Reorienting Birth from a Feminist to a Reproductive Justice Framework

I am a life long student and love to learn. One of the ways this is currently happening is through the Gender and Sexuality Studies program at UNLV. Sharing a recent assignment here showcasing some thoughts on where my midwife practice is headed and the values I chose to center.

I gave birth to my first child in 2006. The event while joyful was surrounded by great fear. I had grown up understanding childbirth to be something awful we must endure to be a mother and while my prenatal care provider tried to reorient this understanding, he was not the person on call when it was time to deliver. I remember being threatened by the attending OB, who I saw twice before the actual delivery for 2 minutes at a time, even though I had an epidural and was unable to move my body below my chest. Later, I was not believed when I voiced that I was experiencing intense pain despite having an epidural until the anesthesiologist came in and confirmed the catheter had come out of my back. The anesthesiologist then proceeded to blame me for making that happen and told me not to move, although the nurses were coming in and repositioning me frequently due to my baby’s decreased heart tones. Overall, I do not remember my personhood being acknowledged or seen by anyone except a highly enthusiastic medical student that no one had asked my permission to include in this most important and intimate event, although, I am still grateful for her presence to this day. I think it was her first birth as well as mine, and her encouragement was a light in the dark through the ultimate moments before my son was born. I walked out of this experience, a fairly straightforward vaginal birth in a hospital with an epidural, deeply distraught and traumatized. It was only in beginning to work through the events of my first birth by talking to my husband and encountering his inability to understand how I felt traumatized by the experience, that I realized childbirth was a particularly gendered experience. It was being unseen, not in control of my body and barely recognized as a cognitive participant in the process that was most unsettling. I have gone on to birth two more children at home and become a midwife and my work around the experience of childbirth is far from done.

My experiences as a birthing woman and now a care provider supporting others through their own births has helped me recognize inherent in childbirth the widespread experience of women being dependent on and undervalued in a patriarchal system. This is evidenced in my research by gendered violence in obstetrics, gender bias in health care, language bias in reproductive health, separation of mom and baby creating conflict between mom’s and baby’s rights, prescribed characteristics of gender – expected sacrifice of women as representative of motherhood, and prioritizing technology over bodily autonomy. Thus, I explore childbirth as a feminist issue.

Quantifying and ascertaining what constitutes a positive birth is a challenging task. It is subjective at best. My research pointed to a couple of methods. In a global context, the success of childbirth is based on maternal and fetal mortality. On this front, the United States is not doing very well. The latest data available on U.S. maternal mortality rates was published in 2017. With a maternal mortality rate of 17.4 per 100,000 live births, this places the United States 55th on a global scale and 10th out of 10 when looking at similarly wealthy countries. According to the World Health Organization, these numbers have been steadily on the rise for decades having increased from 12 deaths per 100,000 live births in 2000 (“Maternal Mortality Ratio”). Important to note is that 17.4 is the average maternal mortality rate (“First Data Release”). When we examine the maternal mortality rate by race and ethnicity, we see some disparities. Black non-Hispanic women in the United States are dying at a rate almost three times white women with a mortality rate of 37.1 per 100,000 live births (“First Data Release”). Hispanic women have a mortality rate of 11.8 per 100,000 live births and white non-Hispanic women 14.7 per 100,000 live births (“First Data Release”). We can see by these statistics that not only is birth a gendered issue but a racial and ethnic one. I will return to this point later.

Rates of surgical birth are another indication of successful birth. The World Health Organization has long held that industrial societies’ surgical birth rates should fall between 10-15% (West 133). Again, The United States fares poorly. The US Cesarean rate is currently around 33% where it has been for most of the last twenty years.

While these statistics give us vital information on the general importance and ability of our society to care for women during childbirth, they are not reflective of women’s lived experience of birth as successful or not. Often, we hear the refrain “healthy mom, healthy baby” from care providers as a determinant of a successful birth. However, evidence shows that women generally define satisfaction with their birth experience using the following criteria: “quality of care provision (reflecting home assessment, birth environment, support, and relationships with health care professionals); women's personal attributes (reflecting ability to cope during labor, feeling in control, childbirth preparation, and relationship with infant); and stress experienced during labor (reflecting distress, obstetric injuries, receiving sufficient medical care, obstetric intervention, pain, long labor, and infant's health)” (Fleming 11). Thus, while women and baby may arrive on the other side of birth physically healthy, they may be experiencing trauma on other levels.

One topic that appeared in my research that demonstrates this fact is obstetric violence. In Sara Cohen Shabot’s article “Making Loud Bodies ‘Feminine’: A Feminist Phenomenological Analysis of Obstetric Violence,” she discusses what constitutes obstetric violence, as well as its gendered nature. Quantifying obstetric violence is challenging, but Shabot notes research studies on the topic are increasing pointing to an increase in occurrence (234). What constitutes obstetric violence? In simple terms, obstetric violence can be defined as abuse and disrespect in the context of pregnancy, labor birth and postpartum. A more formal definition can be found in Venezuelan law in 2007. It reads that obstetric violence is “the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women” (qtd. In Shabot 237).

Shabot goes on to illustrate that obstetric violence is most definitely gendered. This is in part due to the androcentric nature of medical care, an expression of “gender order” in society expressed as the centering of men and maleness. This places women and gender non-confirming and trans people as other. This othering shows up in medicine as gender bias and exists irrespective of a care providers gender. Gender bias is multi-layered, but one example of how it shows up in medical care is seen in research demonstrating that men’s report of symptoms is viewed as organic or actual while women’s report of symptoms is viewed as psychosocial (Hamberg 237). Shabot references gender bias in her description of many victims of obstetric violence reporting “feelings of embodied oppression, the diminishment of self, and physical and emotional infantilization” (233). Of note, there exists no framework to check gender bias in maternity care, as pregnant bodies are overwhelmingly female or in the case of trans or non-binary pregnant people, seen as more other than the feminine other. Another way in which obstetric violence is gendered is in the sexual nature of birth. While pregnancy is not always the result of sexual intercourse, it often is and pregnancy and birth even when involving a surgical birth involve a birthing person’s genitals. The prevalence of obstetric violence is evidence of what has been referred to as the “blind spot” in maternity care or the absence of “respectful, women centered care” (Freedman e42). And a healthcare system that allows unchecked abuse and disrespect is symbolic of a society that does not value women (Freedman e43).

Language bias is another way in which we see patriarchal values undermine women in childbirth. This refers to both spoken and written language. To start with, often language around labor and birth is one of permission. Experientially, I see this often in practice both from healthcare providers and birthing people. I often see Facebook posts where a mom implores support as her doctor will only let her go to 41 weeks pregnant or not allow her to eat or drink anything during an unmedicated labor or have clients seek me out to avoid things their hospital-based care providers won’t let them do. This language reinforces a power differential, and the provider or institution is the one in charge, not the pregnant person of their body or experience. Language bias is found often in reference to VBAC, vaginal birth after cesarean, as Jennifer Ellis West states in her work “’Just Birth’: Childbirth Advocacy and the Rhetoric of Feminine Health Justice.” This article centers around the 2010 National Institutes of Health three-day conference on the safety and accessibility of VBAC. One of the core principles under debate at the time was whether VBAC was defined as a medical procedure or “just birth” (West 141). When a physician remarked that “VBAC is potentially an extremely dangerous procedure for both mother and infant”, a renowned childbirth educator, author and birth advocate responded, “VBAC … is not a procedure. Labor is what inevitably happens at the end of pregnancy” (West 141). They were both talking about the same event, however their language said very different things about it. Hence, the language used not only defines moments of pregnancy and birth but intones them with risk or safety establishing authority and power, most often that of the institution or provider over the birthing person.

Another way in which patriarchal values assert themselves in childbirth is with the separation of the mother/ baby dyad. As a midwife, I recognize that the only direct care provider of a fetus is its mother. Except for surgery on babies in utero, which is strictly the realm of Perinatology, it is impossible to care for an unborn baby without caring for its mother, as the way we improve a baby’s uterine environment is to address the host of the uterus. This signifies a oneness between a mother and child. A baby in utero cannot exist on its own. The belief that one can is the foundation of “fetal politics” (Beckett 266). “The conception of the fetus as a ‘second patient’ has, in turn, given rise to a conception of pregnancy as a conflict of rights between a woman and her fetus and the sense that the primary threat to fetal health comes from pregnant women” (Beckett 266). Ellis West discussed this in relation to the decision to VBAC or have a repeat Cesarean. Increased risk to baby through possible uterine rupture is one of the primary arguments against VBAC; however, increased risk to mom from undergoing another major abdominal surgery is often underplayed, placing the rights of the mother at odds with the rights of her unborn baby (West 134).

This separation serves to reinforce the patriarchal idea that good women and mothers are self-sacrificing and prioritize their children always, a common theme in my research that showed up in relation to several aspects of pregnancy. In Sarah Jane Brubaker’s article on African American teen mothers, she notes that choosing medialized care in a gendered system provided a way for Black teen moms to raise their status by following the rules set forth by their care providers, insinuating that compliant woman are good mothers (543). M. Cristina Alcade also touches on the idea of the self-sacrificing “good” mother in her article “‘To make it through each day still pregnant’: Pregnancy Bed Rest and the Disciplining of the Maternal Body”. Statistically, 20% of all pregnancies lasting at least twenty weeks will include at least a week of prescribed bed rest (210). Alcade describes at length the cost, mentally, physically, socially and financially of bed rest despite evidence that provides no or negative effects to babies. Yet women are expected to unquestionably sacrifice for the purported good of their unborn babies. As she states, “bed rest epitomizes the expectation that women be attuned to the needs of others and of self-sacrifice: women spend varying amounts of time on bed rest for the benefit of the fetus, in spite of the negative side effects on the woman” (Alcade 212).

The theme of choice and thus bodily autonomy featured widely across various aspects of the childbirth experience in my research. It was explored specifically in the context of the history of feminist activism around birth, the medicalization of birth, the alternative birth movement, bed rest, elective surgical birth, VBAC (vaginal birth after Cesarean), fear of childbirth and black teens’ experiences of birth. While the right to choose presented prominently in all these realms, the origin of choice proved the most impactful theme in this commentary. In the article “Cesarean-section, My Body, My Choice: The Construction of ‘Informed Choice’ in Relation to Intervention in Childbirth” the authors explore the constraints that shape choice. As they state, “choice is severely limited at any given time, and is shaped by hegemonic discursive orders and social practices that often privilege the interests of one particular group over those of the individual” (McAra-Couper et al., 82). And in the case of women’s health and reproduction it is specifically society that exercises constraint on women’s choices (McAra-Couper et al., 83). Ultimately, they stress the realization that choice is never neutral. This point is also made in Beckett’s work “Choosing Cesarean”. She emphasizes that we must look at why women are making the choices they are making and under what influence (Beckett 263). She states, “deep social constructionism allows us to think about the complex ways in which women’s assessments of risk, their hopes, and their aspirations are socially produced. There is ample reason to suspect that both the devaluation of women and medical interests are relevant to those processes” (Beckett 264).

We must ask ourselves, under what pressures and values systems are women a part of and susceptible to when making choices around childbirth? Nearly all my sources noted a lack of intersectionality in the research available to them. Yet, obviously the various contexts in which the research was attained are intersectional. Racism, classism, and ableism are all social systems intersecting with sexism to compound negative outcomes for those oriented in different social locations. This is seen in the fact that often when my sources discuss choice in the context of opting out of the medicalized model of birth, the subjects represent the hegemonic social oritentaions of white, middle class and partnered, and conversely often when they reference opting into the medicalized model of birth, the subjects represent marginalized communities where historically they were denied care as in Brubaker’s look at African American teen moms (528). In my research I came across the use of the Ecological Systems Theory or EST system of examining a studied phenomenon. It employs four structures the microsystem, mezzosystem, exosystem and macrosystem. For the purpose of the article’s subject matter of fear of childbirth, the microsystem included “the individual level factors such as social support, mental health, and physiologic experience. The mezzosystem include(d) providers such as nurses, doulas, midwives, or physicians. The exosystem represent(ed) the setting of birth: home, birth center, or hospital. The macrosystem represent(ed) larger social structures such as racism, homo- phobia, sexism, historical factors, and culture” (Roosevelt 2). Moving forward in my research, this system could afford a well-rounded look at the origin of choice.

And so, to bring the feminist critique of birth under the umbrella of the reproductive justice movement, we must bring the origin of choice in conjunction with an intersectional approach to birth inequities. Therefore, we must examine “raced, classed, and ableist—assumptions implicit in the discourses that shape understandings of women’s health” (West 150). Both West and Rachel Hardeman author of “Applying a Critical Race Lens to Relationship-Centered Care in Pregnancy and Childbirth” offer suggestions on how to attain this by suggesting combining an intersectional approach to birth advocacy which is currently lacking with the understanding that all birthing people must be afforded the “human right to a safe, respectful birth experience” (Hardeman 3, West 150). Hardeman goes on to outline concrete steps individual care providers can take to shift power in our reproductive healthcare system in an effort to subvert rather than upend repressive dualisms: they must commit to relationship-centered care based in authenticity and reciprocity; they must commit to an ongoing practice of self-critique and a critical race consciousness; they must share power and shift their perspective to center the margins; and they must acknowledge racism operating from a commitment to racial and social justice (3-6).