Women are spending decades being gaslit, ignored, dismissed and belittled by the medical profession – so BBC newsreader Naga Munchetty and TV personality Vicky Pattison have told the Commons women and equalities committee. Speaking to the committee as part of their enquiry into reproductive health, both women detailed how it took decades for their conditions – adenomyosis and PMDD respectively – to be diagnosed and treated. Worse still, they feel that women who raise concerns about their own health are treated like “troublemakers”.
The female body has been treated as unimportant and frankly, impossible to understand, ever since Aristotle declared us to be “defective males” and probably before that, too. But as the #MeToo movement shows, the collective power of women’s voices can bring about change, whether in pressuring the medical profession to stop sidelining our specific needs, or in demanding autonomy over our fertility and reproductive choices. But there is another area where outrage is still needed, a place where the idea of the female body as defective vessel runs riot: the modern maternity unit.
Simply ask the question: “Did you consent to everything that happened to you in childbirth?” and you will open the floodgates: wave after wave of women’s stories of disrespect and abuse pour through. Often women have not thought about their birth experience in these terms before, so conditioned are they by a lifetime of hearing two key phrases: “Leave your dignity at the door” and “a healthy baby is all that matters”. You risk eliciting shock and anger if you tell them: actually, human dignity also belongs to labouring women; actually, women matter too.
I often liken the way these floodgates open, and the traumatic stories pour through, to the #MeToo movement. One woman’s story paves the way for another’s, and suddenly, many women are reflecting on experiences they have long pushed to the background and reconsider them: “Yes, that was wrong!” In 2017 I was the first person to use the hashtag #metoointhebirthroom when I caught several obstetricians joking on Twitter about women’s birth plans and how “the size of them corresponds to the length of the caesarean scar” and that “the laminated ones are only useful for massive haemorrhages”.
This mockery of women and their hopes and dreams for a positive experience of childbirth is endemic. In Adam Kay’s bestselling book This is Going to Hurt, he talks about the “certain denomination of floaty dressed woman” who inevitably ends up on the operating table. And there’s the conference of obstetricians in 2019 who laughed about Meghan Markle’s plans for a natural birth. “Let’s see how that goes!” they hooted. You don’t have to look far to find the idea that any woman who wants a modicum of dignity or control in her labour will “soon learn her lesson”.
A “positive birth” for women means a sense of autonomy, of being informed and in control
In fact, it is the “difficult women”, the ones who don’t unquestioningly consent to everything they are offered, who disrupt the system. One Irish obstetrician scathingly described them as “over-privileged, middle-class Birthzillas” – in other words women with a voice who won’t take things lying down. Much easier for the system are those quiet and compliant women who don’t have the confidence, support or resources to raise questions.
Just like #MeToo, the birth room power dynamic is firmly stacked in the patriarchy’s favour, and just like #MeToo, it is so embedded in our culture that “this is how birth is” that many women don’t realise that aspects of their experience are wrong, non-consensual and abusive; others do realise it’s wrong but don’t feel they have a voice to complain. In the early days and weeks of motherhood, women often silently relive their trauma but don’t have the bandwidth to make formal objections. If they try, they are often fobbed off, or told: “Enjoy your healthy baby, that’s what matters.”
Women matter too. It’s a common misconception that a positive birth experience can only happen in a pool surrounded by fairy lights and whale song. In fact, the evidence is that a positive birth for women means a sense of autonomy, of being informed and being in control. Of trusting the professionals around her but being the key decision-maker. This can still be the case in a highly medicalised hospital birth, or an emergency caesarean. Respect and consent are key.
One story I often recall is that of a woman who had a textbook home birth in a pool but was deeply traumatised. Just as she neared the moment of her baby being born the midwife said she wanted to examine her. The woman did not want this; she did not consent. The midwife then turned to the woman’s partner and told him that he must persuade her to get out of the pool and be examined, and, in the chaos of the moment, he did. She had the vaginal exam, got back in the pool, and gave birth to a healthy baby, “naturally”. But the way she’d been coerced into unwanted fingers probing her vagina, with her loving partner unwittingly roped into that coercion, stayed with her a long time afterwards.
Consent in birth is poorly understood because of the focus on the “healthy baby” which does, of course, matter. But the welfare of the baby is used to justify all kinds of medical interventions which may or may not be necessary, and to which the mother must not object, because to do so may mark her out as that worst kind of person: “a selfish mother”. Instead, she must be a “good girl” – another phrase widely used in maternity care, and presumably code for “compliant”. If she wavers, health professionals are known to deploy “the dead baby card”, suggesting that unless she conforms, “something bad might happen”.
Milder forms of coercion are abundant. In the covid pandemic, many pregnant women were told they “must” have a vaginal exam before being allowed to have their partner join them in the labour room. At the time, a survey from campaign group Pregnant Then Screwed revealed that two in ten women felt they had no choice but to have the exam, and eight out of ten agreed to the exams only as a means of being reunited with their partner. Vaginal exams, which in the UK are performed routinely every four hours, enable health professionals to plot the progress of a woman’s dilation on a graph, but some argue this is unnecessary and disruptive to the flow of labour. Some women, and I was one of them, choose to decline them completely, whilst others are not aware that they are optional: in a 2016 survey from my organisation The Positive Birth Movement, nearly 35% of women did not know they could say “no” to this invasive procedure.
Not being aware that you have the right to say “no” is not consent. If you were in a sexual relationship where you did not know you could say “stop”, and have your own wishes listened to, that would be considered completely unacceptable. In sexual relationships, knowing you can say “no” (even if you don’t want or need to) is key to building a bedrock of trust between partners. In maternity care, this bedrock of trust is often missing.
Almost everyone involved in childbirth – women and healthcare providers alike – has some confusion about consent. Essentially most people believe that women are free to make choices about what happens to them but that those choices may be overridden by health professionals if they are the “wrong” choices. This dynamic is summed up well by the Margaret Atwood quote: “A rat in a maze is free to go anywhere, as long as it stays inside the maze.”
Legally speaking, in the UK at least, this is not the case. An unborn baby has no rights whatsoever until they are born. A pregnant woman may make any “bad” choices she wishes, even if this puts her or her unborn at risk, unless she “lacks capacity”, which is a term reserved for extreme situations such as brain damage, ongoing heavy intoxication, or severe mental ill health. In all other cases, she is free to make any decision she wants – as the UK Court of Appeal put it in a 1997 case known as MB:
“A competent woman, who has the capacity to decide, may, for religious reasons, other reasons, for rational or irrational reasons or for no reason at all, choose not to have medical intervention, even though the consequence may be the death or serious handicap of the child she bears, or her own death.”
Just like knowing that you can say “no” in sex, but never actually exercising that right, if a woman knows that she calls the shots in the birth room this creates a shift in the power dynamic, even though it’s unlikely she will ever go against medical advice in a way that puts her or her baby at risk. Most women are extremely risk averse in pregnancy, and research and consider their options fastidiously. I sometimes think that misogyny is yet again at play in this fear of acknowledging pregnant women’s ultimate autonomy, as if they are wayward – dangerous even – and in need of paternalistic guidance.
As harsh as the UK law may seem to those who feel there should be times when the woman can be overruled for the sake of the baby, this black and white approach is the only way to set a woman’s full freedom and bodily autonomy in stone. It’s no coincidence that countries such as the US who subscribe to the idea of “fetal personhood”, also have much more state interference in pregnancy, not just via tighter abortion law, but even through prosecutions and convictions for women’s behaviours in pregnancy such as drink or drug use. It is also no coincidence that in other countries sharing similarly ambivalent attitudes to female autonomy, birth tends to be highly medicalised, dehumanised, and treated more like an “extraction” than a psycho-emotional rite of passage. The common thread is the belief that a woman’s reproductive capacity takes priority over her needs.
In these ever-shifting times we need to keep a grip on our relative reproductive freedoms, and fight for those women who don’t enjoy them elsewhere. We need to push back any time we see signs of erosion of women’s bodily autonomy, not just in fertility or abortion rights, but also in pregnancy and birth. Just like #MeToo, the seemingly “small” examples of lack of consent in a woman’s birth story become vitally relevant when placed within a global picture of maternal disrespect. A woman’s body is not a “vessel”: a living container for the baby that can be cast aside once it has served its purpose. A healthy baby is not all that matters. Women matter too.
Milli Hill is a writer and non-fiction author on women’s health. Find her at millihill.substack.com