Wednesday, May 5, 2010

Rachel goes on about mothering and childbirth and breastfeeding and supported choices again

Considering my recent thoughts and posts on these topics, check out the great timing on the posting of the list of The Best and Worst Places to be a Mother by Save the Children. It's already been all over the news this morning that America places pretty low for a wealthy developed nation (28th), and this is largely due to the high maternal mortality rate and our lack of support (like maternity leave) for mothers. And this is precisely my point.

It is a fact that choices can be curtailed in multiple ways. You can give all kinds of lipservice to the benefits of breastfeeding, but as long as medical professionals don't give real help to new mothers trying to get into a good nursing routine, and women are expected to carry most of the domestic labor burden within the home, and pumping is frowned upon in the workplace, and maternity leave is short, and people continue to think of breastfeeding as some repulsive thing that ought not to be done in public, and women experience serious career limitations for altering their work schedules to accommodate breastfeeding and pumping, and formula is pushed as the nutritional equivalent to breastmilk ......we can't really view breastfeeding as a viable option for most mothers. It's not that anyone is explicitly telling them that they can't or shouldn't breastfeed. But there are other ways to constrain a person's choices other than through legal or social prohibitions and physical constraints. And this is a really important distinction we overlook.

When there are multiple barriers to your success in a particular endeavor, then we cannot view that as a choice that one can freely choose in the same way they can choose the options without similar barriers. Take abortion, for example. In my state, abortion is legal. Nobody can legally stop you from terminating a pregnancy. But you can't get an abortion here. There simply are no providers. You can come up with about $500 and drive several hours (depending on where you live) to get to clinics in neighboring states that provide abortions. And then a week or two later you'll need to arrange for transportation to drive back to that clinic for follow up. So if a teenage girl or an unemployed woman or any woman who is financially (and/or transportationally) dependent gets pregnant, it makes no sense to talk about her choices. Unless she can find someone to drive her to an out-of-state clinic and pay for it, she's gonna have that baby. And this is true in more geographical locations than most people realize.

And what of natural childbirth? In some places homebirths are an option. In some places there are birthing centers that are woman-centric and support mothers in whatever informed decisions they make. But most women will give birth in a hospital, either because these choices aren't available where they live or because they aren't covered by their insurance. And new guidelines for midwifery have even further restricted these options in some places. So that leaves most women who desire a natural birth with the sole option of making it work in a hospital setting.

And let me tell you about how that generally goes. From the minute you step through the doors you will be fighting off medical interventions. It will be you against a doctor and several nurses, or possibly you and your midwife and/or doula against a doctor and several nurses. Although you've clearly written in your birthplan that you do not want an epidural, nurses will breeze in all cheerfully right when you're in the middle of a contraction and ask you if you're ready for your epidural yet. Repeatedly. Instead of supporting you in your goals and talking you through the hard stuff, they hit you when you're down, when you're most likely to give in. I'm not the only one with this experience. When you start comparing notes with other women it's astonishing to realize the similarities. It's as if they're working from a script. So women who attempt natural childbirth will not only be dealing with the stress and pain of childbirth, but they will often also be fighting a constant battle to fend off the medical interventions that they have already clearly communicated a desire to avoid in their birth plan. And this is frequently true even in a fairly uncomplicated, quick birth.

In my experience, it took slightly less than an hour from the time I started pushing until my daughter was born. She was in a great position. She was not a particularly big baby. Her heart rate was good. There were no indications whatsoever of any danger. And yet, just as she was crowning the doctor (my midwife was out of town when I went into labor early) decided that I needed an episiotomy. This seems to be prompted by the fact that, when the pressure suddenly ratcheted up, I said "Oh fuck" and then to my partner "I'm not sure this is such a good idea." I was joking in a grim sort of way, because that's how I handle these things. But it said very clearly in my birth plan that I didn't want an episiotomy. In addition, it's generally accepted in the medical community that the vast majority of episiotomies are not only unnecessary, but harmful to women. You heal slower and are more likely to sustain permanent damage to surrounding tissue. But none of this mattered. My consent didn't matter. And let me tell you that seeing someone come at your genitals with a knife that big would be somewhat traumatizing no matter what the context was. But when you're struggling to manage the pain, and ignore the nurses who are cheerleading and babytalking you in spite of your repeated requests that they not do this, and to think your way through this tough process, it's even worse. It's like one of those days when everything is going wrong, and then truly ridiculous shit starts happening, and you're like "what's next, the locusts?" Because having to fight this shit off when you're already handling so much and feeling pretty damn vulnerable is really too much, and they know it. They've dealt with lots of women in labor. They understand the psychology of it. They know that saying no and standing up for yourself is really damn hard in that moment. And sometimes even saying no isn't enough. At first I just looked at the knife and said "I don't want an episiotomy. Is that what that is?" She still held the knife. Then my partner said "absolutely not - she wrote that in her birth plan." She still held the knife. Finally I sat all the way up and looked her squarely in the eye and said "I do not consent. If you cut me I will sue your ass." Then another contraction hit me and I felt that urge to push that kind of drowns out everything else and so I leaned back on my elbows and started pushing again. She made an exasperated "hmmph" sound and set the knife down hard on the table. About 10 minutes and 3 or 4 pushes later my daughter was born. My partner thought she had scared/angered the baby right out of me with that knife. It could have been that the additional adrenaline rush sped things up. I don't know. But I remember how ironic it was when she cheerfully told me after the fact that I had only had a very minimal amount of surface level tearing, and that I didn't need any stitches and it would be all healed up in a day or two. And it was. But I remember thinking, "well, if I had just tried to cut you with a giant knife against your will I would certainly not be talking about how you clearly didn't need to be cut at all in a totally pleased tone of voice." You'd think you would be sort of embarrassed and apologetic.

But if you put my experience in context, it seems pretty minor. So I had to fight off an unnecessary episiotomy and the minor damage that would have accompanied it. But think of all the women who are told they have to have a c-section, and they don't want one, and wonder if it's really necessary, but are bullied into shutting up and getting it over with already. And finding out later that it probably wasn't necessary, and wondering if there was anything more you could have done to prevent it, has got to be a hurty thing. And so the overwhelming feeling you take away from your childbirth experience is impotence and a complete loss of control, because in your vulnerable moment, there was nobody there to support you and take your side and argue your case. Of course your friends and family can try, but their voices get drowned out very quickly in the context of the medical juggernaut, which is backed by our cultural attitudes toward doctors and childbirth.

So that's why I keep yammering on about supported choices. Live options. Robust agency. Because merely having the choice to do something (technically, legally, whatever) doesn't mean shit if it's not viable for you due to the lack of support and the cultural forces against it. And this applies to all of the "choices" women make concerning mothering. If you're clearly going to experience setbacks in your career by choosing to have children while your male counterparts will be unfazed by it, then the choice to have children is not a free one. If it's going to be a constant struggle everyday to breastfeed and deal with social negativity and pay the price for arranging your schedule to accommodate it, then breast vs. bottle is not a free choice. And this, my friends, is why America scores so low when it comes to mothering.


  1. Anonymous5/05/2010

    I think these are all good reasons to talk about reproductive justice rather than reproductive choice. Factoring in the issues of access and support is crucial.

  2. Kudos to you for your threatening to sue over the unfounded episiotomy. I hate the fact that our legal system is abused with overuse of lawsuits but this situation makes me WISH more women would sue over being assaulted in their birth, because what you are describing is assault plain and simple. And until hospitals are more worried about being sued for coerced interventions than for "failure to do a cesarean" you will NOT have any change in the system.

    Great post.

  3. Brandywine5/06/2010

    You're my hero. My bad-ass feminist hero.

  4. diamondsforhorses5/06/2010

    You would think we would have learned something by looking at countries like Switzerland and Denmark where birthing is approached so differently. I wonder what the rationalization is for this within the medical community? I mean, how many years can they have maternal mortality rates that are so much lower than ours before the medical community is forced to take notice and change things?

  5. Anonymous5/06/2010

    Wow. That episeotomy thing is really scary to me.

  6. I wonder what the rationale is behind the apparent complete lack of a felt need for informed consent when it comes to obstetrics and gynecology? I find things like the pelvic exams with no consent or knowledge while being prepped for surgery in teaching hospitals and practice surgeries on bladders when doing hysterectomies thing so deeply disturbing, and yet this seems to be the norm that's just taken for granted in med school culture. Is there an explicit double standard concerning informed consent, or is this kind of shit done to male patients too? Does anyone know?

  7. Anonymous5/08/2010

    I love it. This is great. Choice is nothing without access and support. Breastfeeding is particularly unsupported in the U.S. (in my opinion) Thanks for speaking up.

  8. Rachel5/09/2010

    i had no idea that my hospital is the exception to the rule. we have dedicated lactation nurses to help moms breastfeed, rent them pumps, give them people to call, classes to go to ante-and post partum, the nurses advocate for the moms-- all the moms, not just the white upper middle class ones with written birth plans, and private doctors and insurance, but the homeless prostitute with a drug addiction and no custody of her other children, and will hide scalpels and scissors from docs trying to preform unnecessary epises. we arent hostile to midwifes and doulas that have moms come to us, and several of our nurses are certified doulas.

  9. Anonymous5/09/2010

    you rule! this is the best thing I've read in weeks!

  10. At the NIH conference on vbac a couple of months ago a question was brought up about why there wasn't any mention of women's autonomy in informed refusal of consent.

    The answer was something along the lines of "we can't say whether or not women are able to refuse cesarean due to legalities and ACOG ethics."

  11. Anonymous5/09/2010

    I've never been pregnant, so I've never experienced any of this first-hand. I was present for my niece's birth, and know that my sister felt kind of bullied by the nurses who wouldn't let her leave the bed, shower, or eat anything during her rather long labor. Toward the end she was told she'd "probably have to have" a c-section because she wasn't progressing (we couldn't figure out how they knew that, since they hadn't checked her in about 2 hours), although in the end she didn't have to. But I can't imagine why people like this pretend doctor lady are so rabid about this? Even if you thought it was sort of ill-advised for people to choose not to have medical interventions, why the rabid attacks, and why all the bullying in hospital? You're definitely not making this up - my sister felt that way too - and she wasn't even trying for a natural birth. It's hard to figure out why they feel so defensive and attack so aggressively.

  12. SteelyDana5/09/2010

    Wow. This is all kind of sobering to me. Before I read all the exchanges here and on other blogs where this discussion has been going on I wouldn't have thought these would be such hot-button issues. It seems like a no-brainer to me. Support women's choices? Duh. Help women achieve increased autonomy and minimize physical trauma? Obviously. So I agree with the commenter above. Why would anyone fight to minimize female autonomy and informed consent? Why would anyone fight against increased support for new moms? The mind boggles.

  13. Although you've clearly written in your birthplan that you do not want an epidural, nurses will breeze in all cheerfully right when you're in the middle of a contraction and ask you if you're ready for your epidural yet. Repeatedly. Instead of supporting you in your goals and talking you through the hard stuff, they hit you when you're down, when you're most likely to give in.

    This exact thing happened to me. I think they could hear when my contractions started on the monitor at the nurse's station, and they came in twice during hard contractions. The second time I said yes and got the epidural and pitocin, which made the contractions way harder. But I didn't know that was why until a couple years later when my cousin was pregnant and researching this stuff and asked me if it was true that the pitocin made them harder and closer together. Then I was like "Ooohhhh. I guess it did."

  14. Brioche5/10/2010

    I love the idea of shifting conversation away from "reproductive choice" to "reproductive justice." This is a much overlooked issue, I think.

  15. Loved this post.

    Some days I feel like instead of training a birthing partner I am training my husband to be a feminist soldier who's battle cry is "No epidural! No cutting!"

    I'm due in 7 weeks.

  16. Anonymous3/04/2011

    I just saw this, and it reminded me of this post. Apparently your experience with the episiotomy is fairly common:
    Not everything is an act of violence