep my options open though, and I thought that my local maternity unit might be better (or rather I thought at least women are able to drink during labour) so I booked myself in there too. The initial booking appointment was with a student midwife to whom I confessed my double booking – she said not to worry, that everyone did it. The waiting room felt like a holding pen. The women are weighed in public. It's degrading. One day, while I was waiting, a young Eastern European woman came in alone. She was 18 weeks pregnant with twins. She was having a miscarriage. The midwife taking her details treated her so badly, humiliating her, questioning her, broadcasting her uncertain responses to the room. I realised that this was no better than the semi-private care, worse if anything. I left. In one of our long discussions about it, Malachi suggested having a home birth. What it came down to was being somewhere safe, with someone I trusted – with someone who cared about the baby. Two of our friends had had home births – both had been transferred to hospital but they were both adamant that they would not have done anything differently. I read Anne Enright and Naomi Wolf, which was a turning point for me. Then I read Sheila Kitzinger, Ina May Gaskin, Ann Oakley. I became more confident as it began to make more sense to me.

I was 33 weeks pregnant when I rang the woman who was to become our midwife. She listened while I attempted to explain. She came to see us and stayed for two hours. I trusted her. The decision to have Reuben at home brought with it a huge number of unanticipated problems and decisions. I was so relieved to have made the decision that I'm not sure it really occurred to me we were opening such a can of worms. Responsibility was everywhere – did I really realise what I was doing, what I was getting myself into? No one seemed to have qualms about telling us we were mad. You're so brave. Would you not be worried? Will you be able to have an epidural? Would you not be afraid ...? Would you not just go ahead with it? The first time is always the worst. Just get it over with. Why would you do something so dangerous? What about all the ... mess?

Telling the obstetrician was difficult – she was pregnant too. I think she took my decision as a personal attack on her profession. It was not difficult to arouse her suspicion (I asked some questions – a dead give-away) even before I had decided, I made the mistake of seeking her opinion on home birth: 'the most important day of a baby's life is the day they are born' ... 'do you really think you'll be able to cope with the pain?' (I didn't know, was the honest answer – but the pain wasn't really what I remembered from Evie's birth – it was a distant second to thirst). She would never consider home birth because even if it only takes ten minutes to get to a hospital, those ten minutes could be the difference between life and death. She wrote down a list of different possibilities, a disclaimer. Did I understand that I was more likely to have a baby with cerebral palsy? That both the baby and I were more likely to die? I left with death ringing in my ears.

Our families were worried. They felt it was an unnecessary risk, that I was making a mountain out of a molehill. I began to gain an unlikely reputation as being stubborn and reckless, a troublemaker. Could I not just go in, find a nice doctor who would take pity on me, induce on my due date? Could you not just have the baby and then go straight home again? Magical, life-saving forces were attributed to the hospital (saving me from myself?).

Support came from unexpected places – our neighbours were excited. Kathleen, in her nineties, was delighted. She had had all her children at home, she told me, and no babies had been born on our road for nearly fifty years. She told me about all of them – a midwife arriving on a bike in the middle of the night for one. She told Malachi to let her know if he needed her to come in during the labour. When I went to collect my file from the hospital, a clerical officer marched up and handed it to me and said 'you're dead right! You're well out of here!', and then she was gone, before I had the chance to say anything.

But I felt very alone. I felt that if anything – anything – went wrong, it would be my fault. Despite wholehearted support from my midwife, and Mal's support, I was on my own. They had far more confidence in me than I had in myself. I was worried about having to go for a scan and being put under pressure to stay and be induced, as my midwife had told us might happen. I was so worried that I would have to leave my midwife at the door of the hospital, and that I would be in a worse position than I had been the first time around because they would know I had wanted to have a home birth, and would judge me for it.

And then I went into labour. Evie went to the crèche and Malachi went to work. The beginning of labour was strangely familiar to me. I did some odd things – odd in that I just did them without really thinking about it – I took off my rings. I was quite methodical. I was calm. I was taken over by it, but it never felt out of control. I rang Malachi to tell him he should come home. I rang my midwife to tell her to come. It was about half past ten in the morning. When she arrived, she knew that things were going very quickly and that he was very close to being born. She didn't say or do very much during the labour, but I knew that she understood perfectly. It was a very fast birth, two hours, from start to finish. It all happened so quickly – it was very intense. There were what seemed like quite long, welcome breaks between the contractions at the end. I don't think there had been any breaks when Evie was born. When Reuben was born, after the immediate post-birth things were done, we sat on our bed and beamed at the baby and each other. He had a dimple. He had loads of black hair. It's hard to describe how I felt afterwards – I was elated. I felt like there was nothing I couldn't do, I felt like some kind of warrior queen. I felt completely invincible. Sometimes, looking back on it, I still do, I can draw on it. A friend collected Evie and brought her home. I was so full of energy, not just for the rest of the day, but that night, too, and the following day. At 1 in the morning I got up and had a cup of tea and a sandwich and watched everyone else sleeping. After about three days there was a bit of a crash, and I stayed in bed with Reuben – our window overlooks the canal and trees and I felt as though Spring had come during that week. I went inside during the Winter and came out in Spring. Everything seemed symbolic and loaded with meaning.

It was only in the days and weeks that followed that I talked with my midwife about the birth and began to realise how it had been such a transformative experience – it was empowering, but in ways that I had not expected. There was no fear in any of it. I still think of Reuben as being partly her baby. Everything about Reuben's birth made sense in a way that nothing around Evie's birth did. I had never expected the midwife's role to be as important as it was – I felt that she had given me back something that I didn't know I had lost.

When Reuben was born, I was in the middle of doing my MSc. I had wanted to write my thesis on birth, or women's experiences of different models of birth, but I had very little time, and I realised that what I wanted to do was beyond the scope of a masters. Instead I wrote it on women's experiences of domestic gender roles following childbirth. When I was doing the research, I interviewed several women, all of whom told me about their birth experiences. As I listened to their stories, I realised that women in maternity hospitals in Ireland consistently experience traumatic birth. They are frequently badly treated. More often than not, what matters to them is disregarded. Their concerns are not listened to, their birth plans are laughed at, their wishes to engage with their own experiences are dismissed in place of archaic hospital practices. Birth is not valued, nor are women in labour, nor is motherhood. It is normal to have a traumatic birth. It is normal for a healthy woman with a healthy baby to go into hospital and have a birth that is characterised by unnecessary, unreliable, harmful interventions and it is normal for her to struggle to make sense of it afterwards. The collateral damage associated with these types of birth has lifelong consequences.

Women talk about their birth experiences in intimate groups of three or four, in each other's houses, in coffee shops and playgrounds and at bus stops. They lean in to one another conspiratorially, comparing notes in urgent whispers, consolidating experience. They do not talk to women who have not yet had children about childbirth because there is an unwritten etiquette that it is bad form – you might frighten them. The irony is that by being complicit in the silence around birth, women themselves are contributing to a culture of maternity care which doesn't support questioning, it doesn't support or encourage exploration or discussion of issues around childbirth, it encourages compliance and passivity of women. It supports complacency and powerlessness. The level of public discourse and the information that is in the public arena around birth is very limited. Even much of the evidence-based research is very limited, in many ways – statements like 'women want more control over their care' are oddly superficial. Yes, women do want more control over their care, but this is often interpreted as meaning control over pain relief, being able to choose one obstetrician over another, control over specific aspects of, for example, Active Management of Labour. Birth is considered by the majority of women that I spoke to, as what you have to go through to get your baby. You must do it, and then put it behind you. For most women who go through the hospital system, it is something to be dreaded and feared – the fear isn't specific, it's just everything around birth that is frightening, or potentially frightening.

All of this, inspired by the contrast between the births of both of my children, has made me want to listen to women's stories, and to explore discourses around birth. Women's perceptions of agency and autonomy within different models of maternity care must be examined in order to make sense of the incongruities and confusion that have become a normal part of having a baby in Ireland.

It is almost impossible to see how women-centred care can be truly implemented unless the issues that affect women in real ways are addressed in a manner that enables meaningful control and engagement in birth that strengthens, rather than weakens women. For this to happen, we have to look at the things that are difficult to see and listen to the things that are difficult to hear – obscured by silence and fear, they are the issues that are difficult to quantify, and the things that we have forgotten how to talk about.