‘We do not birth in a vacuum’
Part 2 – The systems and structure of Western birthing culture
Societal norms together with the structures and systems we’ve created for birth make up our ‘birthing culture’. This culture forms the backdrop for our births. Whether consciously or unconsciously and whether they are welcomed or unwelcome we take all of these influences in to birth with us. In a cyclical fashion our perceptions, expectations and beliefs about pregnancy and birth have evolved and shifted in to closer alignment with the systems we’ve created. Today our belief and the systems we’ve created continuously facilitate and validate each other. We do not birth in a vacuum. We birth in a context.
In this final part of a two part series we take a closer look at the systems of birth in Western cultures. We look at the structures we’ve put in place (specifically the NHS Maternity Services) and explore their apparent values and behaviours as we consider what impact they have on us as individuals but also the wider cultural narrative of birth.
Why does the system behave the way it does?
Perhaps the greatest influence for most women and birthing people in the UK specifically is the NHS and specifically our Maternity Services. The structure, attitudes and values of these systems dictate behaviours (both internally and within ourselves). These behaviours and actions heavily inform our experience. But why does it do what it does?
Safety and risk management
One of the key concerns and values of the maternity services systems is safety for mother and baby. This may well feel like a valid position. Safety is of course a significant concern for parents too. It’s highly likely that everyone would wish for a safe birth at the very least. And perhaps no one is more invested in the safe arrival of their child and the wellbeing of the mother than parents.
Safety in the system predicates the identification and mitigation of perceived risks and risk factors. In order to effectively manage risk the system prioritises the continuous monitoring of factors and events in pregnancy and assesses those events against perceived ‘norms’. The boundaries for these norms are often rigid and narrow. Deviation from these arbitrary norms, or requests to access choices which are considered to be ‘outside of guidance’ can lead to mothers being told that they ‘aren’t allowed’ to access that particular choice. Other reasons for limiting choice include that the stated preference is ‘against hospital policy’. This language of permission, alongside the liberal use of the word ‘risk’ can be used as a method for encouraging compliance with norms. Indeed the word ‘risk’ can be hugely worrying for many expectant parents and can induce real fear. This model of placing safety seemingly above all else can leave little room for truly individualised care. Such preoccupation with managing risk by those who’s job is to support the wellbeing of mother and baby can leave gaps where the full spectrum of needs and concerns cannot not met.
A culture of fear
Fear is closely linked to safety and risk management in this context. From a sociological point of view birth has become something largely ‘unseen’ in normal life for many people. Our perceptions and beliefs are generally not drawn from personal experience but instead they are heavily impacted by media portrayal of the sights, sounds and events of birth. We know that many women report feeling fearful of birth. The degree of fear can range from somewhat daunted by the prospect to a clinically recognisable phobia. When the dominant narrative of birth is that it’s not only agonising but dramatic and unpredictable it’s hardly surprising that fear results.
Within the systems of birth fear can manifest itself as defensive practice and a culture of ‘just in case’ treatment. For health care professionals the fear of litigation, fear of recrimination, negative press coverage and even fear of loss of livelihood can translate directly (and indirectly) to the care provided. Fear can and does often lead to a number of potentially unnecessary interventions; from the seemingly benign growth scan ‘just to double check’ to the more invasive stretch and sweep ‘just to get things started’ to invasive procedures like an episiotomy ‘’just a small cut to speed things up’. All of these examples can have both short and longer term consequences both physically and in terms of how we feel about our births.
Obstetrics (the field of medicine relating to pregnancy and birth) is largely centred around the study of abnormality and pathology in pregnancy, birth and the postpartum period. (An interesting comparison here is the teaching of Midwifery which is much more concerned with normality in birth.) The teaching and resulting culture of our Obstetricians therefore has significant focus on identifying and effectively managing abnormality and mitigating risk. Obstetricians are highly skilled in remedy. They are perhaps not so experienced in normality. Fear of what could or may happen is a significant precursor to defensive practice.
Structural bias and the balance of power
In the hierarchy of the system the consultant is king. Many women find themselves in front of a consultant Obstetrician in order to have their choices ‘signed off’ particularly if those choices are beyond the decision making power of her primary carer (often a Midwfe). For example, a mother in her 40s who (after much consideration and research) wishes to birth at home may well find themselves discussing their care with and Obstetrician. The Obstetrician will be assessing the perceived risks associated with her choice of birth place alongside consideration of the hospital’s policies, guidelines and procedures. They may well advocate strongly that the best mitigation for risk in this context is for the mother to birth in the safety of the hospital’s Obstetric unit. The driving forces in this decision making is not necessarily the mother herself, her individual needs, desires, fears, expectations and concerns but in effectively managing potential risk and a fear of what may happen is something should arise.
Day to day Obstetricians see a disproportionate number of cases with poor outcomes by the nature of their roles. It’s understandable perhaps then that we see their experiences translate to a lowered tolerance for risk. Furthermore, how their experience can result in defensive ‘just in case’ practice and how this can become a cultural norm for staff in hospitals. However, it’s right to question the apparent balance of power here. It’s surely only logical that the vast majority of pregnancies and births can and should unfold without complication. Our midwives, who are trained in normality and who’s expertise is the facilitation of physiological birth can and often are side-lined in favour of a more ‘hands on’ approach.
Let me be clear, during an obstetric emergency Obstetricians are extremely valuable. Without doubt, we benefit from the expertise of these highly skilled professionals when emergency complications, significant abnormality and pathology are truly evident. But it’s right that we also consider what may be lost when the study of abnormality is held on such a pedestal and furthermore when the systems of birth facilitate and continually validate this belief.
A fish can’t see water
It would be wrong to suggest that those working in the maternity system do not care deeply about the individuals they care for or that they have lost sight of the individual in favour of following policy and act defensively as a result of out of fear. There are many, many wonderful staff who provide incredible care. All of them enter the profession wishing to provide high quality care and experiences for families during this incredible transition to parenthood. However, collectively and as individuals they too are subject the influences of their environments. Perceptions of pregnancy and birth as being inherently risky, the desire to monitor and assess using technology, a need for efficiency, preoccupation with the strict boundaries of normality, fear and the management of risk are all influencing factors. These values and behaviours we see in the system undoubtedly translate to our care and affect our experience. This also includes the impact on the staff, who are often overworked and experiencing vicarious trauma.
Once we start to see and understand the wider context of our births we can start to consciously inform our journeys and our experiences. In light of everything already discussed in Part 1 and Part 2 of this series it’s perhaps helpful to consider how each of us can attempt to navigate the systems in a way which is comfortable for us. Remembering that we can benefit from all the good that exists but we can also choose to turn away if the weight of the system feels too much. It is not incongruous to want to benefit from being cared for by medical professionals, accepting testing and scanning for example but to refuse offers of induction or suggestions for a caesarean birth. You can pick and choose. You have a right to do so.
We know that a ‘good birth‘ is one which is not just safe but is also satisfying. In a system which doesn’t always place the importance of experience as highly as you may wish to advocate strongly for your experience alongside your safety. Your emotional, spiritual and cultural needs should be supported as well as possible alongside your physical. We are all different. Every body, every baby and every pregnancy are different. Our care should strive to recognise and honour that to support positive experiences.
Each of us have different perceptions of and tolerances for risk. These boundaries can also change during your pregnancy and indeed from one pregnancy to another. Exploring and staying in touch with how you feel about risk can be a useful in navigating and handing the influences of others. Supporting yourself by accessing relevant information from trusted sources can be helpful if and when risk is highlighted to you.
The things we value as individuals will vary greatly. It’s common to feel discomfort when there is a misalignment of our relative values and this can also lead to conflict. This can happen even when our desired outcomes are the same. It can be helpful to remember that the journey matters too. Knowing what feels important to you and what things you value can increase a sense of comfort especially when it comes to decision making.
Finding balance when there are a great number of influences and concerns at play can feel overwhelming. Conflict and discomfort can have a huge impact on how we experience pregnancy, birth and parenthood. With a great many influences and voices surrounding us it can be easy to feel uncomfortable and unsatisfied. At Real Birth Project we believe you should be at the centre of your birth experience. We’re committed to providing support and helping parents find balance during the transitions of parenthood.
- The Maternity Services and NHS systems can have a huge influence and impact on our experiences of pregnancy and birth. In cyclical nature the systems and our culture facilitate and validate each other.
- Safety and risk are key concerns of the current UK birthing system. To manage safety and mitigate risk the system creates guidelines, policies, pathways and procedures. We know that these practices can have significant impact on access to your choices and your experience of birth.
- Understanding and awareness of the variety of influence in addition to the systems which manage our births (with their concerns, priorities and values) can help us navigate this time in a positive way.
- Improved safety at the expense of a good birth experience is a false dichotomy. A good experience doesn’t refer to a perfect birth but one where we feel satisfied and where we are treated as individuals, with dignity and respect.
- Creating a sense of balance can be helpful. You can choose what you accept openly and what you turn away from during your journey. Being at the centre of your experience is important.
Post by Rebecca Robertson, come and share your thoughts and experiences on Instagram does this post resonate with you?