Although Mobbs, Williams and Weeks challenged a range of phrases, the UK tabloid press, who, as you can imagine, didn’t like one bit the thought that infantilising and patronising women was off the menu, seized upon ‘good girl’ with a series of headlines in which the use of shouty capitals expressed their outrage. They even reported that midwives were now ‘BANNED’[20] from using the phrase – which is not true, of course – the BMJ article was merely an opinion piece. It’s interesting to ponder the roots of this outrage, and whether they wind their way down deep to what seems to be a cultural vested interest in the existing power imbalance; an underlying need for women in the birth room to continue to be, like the little children on the schoolroom mat, ‘quiet’, ‘still’ and ‘not challenging’. Does birth as we know it rely on our silence and complicity to function, just – as we have seen from #metoo – as the wider world often does?
Being called a ‘good girl’ makes women feel everything from uncomfortable to outraged,[21] and while it may seem like a trivial detail to some, it is representative of paternalistic attitudes that pervade maternity care and come from care-givers of both genders. It reflects a desire to assert power over the birthing woman, who, in order to meet the expectations of her attendants and therefore show herself to be a ‘good girl’, must remain childlike, behave herself and comply. Often, it is when the woman tries to break free of this dynamic and take the role of ‘permission giver’ rather than ‘permission seeker’, that we see a similar kind of outrage to that expressed in the tabloid ‘good girl’ headlines being played out in the birth room itself.
‘I went in with a suspected hind-water leak and the doctor examined me and told me they would give me steroids and antibiotics and admit me overnight,’ Maryellen Stephens told me. ‘I said no, that I would rather have an ultrasound, I was calm but assertive. She immediately began telling me that my baby would die and quoting a study, which I happened to have read myself. When I suggested that the study only involved ten women and wasn’t really good enough evidence to extrapolate to every single birthing woman, she was enraged, and – literally – stamped her foot and stormed out. She returned with the head obstetrician who was much more measured, agreeing to my plan of coming back in the morning for an ultrasound.’ Another mother, Hayley, told me her obstetrician said she was ‘washing her hands of her’, because she wanted to wait to be induced until the next morning. Similarly, Emily, from Southampton, told a tale I’ve heard multiple times: ‘I was told there were not enough midwives available for my home birth, but I refused to go to hospital, knowing that I had a right to have my baby where I wished. When they finally sent two midwives, they consistently tried to find reasons to transfer me and told me my baby might die if I didn’t. I stayed put and everything was fine but it really affected my experience negatively.’
Professional childbirth attendants, known as doulas, present as a supporter to the mother in the birth room and observing rather than taking any kind of active role, often report this phenomenon of women being admonished when they try to assert themselves. Interestingly, they also report how they themselves are silenced when they try to support women’s autonomy. ‘I have witnessed doctors becoming everything from irritated to enraged when a woman “talks back” about her options,’ one UK doula told me. ‘And if a doula expresses a view or backs up her client she will often be told, “I wasn’t talking to you, I was talking to my patient,” or worse, threatened with being reported or removed from the birth room.’ Another confirmed: ‘On one occasion I was told, “Don’t talk for the patient” as the doctor put on their gloves and went ahead with a vaginal exam my client had not consented to. Another time I quoted the NICE guidelines and the doctor snapped, “Well clearly you know my job better than I do.”’ Doulas are often gently – and sometimes harshly – mocked in the same way that birth plans are. In some countries, such as Guatemala, doulas have even been banned from the birth room, just as a notice in a Dublin hospital waiting area apparently proclaims ‘You Do Not Need a Birth Plan!’ Could it be that doulas, just like birth plans, speak up for the mother and her rights in a way that threatens the status quo?
Obstetric violence
‘Shut up, close your mouth and push: there is only one voice in this room, and it is mine’,[22] a doctor told a mother in Illinois in 2008, and, in 2013, his words were echoed in a California birth room when a young woman named Kimberly Turbin[23] gave birth to her first child. Like many twenty-first-century labours, a home movie was made by a family member. A two-time rape survivor, Kimberly had urged her care providers to treat her gently and to explain to her every detail of what was happening. As her baby began to crown, her doctor, who had been sitting on a stool between her legs, announced he was going to perform an episiotomy (a cut to enlarge the vaginal opening). Pleading with him that she wanted more time to push her baby out naturally, Kimberly repeatedly said no. The situation in the birth room became more heated as both the doctor, the nurse, and Kimberly’s own mother all urged her to comply.
On the movie, which has since been viewed over half a million times, Kimberly can be heard begging, ‘No! Why? Why can’t we try?’ as the doctor’s voice becomes more aggressive, telling her, ‘Listen: I am the expert here,’ and mocking her suggestion that she can do it herself, telling her, ‘You can go home and do it. You go to Kentucky.’ Just to clarify, Kimberly was not from Kentucky – he meant it as a slur and an implication of ‘backwardness’.
The doctor then proceeds to perform the episiotomy with twelve audible cuts to her perineum.
It’s harrowing viewing. Perhaps more harrowing is the thought that Kimberly is very much not alone: a survey in 2013 by Childbirth Connection[24] found that 6 out of 10 US episiotomies were performed without consent. What makes Kimberly’s case unusual is not that her body was violated in the name of expertise and safety, but that she had this violation entirely captured on camera and that b) she was determined to fight back. With the help of advocacy organisation Improving Birth, Kimberly went in search of a lawyer to take her case. It’s notable that this in itself took 18 months. ‘It took us a year and a half to find a lawyer, in spite of clear, video evidence of blatant disregard and abuse,’ Dawn Thompson of Improving Birth explained. ‘This should be really concerning for a lot of people! Women are coming to us and talking about coercion, manipulation, abuse – every single day, and some of it is just being accepted because it’s just considered par for the course of giving birth in our current maternity care system.’
‘Many of the lawyers we’ve spoken to are not sure whether a woman giving birth has the right to say “No” to a medical procedure,’ her colleague Cristen Pascucci told me during their search for legal representation. ‘And they don’t see the dollar value in litigating this kind of a case, when they know that, just like them, any jury probably believes that the best outcome of childbirth is a live baby – irrespective of whether the mother has been maimed by her care providers in the process.’
Eventually the case was settled out of court in 2017, amidst wide praise for Kimberly for highlighting the issue of consent and abuse in the birth room. Her attorney, the prominent civil rights lawyer Mark Merrin, called the lawsuit, ‘a big step for women who have been silenced’. It’s easy to see this story as an isolated case, or to conceptualise it as an American problem, but, unfortunately, it’s just one example of a widespread, global issue, referred to as ‘obstetric violence’.
It’s worth saying at this point that the term ‘obstetric violence’, perhaps understandably, tends to push buttons and cause misunderstanding, first and foremost because people mistakenly think that ‘obstetric’ implies it is only perpetrated by obstetricians. In fact, ‘obstetric’ simply means ‘relating to childbirth and the processes associated with it’, and the term therefore covers any violation a woman experiences in the birth setting. The second word in