“I’m going to have gas and pethidine, but nothing stronger,” my friend Jemma* told me shortly before giving birth to her first child.
“No epidural- I want to be able to walk around – and definitely no episiotomy. Mark will be there of course, but I’m also hiring a doula and I might invite my sister too, for moral support. I’m still thinking about a water birth,” she continued, ticking the items off on her fingers, “but I definitely don’t want to be induced, no matter what. It’s all in my birth plan.”
Things were different in our grandmothers’ day. No more than two generations ago, women tended to enter labour and delivery with very little idea of what the process would entail. In the United States, and to a lesser extent Australia, a significant number were actually anaesthetised for the entire experience.
With the advent of the women’s liberation movement in the 1950s and 1960s however expectant mothers started being formally educated about childbirth, and many came to wish to be active participants in the process.
Today the majority of Australian women enter labour not only with some knowledge of the physiological aspects of the process, but having also developed their own preferences for birth: whether to labour in a hospital, birthing centre or at home, who they want present, what sort of medical interventions they desire or oppose.
Mandy Gray chose to give birth to her son Jack in a birthing unit attached to a city maternity hospital. “I think touring the hospital whilst I was pregnant was what really decided me,” she recalls.
“Everything about the hospital put me off: the smell, the noise, the sterility, the equipment everywhere you turned. I remember saying to my husband that I wasn’t even sure I’d be able to give birth in such an environment. In contrast, the birthing centre felt quiet, private and far more relaxed. I’d been well educated about labour and I liked the fact that I was left to manage it in my own way, rather than being directed by medical staff. As requested, my midwife tended to leave me to my own devices in the early stages, but even later in the difficult phase toward the end he simply offered support and suggestions of ways to deal with the pain rather than taking over.”
Mandy also liked that she was free to make her own decisions about many aspects of the delivery.
“I gave birth kneeling in the shower, which worked well for me and I know wouldn’t have been possible in a standard delivery suite. I was allowed to have as many people with me as I liked – up to four at one stage – and I was reassured that in that setting no-one was going to do an episiotomy or give me an epidural. (Such procedures cannot be carried out in birthing centres.) I was even allowed to choose whether my son was given the Vitamin K injection that is standard practice after birth in all maternity hospitals. As it turned out I had again done my research and decided against this – but that simply wouldn’t have been an option on a maternity ward.”
Mandy felt so positively about the experience that she returned to the same centre three years later to give birth to her daughter.
“I just felt that it was my labour, my birth experience and I wanted to have the chance to do it my way rather than having someone else telling me what to do. Having that control and autonomy was important to me.”
Mandy’s is a success story of an empowered delivery, one where the woman is encouraged and enabled to make her own choices in childbirth, and to labour as she wishes rather than being dictated to or directed by medical staff.
In contrast, for all her planning Jemma Stevenson had a very different experience.
“My obstetrician insisted on inducing me, though I’d stated I was against that,” she said. “I was only two days over but Easter was coming up, and with hindsight I can’t help wondering if she didn’t want to be called out over the holidays. Then because of the drip they use to induce you, my contractions were immediately immensely painful. There was none of this gradual build-up I’d expected, which might have given me a chance to adjust to the pain – just sheer, unrelenting agony. I caved and asked for an epidural, but that meant I couldn’t feel when to push, so they needed to use forceps. I was screaming at my doctor not to do an episiotomy if she thought there was a chance it would go to a C-section… but she did anyway. And guess what? I still ended up with a C-section. Really, apart from the fact that Mia arrived safely, it couldn’t have been less like what I’d hoped for.”
Jan Robinson, a midwife with almost thirty years experience and national coordinator of the Australian Society of Independent Midwives is a firm believer in empowering expectant mothers.
“My practice encourages women to take control of their own labour and birth. There is a one-to-one education session built into every antenatal visit, so by the end of her pregnancy the woman understands all the physiological changes that will take place during her labour, and how to work with them to best help her baby out.”
Glenys Janssen, manager of the Childbirth Education and Training Unit at the Royal Women’s Hospital in Melbourne adds, “It’s important that women are prepared emotionally and psychologically for childbirth as well as knowing what will happen physically. The key to being empowered during labour is being well informed and educated- knowing what your options are and having had a chance to discuss these well ahead of time.”
Examples of such choices may include compiling a birth plan, selecting the environment in which to give birth (home, water, hospital, etc.), having a say in decisions about interventions ranging from the use of analgesia to foetal heart monitors or episiotomies, electing who will oversee the delivery (midwife, GP or obstetrician) and choosing support people and the birthing position, amongst others.
Of course, if medical complications arise not all such options will be able to be exercised. Research suggests however that when things do go smoothly and women in labour are empowered to manage the event in their preferred manner, there can be benefits for all involved.
As Jan Robinson notes, “Empowerment always leads to better outcomes – less interventions, less need of drugs, less stress on the mother and baby.”
A study published in the medical journal Birth last year found that women encouraged to spend at least part of their labour in a hands-and-knees position had shorter labours and were less likely to require a caesarean section. Other research has shown that increasing the support of women in labour can lead to lower rates of analgesia, anaesthesia and surgical intervention, shorter labours, higher Apgar scores (a measure of a newborn’s physical condition) and increased maternal satisfaction, amongst other outcomes.
Not all expectant mothers however wish to be empowered. Adelaide mother of four Paulette Draper recalls that when her first child was born, “I had a strong feeling of wanting someone to tell me what to do. By number four I had the experience to insist on delivering standing up rather than on the bed, but the first time around it was all so new and frightening that I just wanted to be directed.”
Similarly, in her book The Mask of Motherhood, Susan Maushart cites a study which found that as many as 75 per cent of women under the care of private obstetricians exhibited “willing, even enthusiastic acceptance… of the technocratic model” of childbirth, where the doctor makes every decision.
Dr Amber Moore, an obstetrician who has worked in private practice for the past six years agrees. “I’m finding more and more that women come to see me requesting a lot of medical intervention, including elective C-sections. Whilst I don’t have a problem with that per se, I do feel strongly that as their doctor I need to make sure they fully understand the consequences of their decision, and are making it out of education rather than fear or misinformation.”
Other health professionals wonder if pregnant women should even be encouraged to assume they can influence labour and delivery.
Dr Hilary Parker* has worked in the obstetrics unit of a busy public hospital for the past eight years. “I worry that making a birth plan at the best makes no difference and at the worst can give a woman unrealistic expectations. Childbirth is only very, very rarely an event you can control and I don’t believe it is doing women any favours to encourage them to think that they can. Nine times out of ten we find that women do not achieve exactly the birth they have envisaged, and then often they feel they have failed.”
In line with this, a rigorous study of 800 Australian women found that antenatal education had no impact whatsoever on women’s experience of pain, use of pain relief, type or number of interventions or level of satisfaction following labour.
Nothing, mother Fiona Place writes, can adequately prepare you for the “fury of childbirth.” The situation may be further complicated in the public system, where the woman in labour is seen by whoever is on duty and thus quite often no doctor-patient relationship has ever been established.
As Dr Parker notes, “By the time I’m called to a delivery I rarely have the opportunity to read through a birth plan or talk about how the mother feels about interventions. Quite frankly it is usually much quicker and safer just to do what I think is medically suitable.”
“The very word ‘empowerment’ makes me cringe,” declares Lisa Fettling, who has worked as a counsellor specialising in the treatment of post-natal depression (PND) for over 15 years and has written two books on the subject.
“Child birth educators can be as enthusiastic about the idea as they like, but I see the other side: what happens to these women after they leave hospital.”
First time mothers in particular, Ms Fettling notes, seem to expect an awful lot of themselves. “I have women in my PND groups actually articulating that they feel as if they have ‘failed’ because they needed drugs or forceps in labour – even if they have a perfectly healthy baby. Others are angry or depressed because they expected to have more of a say in the process, and feel that their wishes were not respected.”
Ms Fettling suspects that such beliefs stem from a number of sources, including the tendency to delay childbearing until a woman is older and thus more used to controlling her environment, and an increasingly competitive culture.
“But I also think that some antenatal educators falsely encourage women to believe that if they try hard enough they can have the childbirth they want,” she says. “Unfortunately if this doesn’t happen – and often it doesn’t due to medical complications beyond anyone’s control- the woman can be left feeling as if she has fallen at the first hurdle. It’s hardly setting the scene for a positive adjustment to motherhood.”
Author Susan Maushart is even blunter. “Where previous generations of women approached childbirth expecting the worst,” she writes, “today’s generation suffers an even crueller indignity. Having been led to expect the best, the disjuncture between anticipation and experience is a yawning psychic chasm from which we emerge not only battle scarred but angry. For many women, that anger is self-directed: (there is) a sense of shame that we have failed to perform to standard.”
There is a middle ground however. As Dr Moore says, “Empowerment isn’t about choosing a water birth or declining an episiotomy. In my view, a woman is empowered when she is given information and has the opportunity to both ask questions and be listened to herself. Empowerment is all about establishing a dialogue between the healthcare professional and the patient.”
In this situation, midwife Jan Robinson feels that “All births- even an elective C-section- can be empowered.” Lisa Fettling agrees. “The most important thing a woman can do to prepare for labour is to find someone – midwife or doctor – that they trust. That way, even if things don’t go to plan you still know that the person is acting in your interests, so there shouldn’t be any feelings of having lost control or failed. And too many people forget that it is the end product that really matters: the baby, and not how he or she got out.”
Sydney mother of three Sally Machin is one who managed to keep that perspective. In an account of the experience related in Katrina O’Brien’s book Birth Stories, Machin recalls how she went into “excruciating labour” with her first child six weeks before her due date during a conference call at work, and with her husband in the UK.
“I look back on Jessica’s birth and I really think I was stark raving mad,” she says. “I didn’t know I was in labour, I hadn’t done any of the antenatal classes, but I have no regrets. Women have so many expectations when they’re pregnant. There is so much pressure about the experience… [yet] there’s no right way and wrong way of doing this. And once you’ve got those babies, they’re the most precious things in the world and it doesn’t matter how they got here.”
*Not her real name
“A gender-equal society would be one where the word ‘gender’ does not exist: where everyone can be themselves.”*
I’ve always been aware of gender conditioning and actively tried to combat any lingering prejudices or stereotypes in my own parenting, even down to encouraging dolls with my boys when they were little. It’s great to read people writing about gender issues they’re experiencing with their kids. For too long these subjects have been discouraged or silenced. I’d love to publish some more creative writing on this topic, especially if you are struggling with a child who actively tries to move away from gender normative preferences. A society where everyone can be themselves – thanks Gloria for those aspirational words.
* Gloria Steinem