I spent a number of years living in Brazil, and it was there that I gave birth to my first child. I’ll always remember Lucila telling me I was keeping the baby in. I’d met her a few weeks before this, in a rootsy São Paulo cafe that sold Amazonian ice cream. Her wrists were tattooed with the names of her children and she had found the pain of childbirth ecstatic. She’d given up her job in PR to train as a doula because of it, she told me, patting my mountainous belly. The idea of having a life-changing, quasi-orgasmic birth experience sounded excellent and I enlisted her help for my upcoming delivery immediately.
By the time Lucila told me I was keeping the baby in, I was two exhausting days into an induced labour at an expensive Brazilian hospital and had never felt so far from horny in my life. She thought that I was frightened to let go of the baby. I don’t think I was. I had begun to have visions of carrying an eighteen-year-old around in utero which I didn’t find pleasant. What I was was simply frightened. I’d been wheeled into a darkened operating room to have a catheter shoved inside me and then inflated. I’d vomited several times. I had blood running down my legs. My mother-in-law was haunting the hospital corridors trying to break into the delivery room. I was on drugs and strapped up to monitors that flashed heartbeat readings. Women I didn’t know and couldn’t understand kept putting their hands up my vagina. By the third day I was having contractions that made my eyes roll into the back of my head. On day four I believed that either me or the baby would die.
My doctor eventually delivered my daughter as I lay spreadeagle naked on a treatment table under searing light, surrounded by a crowd of green uniforms, attached to two or three drips, the beep beep beep of monitors drowned out periodically by my screams. The doctor wielded scissors and cut my perineum. I remember the moment Layla was born not as joyful but filled simply with raw relief. We left hospital three days later. I was desperate to stay; I didn’t see how my daughter would survive without nurses. I wasn’t able to give birth to her myself, how could I look after her myself? In the last heavy days of pregnancy, blithely tracing limbs under skin, I’d begun to wonder if I’d be up to the job of giving birth, if I’d be up to the job of motherhood. My experience of hospital confirmed to me that I was capable of neither. I left crooked and shuffling, a failure from the very start. The first months of my daughter’s life were bleak and lonely. I didn’t keep up with Lucila and felt stupid for hoping the birth of a baby could be anything other than traumatic.
Five years later, back in England, I was pregnant with my second child. Tramping up and down a wet hill in Norwich, I passed my due date once again. Like one in five British women I was told my labour would be artificially induced in hospital. I cried when the midwife booked the appointment. She looked upset and handed me a tissue together with a photocopied leaflet explaining the process. It made induction sound simple and straightforward, which was not how I remembered it at all. They’re not telling me the whole story here, I thought, and began my own research.
I was surprised to learn that contrary to what I’d come to believe, I was not someone uniquely ill-disposed to birth. Induced first labours are often long, hard and exhausting, and not at all as easy as my Brazilian doctor had presented it. And there was more. The drip I had been attached to for four days was synthetic oxytocin which is used to stimulate contractions. Synthetic oxytocin hampers the body’s ability to make its own oxytocin, the hormone which naturally relieves the pain and stress of labour as well as helping a mother bond with her baby and breastfeed, two things I had not been able to do. I was shocked. Why hadn’t my doctor explained this to me? Could this be the reason things had been so bleak back then? I spoke to Kerstin Uvnäs Moberg, a clinical researcher who has been investigating the effects of oxytocin for over thirty years.
‘We find that mothers who have had synthetic oxytocin drips can sometimes be less open,’ she said, ‘less relaxed with higher cortisol levels and after a while a little less predisposed to be a “perfect mother”. Then there are the effects on the baby. If the mother is more stressed in labour the baby gets less oxygen and less blood. In high amounts it causes longer lasting contractions which can damage the baby. There have also been observations that ADHD and autism could have some relationship to synthetic oxytocin but we don’t know for sure. I think this is the great shame. How can it be that we give oxytocin to almost all women in the developed world without knowing what it really does? No other drug would be given in such large amounts without being tested.’
My doctor had told me it was safer for me to be induced ten days after my due date than wait to give birth naturally. She hadn’t made it seem like a choice. But the Association for Improvements in Maternity Services ‘Guide to Induction’ told me that there is no medical reason to induce a woman until fourteen days after she is ‘term’. Even then, I learnt, not only are due dates notoriously inaccurate but the World Health Organisation recommendation to induce pregnant women who are ‘post-term’ is based on evidence which is, in their own words, ‘weak’ and of ‘low quality’. My traumatic birth and the depression that followed hadn’t been inevitable, I realised. I had walked straight into it.
My experience is part of a trend. In September 2016 the Lancet released a series of papers on the state of maternity care entitled ‘Too Little, Too Late, Too Much, Too Soon’. Their panel of experts claimed that childbirth in the developed world has become increasingly over-medicalised with routine and excessive use of interventions causing harm, raising health costs and contributing to a culture of disrespect and abuse of women.
Of course, medical interventions save lives every day. There have been major glitches – for example when childbirth moved from home to hospital in the nineteenth century, hundreds of thousands of women died needlessly due to infection spread by doctors’ unwashed hands – but it is thanks to advances in obstetrics that women no longer make wills as soon as they find out they are pregnant, as they did in Renaissance Florence. Women such as myself understand this. New research by the Australian midwife Dr Rachel Reed at the University of the Sunshine Coast suggests mothers do not feel abused by the interventions themselves so much as how they are carried out. The women she spoke to reported being lied to, threatened, violated and having their own instincts disregarded at one of the most vulnerable times of their lives. Some women likened their birth to sexual abuse. Many felt the needs of the care provider were put ahead of their own. Brazil, for example, has one of the highest rates of caesarean section in the world, driven not only by the financial incentives of expensive procedures but also by convenience. Obstetricians often charge women more to try and have their baby naturally instead of by C-section as it may happen out of office hours. My own doctor was far more expensive than the average because she didn’t routinely give caesareans. In the US this situation is compounded by policies that set a woman’s well-being against that of her unborn child. Court orders, sheriffs and state attorneys have all been used to force mothers, sometimes hysterical, into interventions that they don’t want and arguably don’t need.
Even in the UK, where there is a rhetoric of woman-centred care and targets to reduce caesarean rates, the National Childbirth Trust reported in January that women are leaving hospital feeling like ‘cattle’, having given birth on a ‘conveyor belt’. Jude, from Brighton, had a life-threatening haemorrhage after the birth of her son but felt safe, cared for and respected. It was after the relatively normal birth of her daughter that she developed post-traumatic stress disorder and she blames this on the way she was treated.
‘It was an induction,’ she said. ‘Nobody talked to me about what was happening. I felt like I was being tortured. The obstetrician was clearly in an absolute rush and needed the bed. I was pressurised into having an epidural. All the lights were up and the doctor kept saying “You just have to have a poo”. I still feel great shame about that. I remember her looking at me saying “This doesn’t hurt”. At that point I lost all of me, I was meat on a table and I thought I was going to die. I vividly remember holding the baby but after that I don’t remember anything. The aftercare was appalling. I sat for two hours in a pool of my own blood. It was like a warzone.’
The term PTSD evolved through the work of psychiatrist Chaim F. Shatan with Vietnam veterans. He described how the terror and dehumanization soldiers experienced in war resulted in an ‘impacted grief’ in which an encapsulated, never-ending past deprives the present of meaning. It was coined with extraordinary situations like battlegrounds or natural disasters in mind, as opposed to difficult but everyday life events such as death or birth. Despite this, around 10,000 new mothers every year develop PTSD in response to their time in British hospitals. Jude became hypervigilant, constantly checking if her daughter was hot or cold. She was terrified of knives and maintained OCD-level routines to regain the feeling of control she lost in birth. Unable to connect with other mothers and babies, she became increasingly isolated. Jude eventually recovered, but many aren’t so lucky. Almost a quarter of maternal deaths in the first year after birth were due to mental health problems, with one in ten deaths due to suicide. I have always seen myself as relatively robust mentally. However, for months after the birth of my daughter, constant thoughts of death, my own and of those I love, played across my mind. Sickness, bodily frailty, the horror of time passing, being born astride a grave, was central to my vision of the world. It was hard to get up in the morning, not because I was tired, which of course I was, but because I was scared. Dr Judy Shakespeare is part of the UK Confidential Enquiry into Maternal Deaths and says it is harrowing. ‘For every woman that dies there are a thousand near misses,’ she said. Maternal mental health is in such crisis that the cash-strapped NHS has recently pledged £40 million to open up twenty new community centres devoted solely to the problem. This is a lot of money if, like Kim Thomas of the Birth Trauma Association, you believe much of the anxiety and depression post-partum mothers develop could have been prevented by better treatment in the delivery room.
‘I think the birth experience has a huge – and largely unacknowledged – impact on a woman’s mental health,’ said Thomas. ‘What’s striking when you talk to women is that, even if, say they’ve had a post-partum haemorrhage or a retained placenta or third-degree tearing, it’s not those things in themselves that have affected them, it’s the way they were treated in hospital: the internal examination carried out without consent, or a refusal to give pain relief when asked, or a midwife making an inappropriate joke or a hostile remark. Many women talk of being belittled or made to feel stupid.’ During the birth of my first daughter I remember a feeling of being a disappointment to the people looking after me. There was an atmosphere in the air, an unspoken opinion that if I had been more in tune with my body, if I had been ready to be a mother, less scared and more open, then my baby would have arrived by now.
It’s hard to blame midwives for hostility in light of a report published this October by the Royal College of Midwives. It revealed staff shortages, bullying and working conditions so bad that midwives felt labouring women were, sometimes, in real danger. They reported feeling burned out, depressed and feared making tragic mistakes. One midwife said she had seen colleagues ‘destroyed by management if something went wrong’ despite the fact they had worked ‘twelve hour shifts without breaks.’
There is a staff shortage across the whole of the NHS but this is compounded in maternity services by a culture of fear driven by the risk of litigation. Claims related to childbirth cost the health service more than any other area – £3.1 billion from 2000 to 2010. Midwifery Professor Soo Downe, from the University of Central Lancaster, believes that routine interventions are being given in the knowledge that they are not in the best interests of a woman’s emotional, or even physical health, because straying from guidelines means being blamed if a problem arises.
‘We are beginning to go back to the time when women were seen as a vessel to deliver from,’ she said, ‘the government rhetoric encouraging philological birth is great but Jeremy Hunt is enacting policies which go against this totally. This makes it very difficult for those working in maternity services. Blanket policies are enacted which probably help one in 1,000 births to the detriment of the other 999.’
Research indicates that the risks for a healthy woman with a normal pregnancy who wants to wait for labour to start naturally, as opposed to being induced, are very low. Despite knowing this, the immense pressure I felt once clinical guidelines classified me ‘overdue’ was too much for me. Sixteen days after my due date I went into hospital to be induced once more. I remember feeling so sad and unhappy as I was shown into the delivery room. I had deeply wanted to at least try to give birth by myself and now I never would. The midwife strapped me up to a monitor and the beeps began once more. A doctor came in to break my waters.
‘I didn’t want this,’ I said.
‘I know,’ he said, looking down at me on the treatment table. ‘It’s after fourteen days. The baby needs to come out.’
I wanted to say to him, no, it doesn’t. Statistically it is as safe to give birth anytime this week as it is at thirty-eight weeks. Instead, I smiled weakly. I was tired of being a nuisance. He put my feet in stirrups and began digging around in me, trying to break my waters, stabbing a needle repeatedly into my cervix. I was in undignified, useless pain and had no trust in the people who were supposed to be caring for me. A bad start to one of the most important moments of my life.
‘Stop,’ I said, ‘I need a break.’
The doctor moved away and so did the midwife. They looked at me.
‘Okay,’ he said. ‘The baby’s safe. There’s no problem, I can come back later.’
For the first time in days I felt someone was engaging with me honestly. The midwife suggested I go for a walk. She told me that once my waters were broken we could wait longer than the stipulated four hours before putting in a drip – I had eighteen hours if I really needed. She was being kind, I realised.
For Professor Downe, concerted and focused compassion is the solution to the problems facing maternity care now.
‘This is a global issue,’ she said. ‘The key to better maternity services is positive relationships catalysed by continuity of care. Research across the world says trust is the most important thing for a labouring woman. If she trusts the person who is looking after her then she feels the things that are done to her are necessary.’
This is not a new idea. In 1942 the obstetrician Grantly Dick-Read published his controversial book, Childbirth Without Fear, in which he claimed that it wasn’t supposed to hurt. When a woman in labour felt scared or unsafe they produced stress hormones which stopped contractions or made them unbearable. A loving atmosphere, on the other hand, meant an easier, oxytocin-filled labour that could actually be joyful. The book is still in print today, but is such kindness just too much to ask of overworked, underpaid, frightened NHS staff? Downe says no, and recommends new policies that make building relationships between mothers and midwives a priority.
‘We can’t force people to be kind,’ she said, ‘but if a proxy for kindness is knowing someone, then chances are staff are going to be happier, there will be less absenteeism and you are going to save a shedload of money. If we were kinder the NHS would have less cost – the evidence is there that labour progresses better if we feel safe. Research shows there would be less premature babies – which cost an enormous amount – less babies that die and less caesarean sections.’
I never did go for my walk. As soon as my midwife left the room I began to have sharp, stabbing pains where the doctor had been prodding me. These quickly turned into contractions so brutally intense that I collapsed to my knees as I was putting on my shoes. The midwife wandered back in and looked at me.
‘Just keep breathing,’ she said.
I hated her when she said that. I didn’t need to breathe. I needed to take my head off with a sledgehammer. Dick-Read had been talking rubbish. This was agony. I writhed through the contractions and tried to escape the monitors that I was attached to. I lost control of my limbs, my vision went, I was drowning in pain. A song my husband must have put on broke through the fog. It was by Gal Costa, a Brazilian singer we play in the evening, about watching her lover cry. It made me think of home, of hot nights on the beach, and things got better. By this point I was kneeling on the bed. I began to work with my midwife. I stopped trying to fight the pain, went into myself, bent over and clinging to the upturned mattress. Suddenly she told me to push. It did not feel beautiful but raw and weird and nasty.
‘I can see the head,’ said the midwife.
I began to feel the power of it then. I’d made a life and I was pushing it into the world.
‘The head’s out!’ she said.
I slumped into myself, believing the work to be over. It wasn’t. After three more contractions the body was still stuck inside, the head going blue. My midwife pushed the emergency button.
When the head of a baby is born but its shoulders stay stuck behind the pelvis, the umbilical cord becomes compressed, depriving the baby of oxygen. This can, in difficult cases, lead to brain damage or death. No kind of routine intervention or monitoring can predict when this will happen. Thankfully, I pushed out my daughter Elis just before the room filled with emergency staff. She is now eight weeks old, sleeping beside me, unaffected by this moment of panic. But she was not given straight to me, crying and red, like my first daughter Layla. The midwife cut the cord and whipped her blue, limp body over to the resuscitation trolley as I moaned ‘Is she okay?’ over and over again. The moments between her being taken away and the small weak sound that finally came will always hang suspended, bauble-like, in my memory.
This, more than anything, highlighted just how risky childbirth is and how difficult it must be for midwives and doctors to trust their own instincts and those of a mother’s instead of falling back on blanket policies. If my daughter had been born with brain damage, would it have been my fault for waiting those two extra days? I noticed my midwife was pregnant as she was stitching me up. This must make what is already an emotionally and physically taxing job yet more so. If things had gone wrong, would she have been blamed for waiting those few moments more, to see if I could push the baby out alone, before calling for help?
It must be draining, to be gatekeeper of the most transformative moments of people’s lives, day in and day out. Both women and their carers need a system which supports them to work together as opposed to against one another. Government guidelines which encourage woman-centred care combined with a strong culture of midwifery should mean that the UK is one of the best places in the world to give birth. In practice, however, these positive philosophies come head-to-head with risk management leaving British women in the middle. ‘Continuity of care’ as proposed by Professor Downe could be one way of tackling this problem. Towards the end of my pregnancy, like many women, my emotions were taut, stretched thin like the skin round my middle. Every word said to me was loaded. Any kindness or unkindness I was shown was profound. A simple call from a midwife I had met a few times in my health centre, to check on how I was feeling about induction, gave me a swell of love and confidence that everything would be okay. A cursory assessment in hospital by another midwife the next day made me cry bitterly and scuppered all my previous optimism.
I’m not sure many people would call my most recent labour an exemplary birth experience. It wasn’t pain-free and I definitely wasn’t ecstatic. Neither was it straightforward, at the beginning or at the end. But giving birth to Elis by myself, as I dearly wanted to do, has given me not only an immense sense of achievement but powerful feelings of well-being towards myself and both of my children. This joy has been as surprising to me as the misery I first felt as a mother. I don’t remember Layla’s first smile; we are both now delighted with the big grins her sister gives us. After Layla was born I held onto the much-used adage that ‘A healthy baby is all that matters’. Since Elis, I’ve changed my mind. I’m important too. I prefer now that other old saying: ‘If mother’s happy, everyone’s happy.’
This article is dedicated to Xul Stanton.
Photographs © Mike Tinney
