Why I don't do vaginal exams ~ Wisdom from a Traditional Birth Companion
I let my new client know what would happen when I arrived at her home when she was in labour. We talked about sanitation measures, spending time in the kitchen, setting up the pool, and where I could take a nap if she needed some privacy. I said I would not be doing any vaginal exams as I think they’re rude, and she wept with relief.
I specialise in trauma and the majority of my clients are refugees from the medical system, running from ritual abuse and routines that protect the industry. They want someone to mentor them through to a healthy birth without the traps and trappings of the industry that removed their choice, and violated their autonomy and their dignity.
As a traditional birth attendant, I don’t do vaginal exams.
I was talking with my new client about what would likely happen when I arrived at her home when she was in labour. We talked about sanitation measures, spending time in the kitchen, setting up the pool, and where I could take a nap if she needed some privacy. I said I would not be doing any vaginal exams as I think they’re rude, and she wept with relief.
I specialise in trauma and the majority of my clients are refugees from the medical system, running from ritual abuse and routines that protect the industry. They want someone to mentor them through to a healthy birth without the traps and trappings of the industry that removed their choice, and violated their autonomy and their dignity.
We won’t go into the history of obstetrics that began with the burning of witches (midwives and healers), the rise of the man-midwife, the development of lying-in hospitals, and eventually the wholesale co-opting and medicalisation of birth. Suffice it to say that obstetrics and hospitalisation didn’t “save” women and babies (1). It created untold harm and mortality until they learned better infection control and saner behaviours. Today, it’s still leaving a trail of destruction as about 1/3 of their clients are traumatised (2,3,4) and about 1 in 8 enter parenthood with postpartum post-traumatic stress disorder (5,6,7). Suicide is a leading cause of maternal death in the first year and is highly correlated to trauma (8,9,10,11,12,13,14,15,16). It’s an industry out of control with unjustifiable caesarean rates, dangerous inductions for spurious reasons, and wholesale overuse of medications and interventions.
What women didn’t notice in this process of medicalisation and co-opting of their physiology for profit is that the medical industry took ownership of their vaginas once they became pregnant. Pregnancy transfers ownership of the vagina from the woman to the industry. Midwifery and obstetrical regulations stipulate that inserting an instrument, hand, or finger beyond the labia majora is a restricted practice sanctioned by legislation (17). To test this, see how long it takes for someone in the industry to file a Cease and Desist or start a campaign of persecution for the purpose of prosecution if they catch wind of anyone but one of their own sticking their fingers up there. No one but an insider sticks their fingers into their territory. It doesn’t matter who the mother gives her permission and consent to - it must be a member of the priesthood of modern medicine.
Of course, in their benevolence, they’re generally quite accommodating where partners are concerned, because most partners are male and obstetrics is exceedingly misogynistic. They value the needs and the pleasures of the D.
As a traditional birth attendant, I don’t do vaginal exams. For one thing, it’s considered a restricted practice for just the medical pundits and not doing them with my clients keeps the industry players somewhat placated knowing I’m not intruding into their turf. But the real reason is because I think they’re completely unnecessary and wouldn’t do them even if the medical folks begged me to under the guise that it would make birth safer.
To better understand the offence of the routine vaginal exam, we have to go back in time to when the male-midwife moved into the sanctity of women-centred birth and the domain of the midwife. It was profitable. And they convinced the public that they would provide a superior service based on the cultural belief of the time that women were disadvantaged by an inferior intellect and a predilection for sorcery (18,19). They also brought with them the medical perspective that women were an error of nature and that the world, and thus its inhabitants, were but a machine that could be best understood by coming to know its parts in isolation of the whole.
And so began dissection, mechanisation, and reducing birthing women to their parts. She became a womb expelling a foetus through a vagina. Think of today’s obstetrical “power, passenger, passage” perspective on how birth unfolds. Not much has changed in 400 years.
By sticking their fingers up there, they discovered that the cervix opens to expel the foetus. Oh, happy day! From the morgue to the birth suite, physician fingers were poking everything. Throughout the early and mid 1800’s, the infection rate in some hospitals soared as high as 60% from the mysterious childbed fever, with death rates as high as 1 in 4 (20). Nothing the doctors did was contributing to this mystery as physicians were gentlemen and gentlemen didn’t carry germs (21). And once they did accept that their filthy practices were killing women, rather than abandon the idiocy of penetrating their patients in labour, they eventually figured out how to make it less dangerous.
The practice of obstetrics has always been highly resistant to change and common sense. After all, they’ve had 400 years to figure things out and women are still birthing on their backs!
Once it was discovered that the cervix dilates as part of the labouring process, the medical industry has been fixated on that bit of tissue and made it the focus of their entire assembly line drive-through everyone-gets-what’s-on-the-menu service. That bit of tissue determines how the ward allocates services, whether the client will be permitted to stay, and how long she’ll be allowed to use their services before the next client needs the bed.
Thanks to Dr. Emanuel Friedman, who examined the cervices of 500 sedated first-time mothers in the 1950’s and plotted their dilation on a graph and matched it to the time of their birth – we now have the infamous Friedman’s Curve and the partogram.
© Evidence Based Birth
The partogram is a graph that plots cervical dilation and descent of the foetal head against a time-line. When the graph indicates that progress is slower than is allowable according to the particular chart chosen by their institution, then the practitioner is called upon to administer various interventions to speed things up to keep the labour progressing well, aka, profitably. Should these acceleration measures fail to produce a baby in a timely manner or cause foetal distress, then a caesarean section is the solution. “Failure to progress”, and the accompanying foetal distress that is often a consequence of those acceleration measures, are the leading causes of a primary caesarean (22).
Obstetrical partogram
In addition to clearing the bed for the next client, obstetrics has another reason for expediting labour. The more vaginal exams a woman receives, the greater the likelihood she’ll develop a uterine infection (23). So, once they start the poking, they need to get the baby out before their prodding adds another problem for them to solve.
In the absence of a medical situation, routine vaginal exams in labour are for the purpose of charting in order to maintain a medicalised standard of modern technocratic birth.
A labouring client will not be admitted to a hospital without a vaginal exam to determine if her dilation is far enough along for their services (unless she’s clearly pushing). And this isn’t necessarily a bad thing. Early admission to the hospital results in more interventions and more caesareans than later admission (24). This is a business and time is money.
A regulated midwife attending a homebirth will likewise perform a vaginal exam upon arrival at the client’s home to determine if the client is far enough along to warrant their limited resources and time by staying and beginning the partogram or leaving and waiting to be called back later. They must also follow the rules of the hospital at which they have privileges or their regulatory agency and transport for augmentation/acceleration if the partogram shows a significant variation.
All of this is predicated on the outdated and obsolete notion that women are machines and birth is a linear process. The only thing a vaginal exam reveals is where the cervix is sitting at that particular moment and how it’s interpreted by that particular practitioner. Women are not machines and birth is not linear. Just like any mammal, birth can be slowed, stopped, or sabotaged by an unfavourable environment or reckless attendants. I’ve said for years that it’s so easy to sabotage a good birth, it’s embarrassing.
“Years ago, I was with a first-time mother planning a family-centred homebirth. She was on the clock and had a deadline. At 42 weeks gestation, she had until midnight that night to produce a baby in order to have a midwife-attended homebirth. After that, she was expected to report to the hospital for a chemical induction. As her contractions built throughout the day, her preferred midwife arrived and labour was progressing well. She was enjoying the process and the camaraderie of her sisters-in-birth. Eventually, one of the vaginal exams revealed a cervical dilation of 8 cm, indicating it was time to call in the 2nd midwife. Only, it was a midwife that had routinely upset the mother throughout pregnancy with requests for various tests and talk of all the dangers of declining routine testing. Upon learning this midwife was coming to the birth, labour slowed.
Soon enough, the 2nd midwife arrived and assumed authority over the birth process and insisted on repeated vaginal exams for the purpose of staying within the parameters of the partogram. Her vaginal exams were excruciating, no doubt because she was trying to administer a non-consenting membrane stripping as an intervention to address the slowed and almost non-existent contractions. Eventually, an exam revealed a dilation of only 6 cm. After several more hours of “torture” (according to this mother’s recount) to keep labour going rather than just leaving the mother to rest and accepting that this labour had been hijacked and needed time to regroup and restart, dilation regressed to 4 cm and the mother eventually ended up acquiescing to a hospital transfer, and experienced an all-the-bells-and-whistles birth, trauma, and postpartum PTSD.
This mother’s subsequent birth a couple of years later didn’t include inviting midwives and unfolded as it was meant to. After a day of productive and progressing labour that was clearly evident without sticking fingers up her vagina, she eventually got tired and labour slowed and stopped. She went to bed and I went home. When she woke up, labour resumed and a baby emerged swiftly and joyously. As it turns out, for her, she has a baby after a good sleep with people she trusts.”
What about the routine vaginal exams in late pregnancy? Glad you asked!
Since they don’t have good predictive value, meaning they won’t diagnose when labour will begin, how long it will take, or whether the woman’s pelvis will accommodate that particular baby prior to labour, they have 2 functions.
The first is to plan and initiate your induction.
A cervical exam provides information that is measured against a Bishop Score. A Bishop Score provides a predictive assessment on whether an induction is likely to result in a vaginal birth or is more likely to result in a caesarean for “failure to progress”. A cervix that scores higher is more likely to respond to an induction whereas a lower score indicates a less favourable outcome (25). Further, a vaginal exam allows the practitioner to begin the induction process with a membrane stripping/stretch-and-sweep.
The second purpose for routine vaginal exams in pregnancy is to build in sexual submission. It reaffirms the power dynamic where someone who is not the woman’s intimate sexual partner is allowed to penetrate her genitals at will. It makes their job much simpler once she’s is in labour. She has been trained to accept this violation.
A vaginal exam during labour might rarely be indicated when there is a problem that requires more information. A vaginal exam can help determine if there’s a possible cord prolapse requiring immediate medical attention, or can asses the position and descent of the baby to help suggest strategies to encourage the baby to move into a better position. However, when a labour is spontaneous, meaning it hasn’t been induced by any mechanical, chemical, or “natural” means, the labour isn’t augmented with artificial rupture of membranes or synthetic oxytocin, and the labouring woman is untethered and free to move as her body indicates, complications are far less likely.
Throughout my 35 years in supporting birthing families, I can say that babies do indeed come safely and spontaneously out of vaginas when there’s no one sticking their fingers up there. And they tend to come more quickly. Routine vaginal exams don’t contribute to the safety of the mother/baby. However, they do add to the safety of the practitioner who is tasked with placating the technocratic gods who demand they follow protocols and keep the wheels of the business running on track.
My reasons for not doing vaginal exams, even if the the technocratic gods gave their blessing, include:
They’re rude
They’re unnecessary
They shift the locus of power from the birthing woman to the person with the gloves
They introduce the potential for infection
They interrupt labour and can sabotage a good birth
They often hurt
They can traumatise the cervix
They can traumatise the mother
They can impact the experience of the baby
There are so many simpler ways to determine how labour is progressing
I don’t practice medicine or midwifery or engage in its absurdities
I really am not that interested in other people’s vaginas
Let’s talk about when labour does veer from a normal physiological process.
When the power dynamic places the labouring and birthing mother in charge of the experience, it actually becomes a safer and simpler process. She is the one who is experiencing the labour and birth and is the one relaying information. Only she is in direct communication with her baby. She is the one who knows when labour has exceeded her resources and she needs medical help, pharmacologic pain relief, or the reassurance of the technocratic model.
Of course, not all births unfold simply. However, my experience over these many years is that when women are not expected to submit to exams for the purpose of charting and the subsequent limitations imposed by those charts, birth unfolds a lot more simply far more often.
Much love,
Mother Billie ❤️
Endnotes
Tew, Marjorie. Safer childbirth?: a critical history of maternity care. (2013). Springer.
Garthus-Niegel, S., von Soest, T., Vollrath, M. E., & Eberhard-Gran, M. (2013). The impact of subjective birth experiences on post-traumatic stress symptoms: a longitudinal study. Archives of women's mental health, 16(1), 1-10.
Creedy, D. K., Shochet, I. M., & Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth, 27(2), 104-111.
Schwab, W., Marth, C., & Bergant, A. M. (2012). Post-traumatic stress disorder post partum. Geburtshilfe und Frauenheilkunde, 72(01), 56-63.
Montmasson, H., Bertrand, P., Perrotin, F., & El-Hage, W. (2012). Predictors of postpartum post-traumatic stress disorder in primiparous mothers. Journal de gynecologie, obstetrique et biologie de la reproduction, 41(6), 553-560.
Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a two‐stage US National Survey. Birth, 38(3), 216-227.
Shaban, Z., Dolatian, M., Shams, J., Alavi-Majd, H., Mahmoodi, Z., & Sajjadi, H. (2013). Post-traumatic stress disorder (PTSD) following childbirth: prevalence and contributing factors. Iranian Red Crescent Medical Journal, 15(3), 177-182.
Oates, M. (2003). Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British medical bulletin, 67(1), 219-229.
Oates, M. (2003). Suicide: the leading cause of maternal death. The British Journal of Psychiatry, 183(4), 279-281.
Cantwell, R., Clutton-Brock, T., Cooper, G., Dawson, A., Drife, J., Garrod, D., Harper, A., Hulbert, D., Lucas, S., McClure, J. and Millward-Sadler, H. (2011). Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG: an international journal of obstetrics and gynaecology, 118, 1-203.
Austin, M. P., Kildea, S., & Sullivan, E. (2007). Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Medical Journal of Australia, 186(7), 364-367
Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstetrics and gynecology, 118(5), 1056.
Grigoriadis, S., Wilton, A.S., Kurdyak, P.A., Rhodes, A.E., VonderPorten, E.H., Levitt, A., Cheung, A. and Vigod, S.N. (2017). Perinatal suicide in Ontario, Canada: a 15-year population-based study. Cmaj, 189(34), E1085-E1092.
CEMD (Confidential Enquiries into Maternal Deaths) (2001) Why Mothers Die 1997–1999. London: Royal College of Obstetricians and Gynaecologists.
Sareen, J., Cox, B. J., Stein, M. B., Afifi, T. O., Fleet, C., & Asmundson, G. J. (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic medicine, 69(3), 242-248.
Hudenko, William, Homaifar, Beeta, and Wortzel, Hal. (July 2016). The Relationship Between PTSD and Suicide. PTSD: National Center for PTSD, U.S. Department of Veterans Affair.
Act, Ontario Midwifery. "SO 1991, c. 31." (1991).
Smith Adams, K. L. (1988). From 'the help of grave and modest women' to 'the care of men of sense': the transition from female midwifery to male obstetrics in early modern England. (Master’s thesis, Portland State University.
Burrows, E. G., & Wallace, M. (1998). Gotham: a history of New York City to 1898. Oxford University Press.
Semmelweis, I. (1983). Etiology, concept, and prophylaxis of childbed fever. Carter KC, ed. Madison, WI.
Halberg, F., Smith, H. N., Cornélissen, G., Delmore, P., Schwartzkopff, O., & International BIOCOS Group. (2000). Hurdles to asepsis, universal literacy and chronobiology-all to be overcome. Neuroendocrinology Letters, 21(2), 145-160.
Caughey, A. B., Cahill, A. G., Guise, J. M., Rouse, D. J., & American College of Obstetricians and Gynecologists. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology, 210(3), 179-193.
Curtin, W. M., Katzman, P. J., Florescue, H., Metlay, L. A., & Ural, S. H. (2015). Intrapartum fever, epidural analgesia and histologic chorioamnionitis. Journal of Perinatology, 35(6), 396-400.
Kauffman, E., Souter, V. L., Katon, J. G., & Sitcov, K. (2016). Cervical dilation on admission in term spontaneous labor and maternal and newborn outcomes. Obstetrics & Gynecology, 127(3), 481-488.
Vrouenraets, F. P., Roumen, F. J., Dehing, C. J., Van den Akker, E. S., Aarts, M. J., & Scheve, E. J. (2005). Bishop score and risk of cesarean delivery after induction of labor in nulliparous women. Obstetrics & Gynecology, 105(4), 690-697.
Why I don't do vaginal exams ~ Wisdom from a Traditional Birth Companion
I let my new client know what would happen when I arrived at her home when she was in labour. We talked about sanitation measures, spending time in the kitchen, setting up the pool, and where I could take a nap if she needed some privacy. I said I would not be doing any vaginal exams as I think they’re rude, and she wept with relief.
I specialise in trauma and the majority of my clients are refugees from the medical system, running from ritual abuse and routines that protect the industry. They want someone to mentor them through to a healthy birth without the traps and trappings of the industry that removed their choice, and violated their autonomy and their dignity.
As a traditional birth attendant, I don’t do vaginal exams.
I was talking with my new client about what would likely happen when I arrived at her home when she was in labour. We talked about sanitation measures, spending time in the kitchen, setting up the pool, and where I could take a nap if she needed some privacy. I said I would not be doing any vaginal exams as I think they’re rude, and she wept with relief.
I specialise in trauma and the majority of my clients are refugees from the medical system, running from ritual abuse and routines that protect the industry. They want someone to mentor them through to a healthy birth without the traps and trappings of the industry that removed their choice, and violated their autonomy and their dignity.
We won’t go into the history of obstetrics that began with the burning of witches (midwives and healers), the rise of the man-midwife, the development of lying-in hospitals, and eventually the wholesale co-opting and medicalisation of birth. Suffice it to say that obstetrics and hospitalisation didn’t “save” women and babies (1). It created untold harm and mortality until they learned better infection control and saner behaviours. Today, it’s still leaving a trail of destruction as about 1/3 of their clients are traumatised (2,3,4) and about 1 in 8 enter parenthood with postpartum post-traumatic stress disorder (5,6,7). Suicide is a leading cause of maternal death in the first year and is highly correlated to trauma (8,9,10,11,12,13,14,15,16). It’s an industry out of control with unjustifiable caesarean rates, dangerous inductions for spurious reasons, and wholesale overuse of medications and interventions.
What women didn’t notice in this process of medicalisation and co-opting of their physiology for profit is that the medical industry took ownership of their vaginas once they became pregnant. Pregnancy transfers ownership of the vagina from the woman to the industry. Midwifery and obstetrical regulations stipulate that inserting an instrument, hand, or finger beyond the labia majora is a restricted practice sanctioned by legislation (17). To test this, see how long it takes for someone in the industry to file a Cease and Desist or start a campaign of persecution for the purpose of prosecution if they catch wind of anyone but one of their own sticking their fingers up there. No one but an insider sticks their fingers into their territory. It doesn’t matter who the mother gives her permission and consent to - it must be a member of the priesthood of modern medicine.
Of course, in their benevolence, they’re generally quite accommodating where partners are concerned, because most partners are male and obstetrics is exceedingly misogynistic. They value the needs and the pleasures of the D.
As a traditional birth attendant, I don’t do vaginal exams. For one thing, it’s considered a restricted practice for just the medical pundits and not doing them with my clients keeps the industry players somewhat placated knowing I’m not intruding into their turf. But the real reason is because I think they’re completely unnecessary and wouldn’t do them even if the medical folks begged me to under the guise that it would make birth safer.
To better understand the offence of the routine vaginal exam, we have to go back in time to when the male-midwife moved into the sanctity of women-centred birth and the domain of the midwife. It was profitable. And they convinced the public that they would provide a superior service based on the cultural belief of the time that women were disadvantaged by an inferior intellect and a predilection for sorcery (18,19). They also brought with them the medical perspective that women were an error of nature and that the world, and thus its inhabitants, were but a machine that could be best understood by coming to know its parts in isolation of the whole.
And so began dissection, mechanisation, and reducing birthing women to their parts. She became a womb expelling a foetus through a vagina. Think of today’s obstetrical “power, passenger, passage” perspective on how birth unfolds. Not much has changed in 400 years.
By sticking their fingers up there, they discovered that the cervix opens to expel the foetus. Oh, happy day! From the morgue to the birth suite, physician fingers were poking everything. Throughout the early and mid 1800’s, the infection rate in some hospitals soared as high as 60% from the mysterious childbed fever, with death rates as high as 1 in 4 (20). Nothing the doctors did was contributing to this mystery as physicians were gentlemen and gentlemen didn’t carry germs (21). And once they did accept that their filthy practices were killing women, rather than abandon the idiocy of penetrating their patients in labour, they eventually figured out how to make it less dangerous.
The practice of obstetrics has always been highly resistant to change and common sense. After all, they’ve had 400 years to figure things out and women are still birthing on their backs!
Once it was discovered that the cervix dilates as part of the labouring process, the medical industry has been fixated on that bit of tissue and made it the focus of their entire assembly line drive-through everyone-gets-what’s-on-the-menu service. That bit of tissue determines how the ward allocates services, whether the client will be permitted to stay, and how long she’ll be allowed to use their services before the next client needs the bed.
Thanks to Dr. Emanuel Friedman, who examined the cervices of 500 sedated first-time mothers in the 1950’s and plotted their dilation on a graph and matched it to the time of their birth – we now have the infamous Friedman’s Curve and the partogram.
© Evidence Based Birth
The partogram is a graph that plots cervical dilation and descent of the foetal head against a time-line. When the graph indicates that progress is slower than is allowable according to the particular chart chosen by their institution, then the practitioner is called upon to administer various interventions to speed things up to keep the labour progressing well, aka, profitably. Should these acceleration measures fail to produce a baby in a timely manner or cause foetal distress, then a caesarean section is the solution. “Failure to progress”, and the accompanying foetal distress that is often a consequence of those acceleration measures, are the leading causes of a primary caesarean (22).
Obstetrical partogram
In addition to clearing the bed for the next client, obstetrics has another reason for expediting labour. The more vaginal exams a woman receives, the greater the likelihood she’ll develop a uterine infection (23). So, once they start the poking, they need to get the baby out before their prodding adds another problem for them to solve.
In the absence of a medical situation, routine vaginal exams in labour are for the purpose of charting in order to maintain a medicalised standard of modern technocratic birth.
A labouring client will not be admitted to a hospital without a vaginal exam to determine if her dilation is far enough along for their services (unless she’s clearly pushing). And this isn’t necessarily a bad thing. Early admission to the hospital results in more interventions and more caesareans than later admission (24). This is a business and time is money.
A regulated midwife attending a homebirth will likewise perform a vaginal exam upon arrival at the client’s home to determine if the client is far enough along to warrant their limited resources and time by staying and beginning the partogram or leaving and waiting to be called back later. They must also follow the rules of the hospital at which they have privileges or their regulatory agency and transport for augmentation/acceleration if the partogram shows a significant variation.
All of this is predicated on the outdated and obsolete notion that women are machines and birth is a linear process. The only thing a vaginal exam reveals is where the cervix is sitting at that particular moment and how it’s interpreted by that particular practitioner. Women are not machines and birth is not linear. Just like any mammal, birth can be slowed, stopped, or sabotaged by an unfavourable environment or reckless attendants. I’ve said for years that it’s so easy to sabotage a good birth, it’s embarrassing.
“Years ago, I was with a first-time mother planning a family-centred homebirth. She was on the clock and had a deadline. At 42 weeks gestation, she had until midnight that night to produce a baby in order to have a midwife-attended homebirth. After that, she was expected to report to the hospital for a chemical induction. As her contractions built throughout the day, her preferred midwife arrived and labour was progressing well. She was enjoying the process and the camaraderie of her sisters-in-birth. Eventually, one of the vaginal exams revealed a cervical dilation of 8 cm, indicating it was time to call in the 2nd midwife. Only, it was a midwife that had routinely upset the mother throughout pregnancy with requests for various tests and talk of all the dangers of declining routine testing. Upon learning this midwife was coming to the birth, labour slowed.
Soon enough, the 2nd midwife arrived and assumed authority over the birth process and insisted on repeated vaginal exams for the purpose of staying within the parameters of the partogram. Her vaginal exams were excruciating, no doubt because she was trying to administer a non-consenting membrane stripping as an intervention to address the slowed and almost non-existent contractions. Eventually, an exam revealed a dilation of only 6 cm. After several more hours of “torture” (according to this mother’s recount) to keep labour going rather than just leaving the mother to rest and accepting that this labour had been hijacked and needed time to regroup and restart, dilation regressed to 4 cm and the mother eventually ended up acquiescing to a hospital transfer, and experienced an all-the-bells-and-whistles birth, trauma, and postpartum PTSD.
This mother’s subsequent birth a couple of years later didn’t include inviting midwives and unfolded as it was meant to. After a day of productive and progressing labour that was clearly evident without sticking fingers up her vagina, she eventually got tired and labour slowed and stopped. She went to bed and I went home. When she woke up, labour resumed and a baby emerged swiftly and joyously. As it turns out, for her, she has a baby after a good sleep with people she trusts.”
What about the routine vaginal exams in late pregnancy? Glad you asked!
Since they don’t have good predictive value, meaning they won’t diagnose when labour will begin, how long it will take, or whether the woman’s pelvis will accommodate that particular baby prior to labour, they have 2 functions.
The first is to plan and initiate your induction.
A cervical exam provides information that is measured against a Bishop Score. A Bishop Score provides a predictive assessment on whether an induction is likely to result in a vaginal birth or is more likely to result in a caesarean for “failure to progress”. A cervix that scores higher is more likely to respond to an induction whereas a lower score indicates a less favourable outcome (25). Further, a vaginal exam allows the practitioner to begin the induction process with a membrane stripping/stretch-and-sweep.
The second purpose for routine vaginal exams in pregnancy is to build in sexual submission. It reaffirms the power dynamic where someone who is not the woman’s intimate sexual partner is allowed to penetrate her genitals at will. It makes their job much simpler once she’s is in labour. She has been trained to accept this violation.
A vaginal exam during labour might rarely be indicated when there is a problem that requires more information. A vaginal exam can help determine if there’s a possible cord prolapse requiring immediate medical attention, or can asses the position and descent of the baby to help suggest strategies to encourage the baby to move into a better position. However, when a labour is spontaneous, meaning it hasn’t been induced by any mechanical, chemical, or “natural” means, the labour isn’t augmented with artificial rupture of membranes or synthetic oxytocin, and the labouring woman is untethered and free to move as her body indicates, complications are far less likely.
Throughout my 35 years in supporting birthing families, I can say that babies do indeed come safely and spontaneously out of vaginas when there’s no one sticking their fingers up there. And they tend to come more quickly. Routine vaginal exams don’t contribute to the safety of the mother/baby. However, they do add to the safety of the practitioner who is tasked with placating the technocratic gods who demand they follow protocols and keep the wheels of the business running on track.
My reasons for not doing vaginal exams, even if the the technocratic gods gave their blessing, include:
They’re rude
They’re unnecessary
They shift the locus of power from the birthing woman to the person with the gloves
They introduce the potential for infection
They interrupt labour and can sabotage a good birth
They often hurt
They can traumatise the cervix
They can traumatise the mother
They can impact the experience of the baby
There are so many simpler ways to determine how labour is progressing
I don’t practice medicine or midwifery or engage in its absurdities
I really am not that interested in other people’s vaginas
Let’s talk about when labour does veer from a normal physiological process.
When the power dynamic places the labouring and birthing mother in charge of the experience, it actually becomes a safer and simpler process. She is the one who is experiencing the labour and birth and is the one relaying information. Only she is in direct communication with her baby. She is the one who knows when labour has exceeded her resources and she needs medical help, pharmacologic pain relief, or the reassurance of the technocratic model.
Of course, not all births unfold simply. However, my experience over these many years is that when women are not expected to submit to exams for the purpose of charting and the subsequent limitations imposed by those charts, birth unfolds a lot more simply far more often.
Much love,
Mother Billie ❤️
Endnotes
Tew, Marjorie. Safer childbirth?: a critical history of maternity care. (2013). Springer.
Garthus-Niegel, S., von Soest, T., Vollrath, M. E., & Eberhard-Gran, M. (2013). The impact of subjective birth experiences on post-traumatic stress symptoms: a longitudinal study. Archives of women's mental health, 16(1), 1-10.
Creedy, D. K., Shochet, I. M., & Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth, 27(2), 104-111.
Schwab, W., Marth, C., & Bergant, A. M. (2012). Post-traumatic stress disorder post partum. Geburtshilfe und Frauenheilkunde, 72(01), 56-63.
Montmasson, H., Bertrand, P., Perrotin, F., & El-Hage, W. (2012). Predictors of postpartum post-traumatic stress disorder in primiparous mothers. Journal de gynecologie, obstetrique et biologie de la reproduction, 41(6), 553-560.
Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a two‐stage US National Survey. Birth, 38(3), 216-227.
Shaban, Z., Dolatian, M., Shams, J., Alavi-Majd, H., Mahmoodi, Z., & Sajjadi, H. (2013). Post-traumatic stress disorder (PTSD) following childbirth: prevalence and contributing factors. Iranian Red Crescent Medical Journal, 15(3), 177-182.
Oates, M. (2003). Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British medical bulletin, 67(1), 219-229.
Oates, M. (2003). Suicide: the leading cause of maternal death. The British Journal of Psychiatry, 183(4), 279-281.
Cantwell, R., Clutton-Brock, T., Cooper, G., Dawson, A., Drife, J., Garrod, D., Harper, A., Hulbert, D., Lucas, S., McClure, J. and Millward-Sadler, H. (2011). Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG: an international journal of obstetrics and gynaecology, 118, 1-203.
Austin, M. P., Kildea, S., & Sullivan, E. (2007). Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Medical Journal of Australia, 186(7), 364-367
Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstetrics and gynecology, 118(5), 1056.
Grigoriadis, S., Wilton, A.S., Kurdyak, P.A., Rhodes, A.E., VonderPorten, E.H., Levitt, A., Cheung, A. and Vigod, S.N. (2017). Perinatal suicide in Ontario, Canada: a 15-year population-based study. Cmaj, 189(34), E1085-E1092.
CEMD (Confidential Enquiries into Maternal Deaths) (2001) Why Mothers Die 1997–1999. London: Royal College of Obstetricians and Gynaecologists.
Sareen, J., Cox, B. J., Stein, M. B., Afifi, T. O., Fleet, C., & Asmundson, G. J. (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic medicine, 69(3), 242-248.
Hudenko, William, Homaifar, Beeta, and Wortzel, Hal. (July 2016). The Relationship Between PTSD and Suicide. PTSD: National Center for PTSD, U.S. Department of Veterans Affair.
Act, Ontario Midwifery. "SO 1991, c. 31." (1991).
Smith Adams, K. L. (1988). From 'the help of grave and modest women' to 'the care of men of sense': the transition from female midwifery to male obstetrics in early modern England. (Master’s thesis, Portland State University.
Burrows, E. G., & Wallace, M. (1998). Gotham: a history of New York City to 1898. Oxford University Press.
Semmelweis, I. (1983). Etiology, concept, and prophylaxis of childbed fever. Carter KC, ed. Madison, WI.
Halberg, F., Smith, H. N., Cornélissen, G., Delmore, P., Schwartzkopff, O., & International BIOCOS Group. (2000). Hurdles to asepsis, universal literacy and chronobiology-all to be overcome. Neuroendocrinology Letters, 21(2), 145-160.
Caughey, A. B., Cahill, A. G., Guise, J. M., Rouse, D. J., & American College of Obstetricians and Gynecologists. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology, 210(3), 179-193.
Curtin, W. M., Katzman, P. J., Florescue, H., Metlay, L. A., & Ural, S. H. (2015). Intrapartum fever, epidural analgesia and histologic chorioamnionitis. Journal of Perinatology, 35(6), 396-400.
Kauffman, E., Souter, V. L., Katon, J. G., & Sitcov, K. (2016). Cervical dilation on admission in term spontaneous labor and maternal and newborn outcomes. Obstetrics & Gynecology, 127(3), 481-488.
Vrouenraets, F. P., Roumen, F. J., Dehing, C. J., Van den Akker, E. S., Aarts, M. J., & Scheve, E. J. (2005). Bishop score and risk of cesarean delivery after induction of labor in nulliparous women. Obstetrics & Gynecology, 105(4), 690-697.
The system isn’t broken - but its people are
One third of birthing parents has a traumatic birth.
“The system is broken.”
One in 8 new parents enters parenthood with postpartum PTSD from the experience.
“The system is broken.”
Depending on where you live, one third, one half, or almost everyone has a surgical birth.
“The system is broken.”
One in 6 women are abused during their births.
“The system is broken.”
If we say it enough, we might believe it. However, the “system” is decidedly NOT broken. It is doing exactly what it was set up to do by any means available to it.
One third of birthing parents has a traumatic birth.[i] [ii] [iii]
“The system is broken.”
One in 8 new parents enters parenthood with postpartum PTSD from the experience.[iv]
“The system is broken.”
Depending on where you live, one third, one half, or almost everyone has a surgical birth.[v]
“The system is broken.”
One in 6 women are abused during their births.[vi]
“The system is broken.”
If we say it enough, we might believe it. However, the “system” is decidedly NOT broken. It is doing exactly what it was set up to do by any means available to it.
The “system” is how we deliver maternity services. It began when male-midwives, those physicians who broke social etiquette, began attending women in birth. They were barbaric in means because they were sanctioned by the Catholic church to carry sharp instruments that women were forbidden to use. Male barber-surgeons, the Chamberlains, invented the forceps but kept their secret hidden for a century. A few centuries of witch hunts where midwives and female healers were persecuted and executed taught the public to shy away from learning these skills – if they were women. The collusion of religion and medicine ensured that men gained and maintained a monopoly over sick care and what women were allowed to do with their own bodies.[vii]
Eventually, through clever marketing, the male midwife became the preferred attendant as they were considered superior in intellect.[viii] [ix] Women were forbidden to attend universities, practice medicine, or serve in leadership in religions that ruled the western politic, thus unable to influence how women were treated in childbirth.[x]
Sure enough, these clever men discovered how much more profitable it was to bring birthing clients to them rather than going out to their homes.[xi] And so emerged the ‘lying-in’ hospital. The wholesale slaughter of women in these death traps was on par with the witch hunts of a few centuries prior. One in ten women died from puerperal fever, brought on by the unwashed hands of physicians who went from cadaver to the birthing vagina.[xii] Despite the protests of the offensive Semmelweis to wash their hands, ego and elitism prevented them from adopting this simple strategy for many more years thus ensuring the needless deaths of countless more women.[xiii]
Ignaz Semmelweis washing hands with chlorine-water, 1846
Once chloroform and other means of anesthesia were available for use in childbirth, the medical societies lobbied the government to grant them exclusive access. Not that they were any more qualified to use these powerful drugs than any other discipline, they merely had the ear of those in power who made these decisions.[xiv] Next followed the most effective smear campaign in all of history to drive midwives and alternative healing modalities out of business. [xv] [xvi] By the end of WW2 the campaign was almost complete. Next came effective lobbying to ensure governments were only favourable to their approach and the money, legislations, and endorsements flowed to hospital based technocratic birth where the obstetrician is royalty.
Even today, midwives around the world are persecuted and legislated out of business for offering client-centred care and serving women outside of hospitals.
Leaning heavily on Henry Ford’s conveyor belt system of turning out cars, optimisations and standardisations were implemented to cut costs, increase revenue, and turn the business of birth into a well-oiled machine.[xvii]
What we have is an effective system of profit for those industry players who set it up this way.
Of course, women are abused in birth! It’s an effective means of getting them to submit to a routine, one-size-fits-all, conveyor belt, in-and-out, profitable baby factory.
Even the current schedule of prenatal visits has no basis in science, evidence, or benefit. It was created by those same male-midwives who took a good thing and made it $tandard. Certainly, diagnosing and treating medical issues is an important healthcare strategy, whether pregnant or not. In light of the evidence that today’s current schedule and routines have not produced the promised results of healthier pregnancies or births, the industry recommended and implemented a strategy to convince the public that the process of pregnancy could not be trusted to stay normal without their surveillance.[xviii]
Now let’s talk about the people.
Some people enter this industry because it’s proven itself as a profitable endeavour. Obstetrics includes a great deal of power and control over a physiological process that in most cases would unfold quite simply without them. This appeals to some people. It’s a position of elitism and sits higher on the social hierarchy. There’s nothing to see there. Nothing to reach. Nothing to change.
And some enter this industry because they believe they have something valuable to offer during one of the most sacred and vulnerable times in a person’s life. They believe in the importance of how new humans are greeted into this world.
But because they have entered a highly successful system, they witness and sometimes participate in horrific abuses of mothers and babies. Some are broken by this and are the walking and working wounded, grappling with trauma, burnout, PTSD, and even suicidal ideation. Some survive and continue doing the best they can without the learned skillset of trauma-informed care that protects them and their clients. And some become part of the system of abuse and profit as their initial purpose is co-opted by internalised patriarchy and misogyny.
But what’s to be done with those who are broken and those who are merely surviving? The system doesn’t care if they burnout and leave. Players are easily replaced by new inductees at beginner salaries. It was never set up to take care of anyone. It was set up as a profitable means of co-opting physiology for profit based on fear and coercion.
“What we have is a medical system that is literally killing people through suicide.”
Break time. Nature and birth are not always kind. Women have always benefited from the companionship and knowledge of their midwives. And when events became problematic, skilled surgeons and expert paediatricians have brought hope and life where there was once only death. This post only speaks to the system of facility-based birth that currently exists within a patriarchal, misogynistic, and technocratic paradigm.
Back to the people.
‘Burnout’ consists of three features
Emotional exhaustion – feeling emotionally depleted from being overworked
Depersonalisation and cynicism – unfeeling towards patients and peers with often negative, callous, and detached responses
Reduced personal efficacy – a reduced sense of competence or achievement in one’s work
Burnout, compassion fatigue, and trauma are often intermingled in the academic literature so it’s hard to get a sense of the enormity of the issue. However, we do know this:
Physicians
Female physicians have higher rates of burnout and less work satisfaction than males[xxiii]
Physicians have the highest rate of suicide of any profession[xxiv]
General population - 12.3 per 100,000
Physicians -28 to 40 per 100,000
Equal numbers of male and female physicians complete a suicide
Midwives
Midwives around the world report rates of burnout from 20%[xxv] to 65%[xxvi]
One third of midwives have clinical PTSD[xxvii]
Witnessing abusive care of patients creates more severe PTSD[xxviii]
Nurses
35% of labour and delivery nurses have moderate to severe secondary traumatic stress[xxix]
Witnessing or participating in abusive births is a direct contributor to trauma
24% higher rate of suicide than those outside the profession[xxx]
Nurses and Midwives
Female 192% more likely to complete suicide than females in other occupations
8.2 per 100,000 vs 2.8 per 100.000
Male 52% more likely to complete suicide than males in other occupations
22.7 per 100,000 vs 14.9 per 100.000
Male 196% more likely to complete suicide than female colleagues
22.7 per 100,000 vs 8.2 per 100.000[xxxi]
Doulas
Half of doulas report burnout[xxxii] where traumatic incidences and witnessing the mistreatment of labouring clients were direct causes of burnout. Secondary trauma causes doulas to leave the profession early, especially in light of institutional hostility, low income, and routine abuses of their clients[xxxiii]
From the client’s perspective, the simple answer is to birth outside the system.[xxxiv] It’s a reasonable option – unless you’ve drunk the Kool Aid and feel these parents are a danger to their foetus and must be punished through disrespectful care[xxxv] and calls to Childrens Apprehension Services. If enough clients choose an alternative to the system, then simple economics will drive change to bring back the customers.
Birthing families are paying a steep price for system-driven birth. High rates of trauma, postpartum PTSD, postpartum depression and anxiety, relationship breakdowns, and postpartum suicide.[xxxvi] [xxxvii] [xxxviii] [xxxix] [xl] [xli] What we have is a medical system that is literally killing people through suicide.
So, what to do with the crippling loss of health and wellness in those professionals who chose to enter the system to support families in a humane and compassionate manner? Is it even possible to bring back those who have lost their way?
Because the system of institutionalised maternity services is predicated on a patriarchal and misogynistic paradigm of control and elitism, it will never take care of those who are on the front lines. We must learn to take care of ourselves and each other.
Many good and decent people entered into the system of technocratic birth services with all the requisite technical skills and a desire to make a difference in the lives of birthing families. What was missing from their education and skills development were those specific skills that would equip them to work in that environment without losing their soul, their identity, or their life.
Fortunately, the same research that identifies the many problems with this delivery system of services, also identifies the many solutions. For those that are on a journey out of trauma and professional burnout towards recovery and professional efficacy, there are proven strategies that can help walk you towards recovery and wholeness. You can learn
A research-based understanding of the causes and consequences of birth trauma in the birthing client and how to avoid participating
A thorough understanding of secondary and vicarious trauma and its effects in healthcare providers
How to build neurological, biological, psychological, social, cultural, and structural resilience
The positive impact of affective empathy and how to use it
How to employ a trauma-informed approach with clients and peers that improves clinical accuracy, client and professional well-being, and reduces burnout, medical mistakes, and litigation
A knowledge of therapeutic modalities that are specific to trauma
Recovery is possible for those who seek it. While the system runs perfectly as it was designed to, it’s also possible that with enough recovered, equipped, and healthy participants we might see some significant changes that actually helps it to live up to its marketing of “healthy baby healthy mother”. In time, it might even include “healthy professionals”.
I’ve got the science. I’ve got the experience. And I’ve got the tools to help. Let’s do this together.
Much love,
Mother Billie
Endnotes
[i] Garthus-Niegel, S., von Soest, T., Vollrath, M. E., & Eberhard-Gran, M. (2013). The impact of subjective birth experiences on post-traumatic stress symptoms: a longitudinal study. Archives of women's mental health, 16(1), 1-10.
[ii] Creedy, D. K., Shochet, I. M., & Horsfall, J. (2000). Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth, 27(2), 104-111.
[iii] Schwab, W., Marth, C., & Bergant, A. M. (2012). Post-traumatic stress disorder post partum. Geburtshilfe und Frauenheilkunde, 72(01), 56-63.
[iv] Montmasson, H., Bertrand, P., Perrotin, F., & El-Hage, W. (2012). Predictors of postpartum post-traumatic stress disorder in primiparous mothers. Journal de gynecologie, obstetrique et biologie de la reproduction, 41(6), 553-560.
[v] Boerma, T., Ronsmans, C., Melesse, D. Y., Barros, A. J., Barros, F. C., Juan, L., ... & Neto, D. D. L. R. (2018). Global epidemiology of use of and disparities in caesarean sections. The Lancet, 392(10155), 1341-1348.
[vi] Vedam, S., Stoll, K., Taiwo, T. K., Rubashkin, N., Cheyney, M., Strauss, N., ... & Schummers, L. (2019). The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reproductive health, 16(1), 77.
[vii] Ehrenreich, B., & English, D. (2010). Witches, midwives, & nurses: A history of women healers. The Feminist Press at CUNY.
[viii] Smith Adams, K. L. (1988). From 'the help of grave and modest women' to 'the care of men of sense': the transition from female midwifery to male obstetrics in early modern England. (Master’s thesis, Portland State University.
[ix] Burrows, E. G., & Wallace, M. (1998). Gotham: a history of New York City to 1898. Oxford University Press.
[x] Minkowski, W. L. (1992). Women healers of the middle ages: selected aspects of their history. American journal of public health, 82(2), 288-295.
[xi] Tew, M. (2013). Safer childbirth?: a critical history of maternity care. Springer.
[xii] Loudon, I. (2000). The tragedy of childbed fever. New York, Oxford University Press.
[xiii] Tew, M. 2013, op. cit.
[xiv] Bonner, T. N. (1989). Abraham Flexner as critic of British and Continental medical education. Medical history, 33(4), 472-479.
[xv] Getzendanner, S. (1988). Permanent injunction order against AMA. JAMA, 259(1), 81-82.
[xvi] Weeks, John. (n.d.). “AMA ‘Thwarts’ Other Professions Practice Expansion and a Challenge to CAM-IM Fields”. The Integrator Blog. http://theintegratorblog.com/?option=com_content&task=view&id=73&Itemid=1
[xvii] Perkins, B. B. (2004). The medical delivery business: Health reform, childbirth, and the economic order. Rutgers University Press.
[xviii] Ball, J. (1993). The Winterton report: difficulties of implementation. British Journal of Midwifery, 1(4), 183-185.
[xix] Peckham, C. (2016). Medscape lifestyle report 2016: bias and burnout. New York, NY: Medscape.
[xx] Avery, Granger, M.D., (2017). The role of the CMA in physician health and wellness. Canadian Medical Association.
[xxi] Imo, U. O. (2017). Burnout and psychiatric morbidity among doctors in the UK: a systematic literature review of prevalence and associated factors. BJPsych bulletin, 41(4), 197-204.
[xxii] Wu, F., Ireland, M., Hafekost, K., & Lawrence, D. (2013). National mental health survey of doctors and medical students.
[xxiii] Peckham, C., 2016, op. cit.
[xxiv] T’Sarumi, O., Ashraf, A., & Tanwar, D. (2018). Physician suicide: a silent epidemic. Reunión Anual de la American Psychiatric Association (APA). Nueva York, Estados Unidos, 1-227.
[xxv] Henriksen, L., & Lukasse, M. (2016). Burnout among Norwegian midwives and the contribution of personal and work-related factors: a cross-sectional study. Sexual & Reproductive Healthcare, 9, 42-47.
[xxvi] Creedy, D. K., Sidebotham, M., Gamble, J., Pallant, J., & Fenwick, J. (2017). Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey. BMC pregnancy and childbirth, 17(1), 13.
[xxvii] Sheen, K., Spiby, H., & Slade, P. (2015). Exposure to traumatic perinatal experiences and posttraumatic stress symptoms in midwives: prevalence and association with burnout. International journal of nursing studies, 52(2), 578-587.
[xxviii] Leinweber, J., Creedy, D. K., Rowe, H., & Gamble, J. (2017). Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives. Women and birth, 30(1), 40-45.
[xxix] Beck, C. T., & Gable, R. K. (2012). A mixed methods study of secondary traumatic stress in labor and delivery nurses. Journal of Obstetric, Gynecologic & Neonatal Nursing, 41(6), 747-760.
[xxx] Office for National Statistics. (2017). Suicide by occupation, England: 2011 to 2015.
[xxxi] Milner, A.J., Maheen, H., Bismark, M.M., & Spittal, M.J. (2016) Suicide by health professionals: a retrospective mortality study in Australia, 2001–2012. Medical Journal of Australia 205 (6): 260-265.
[xxxii] Naiman-Sessions, M., Henley, M. M., & Roth, L. M. (2017). Bearing the burden of care: emotional burnout among maternity support workers. In Health and Health Care Concerns Among Women and Racial and Ethnic Minorities (pp. 99-125). Emerald Publishing Limited.
[xxxiii] Roth, L. M., Heidbreder, N., Henley, M. M., Marek, M., Naiman-Sessions, M., Torres, J. M., & Morton, C. H. (2014). Maternity support survey: A report on the cross-national survey of doulas, childbirth educators and labor and delivery nurses in the United States and Canada.
[xxxiv] Holten, L., & de Miranda, E. (2016). Women׳ s motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on ‘birthing outside the system’. Midwifery, 38, 55-62.
[xxxv] Vedam, S., Stoll, K., Rubashkin, N., Martin, K., Miller-Vedam, Z., Hayes-Klein, H., & Jolicoeur, G. (2017). The Mothers on Respect (MOR) index: measuring quality, safety, and human rights in childbirth. SSM-Population Health, 3, 201-210.
[xxxvi] Oates, M. (2003). Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British medical bulletin, 67(1), 219-229.
[xxxvii] Oates, M. (2003). Suicide: the leading cause of maternal death. The British Journal of Psychiatry, 183(4), 279-281.
[xxxviii] Lewis, G. (2007). Saving mothers' lives: reviewing maternal deaths to make motherhood safer 2003-2005: the seventh report of the confidential enquiries into maternal deaths in the United Kingdom. CEMACH.
[xxxix] Austin, M. P., Kildea, S., & Sullivan, E. (2007). Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Medical Journal of Australia, 186(7), 364-367.
[xl] Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstetrics and gynecology, 118(5), 1056.
[xli] Grigoriadis, S., Wilton, A. S., Kurdyak, P. A., Rhodes, A. E., VonderPorten, E. H., Levitt, A., ... & Vigod, S. N. (2017). Perinatal suicide in Ontario, Canada: a 15-year population-based study. Cmaj, 189(34), E1085-E1092.
The Textbook is Wrong
We were sitting across her kitchen table. A tissue was being nervously mangled in her trembling hands.
“I just can’t do it again,” she said. “Can you tell me about your daughter’s birth,” I asked her?
She explained that everyone told her it was a good birth. Her doctor said it was textbook perfect. Her mother was there and repeated her version of her granddaughter’s birth to everyone who would listen. It was natural. It was quick. It was the best day ever.
And as the story unfolded, tears welled up in my eyes, finally spilling down my own cheeks. It was an awful experience. And my heart broke into pieces again.
She described a birth where she was tortured with screamingly painful vaginal exams, weeping for them to stop, thrashing to escape the confines of the hospital bed where she was tethered to the monitoring machine for policy’s sake, begging to stand up, move, sway, anything to cope with her rapidly advancing labour. Her voice buried under a gentle shush so as not to scare the other mothers.
We were sitting across her kitchen table. A tissue was being nervously mangled in her trembling hands.
“I just can’t do it again,” she said. “Can you tell me about your daughter’s birth,” I asked her?
She explained that everyone told her it was a good birth. Her doctor said it was textbook perfect. Her mother was there and repeated her version of her granddaughter’s birth to everyone who would listen. It was natural. It was quick. It was the best day ever.
And as the story unfolded, tears welled up in my eyes, finally spilling down my own cheeks. It was an awful experience. And my heart broke into pieces again.
She described a birth where she was tortured with screamingly painful vaginal exams, weeping for them to stop, thrashing to escape the confines of the hospital bed where she was tethered to the monitoring machine for policy’s sake, begging to stand up, move, sway, anything to cope with her rapidly advancing labour. Her voice buried under a gentle shush so as not to scare the other mothers.
When the baby emerged, she was placed on her mother as the room cheered. Only, she felt nothing. Grateful that those hands wouldn’t enter her again, except in her dreams. The symptoms of PTSD followed her for the first year of her child’s life as she struggled to connect the version of her birth she’d been told and her personal experience of it.
And she just couldn’t do it again.
This is the story I hear over and over by mothers in all parts of the world. She’s told to be grateful for her healthy baby, to be grateful for the care she received, that her expectations were too high, that having a baby is hard and she had a low pain threshold, or that she was foolish for not taking the drugs offered her. She’s told anything except, “I’m sorry. It wasn’t meant to be that way.”
Research tells us that trauma is not particularly related to any emergencies or complications, but is dependent on how the mother experiences her birth. What can seem like a “textbook” birth to the clinician can be a devastating experience for the mother.
Birth is a hormonal process driven by our para-sympathetic nervous system, our “calm and connected” system. The primary driver of birth is oxytocin, which is the hormone of love, trust and bonding. Endorphins and prolactin ensure the experience is filled with pain-relief and joy. In today’s culture of fear, mothers are increasingly experiencing their births as traumatic as hospital policies serve the business end of cost-control, expediency, and insurance regulations. Doctors, nurses and midwives are sometimes constrained by policy in spite of the best interests of their clients.
Where birth is biologically programmed to be joyous, active, patient and primed for love and bonding, how we do birth in this culture is at odds with this biological imperative. The problem comes from what we call “textbook perfect”. The textbook is written from a medicalised perspective that is brand new in the biology of humans. Humans haven’t yet adapted to forced fasting, routine IVs, ultrasounds, continuous monitoring, hospital acquired infections, vaginal penetrations, forced on-her-back pushing, an inability to move and strangers between her legs.
When one third of mothers say their births were traumatic and one in ten struggle with PTSD, we know that birth is in crisis. And the textbook is wrong.
Of course, some births require medical assistance. Yet the question becomes, how can we protect a mother from trauma? And what happens when a pregnant mother says she can’t do that again?
In spite of the law that says a medical procedure cannot be performed on a non-consenting patient and that consent may be withdrawn at any point for any reason, the truth is that many things happen to a mother in labour in which she has no choice. In order to gain compliance, she may be told the baby might die. We call this ‘playing the dead baby card’ and it’s so common it’s becoming a laughing point.
There have been many a new textbooks written – from the mother’s perspective, from the baby’s perspective, from the vantage of good science, and yet mothers are still struggling. When a mother says she can’t do it again, it means we have to take a long hard look at what is happening today.
Strong and courageous leadership from medical associations including obstetricians, family physicians, nurses and midwives could lead the way in changing non-evidence based policies that serve the institution and insurance regulations but harm mothers and babies.
Mothers are increasingly learning the science of safe birth for themselves and are changing the conditions under which they give birth. Perhaps the quickest route to change is to spend our birthing dollars in those places that support the biology of birth and the law of informed consent and refusal.
It’s not selfish to want a great experience – it’s biology.