Navigating medicalisation and risk in birth: questions we should all be asking (Part 1).
learnings and musings from a medicalised pandemic birth
AI Art: DALL- E3
“In today’s women’s movements, abortion is a central issue. What is still missing, however, at least in many white feminists groups, is the recognition that control over our bodies calls for a broader struggle, to determine the conditions under which we give birth, under which we raise children, to obtain the resources enabling us to become mothers without sacrificing our lives. This is why Black women, like Loretta Ross, have criticized the concept of ‘reproductive choice’ and called, instead, for a movement for ‘reproductive justice.’”
Silvia Federici
Silvia Federici on Witch Hunts, Body Politics, and Rituals of Resistance
Every birth carries potential risks and dangers that birthing people must navigate and contend with in the birth setting they choose (or end up in). As many wild/autonomous- birthing advocates may attest to, the medicalisation of birth has capitalised on the narratives of risk, to create a normative perception of birth as something dangerous, deadly and fearsome- something that the the bearers of life themselves are incapable of doing without medical assistance. The medicalisation of birth also intersects with the legacies of colonisation and apartheid, which have left lasting imprints of structural violence- disenfranchising women, especially black women, from their bodies, birthing environments and birthing cultures.1
Birth as fear, blood, intervention and rupture
Birthing is complex. It is painful. It is joyful. Some people have easy births, some people have challenging births. But how birthing people qualitatively experience birth is often overlooked. The fears, hopes and expectations of birthing people are rarely documented as important ‘data points’ in medical research. I birthed in the middle of the ‘3rd wave’ of the Covid pandemic in South Africa. For many, especially those birthing for the first time, like myself, it meant birthing in an environment of fear, and possible scarcity; healthcare systems faced many constraints and uncertainties during this period. However, I birthed in the private medical system, and was supported at various stages of pregnancy and birth by my partner, doula, obgyn and several nurses. Yet, my birth story, well- supported as it was- still left me puzzling at how the private medical birthing model is the model of birthing rights and care we most commonly advocate for, and how even this system, functioning at its most optimal, can still impart so much trauma during birth and beyond.
In my case (and a very long story short), many hours after spontaneous labour first commenced, and after many hours spent labouring in a hospital setting, we were counseled by our obgyn ,who dutifully outlined the risks with each option given our baby’s particular situation. I requested the obgyn to go ahead with a c- section. Just before and during the caesarian birth, the fears that ran through my mind and body included the fear of things going wrong during the procedure- organs being damaged or removed, blood loss, gaining sensation due to inadequate or incorrect anaesthesia, surgical tools being left inside, infection. Fears of being left in a condition that would limit my ability to care for and keep my newborn safe (more so even than a c- section alone already would). These are fears of even greater prominence if you are birthing in a public setting, given the standing of health facilities in the country, and the institutionalisation of obstetric violence2 in public healthcare. While I was lucky to have had the technical aspects of risk unpacked for me, my fears were never directly addressed. And facing these fears can be traumatic- during a surgical birth, you are entirely at the mercy of the medical system, with limited agency and role in the outcome of birth; a terrifying disenfranchisement from the birthing process, more so if one has not had adequate preparation and emotional support.
Of course medical birth interventions do also save lives. Beyond that, many also actually limit trauma and damage that can arise during difficult births. The private medical setting itself also offers a lot of very much needed support: nurses on call 24/7 to assist with everything, from changing blood- soaked pads, to inserting anti- inflammatory suppositories, breastfeeding advice, breast massage. If you are lucky to have great nurses at your service, they will even be there as a gentle but firm emotional support to calm the panic attack you have when you first try to get out of bed post- c section. I recall feeling nauseous from the searing pain, certain that my stitches were about to tear open, and also convinced that my abdominal muscles had mistakenly been removed in the procedure too (they had not). The warm, patient, certain ‘‘I’ve- seen-everything- you’re- not- going- to- die- just- take- it-slow’ demeanor of a woman who has both birthed and cares for birthers is magic for the anxiety of a new mother (and I’ll get into alternatives later, but this magic person need not be a hospital nurse for every birth/er).
For many months after the caesarian birth, I engaged in many conversations with friends, family and even strangers, and this spurred reflections on how birthing in general affects women. I researched the politics of birth and reflected on how birth had affected me. I was never prepared, mentally and emotionally, nor provisioned practically with the support needed to make up for the immense loss of functionality that a c section (or I imagine, difficult vaginal birth) would bring in those first few weeks post- birth. I’d never needed so much hands- on help to do simple tasks before. The most harrowingly (ableist) part of the c- section was not the operation or even the pain. It was the initial loss of capability in a time that required me to feel confidence in my capability- not only for myself, but for a entirely dependent little life. It was the constant fear of not being able to manage. I am not a proponent of ‘bounce back’ culture, nor was I expecting to feel back to any kind of ‘normal’ after birth. Yet, it is the gravity and scope of disruption to functionality (a functionality and expectation of care that is required of women, especially black, economically marginalised women, far too soon after birth) and being able to ‘manage’ that comes with difficult births, which are also very often, medicalised births,3 that we do not seem to account for. And this is especially considering their lasting impacts on the well being of mothers, many of whom have no option but to queue for hours for follow- up medical care and administrative services soon after giving birth. Given increasing rates of medical intervention, caesarian birth and obstetric violence, in an under- provisioned medical and post- partum healthcare set up, this is of major concern.
Establishing a sense of safety: respect and dignity within and beyond medical birthing systems
There is a great dissonance between the narratives of risk that mothers are presented with, and the qualitative experience of safety and well being during birth. I’ve used my birthing experience as an example of the qualitative experience of birth, specifically, medical birth, and this has been a privileged contextualisation of medical birth. Yet, in the broader political context, I was left wondering, in our quest to widen access to improved healthcare services for birthing people, how do we identify and name the subtle and entrenched violence and inequities in the existing system? In our fight against GBV, and institutionalised obstetric violence, how do we open up conversations and share our stories, and what are the alternatives? What might a framework like reproductive justice4 hold for countering harmful narratives and practices?
Whom do our birthing narratives serve?
It took me much unlearning to understand that birth is not by default a medical condition- how then does the medicalisation affect black and economically disenfranchised mothers? It is well- documented that the medical system was historically never designed to serve politically ‘undesirable’ mothers. On average, over 80% of births in South Africa occur in public health facilities. Where public (and even private) health is serving up the bare minimum, reproductive justice requires us to go deeper than simply expanding access to a bare minimum medical system, but to understand how narratives of risk, choice, well- being, and our relations with those who provide care during birth have themselves been transformed through colonial legacies. It requires us to interrogate the power dynamics between birthers, medical professionals and birthworkers, and this is all fundamental to addressing obstetric violence as well.
We must acknowledge that the medicalisation of birth, in our current socio- economic context, has very real impacts on mothers and their well being post- partum, and thus for infants and families too. It is from this standpoint that we must continue to challenge our existing narratives, with questions such as:
How can we uplift indigenous practices and community care beyond reductive ‘hospital birth vs home birth’ binaries?
How do we ensure that the well- being and rights of the birther take greater precedence in how we design systems and solutions in order to realise reproductive justice?
How do we grapple with the seeming moral challenges this presents us with in our existing risk evaluation frameworks?
What, for eg, would risk evaluation frameworks informed by indigenous knowledge look like?
How do we involve a diversity of birth workers even within the medical system?
How do we support and engage the work of those that recognise that birthing people need a range of birthing options that includes medical care when necessary?
How do we advocate for the preservation of indigenous birthing practices and knowledge?
I continue to learn and seek alternatives. There are a growing number of exceptional birthworkers who are living this change. Mamandla Fellow, Doula Kefilwe, is doing exceptional work in birthing and indigenous practice, and has written this short piece that demonstrates practically what may be needed to support birth and indigenous birth practices beyond medicalisation of birth.
eg for contemporary academic discussion see ‘Where have the midwives gone?’ by T. Botes (2022) and ‘Safety, Pain, Home, Freedom : A Thematic Exploration of the Medicalization of Childbirth as a Tool of Racism and Colonialism’ by H. Ginsberg (2021). For reflection on the pathologising of birth, see ‘The Birth of the Clinic and the Advent of Reproduction: Pregnancy, Pathology and the Medical Gaze in Modernity’ by J Shaw (2012).
Ongoing research demonstrates that obstetric violence in SA must be considered a national crisis:
Chadwick (2016) also highlights:
“In these contexts, high rates of medicalisation are also recognised as sources of abuse.[5,9] In the SA context, there has been a lack of attention to potential abuses in private sector facilities, with the predominant assumption that mistreatment and abuse is only a problem in public sector maternity services. This is surprising, given that the private sector in SA has one of the highest rates of caesarean section in the world, with estimates ranging between 40% and 82%.[15,16] Such estimates are far above the rate of 15% recommended by the World Health Organization and raise concerning questions about levels of unnecessary medical intervention in private sector obstetrics in SA.”
(c-sections, inductions, NICU admissions, exacerbated tearing due to medical interventions that are not always weighted against their risks or real need)
What is the Reproductive Justice framework?
According to SisterSong Women of Color Reproductive Justice Collective, reproductive justice is “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”
Ross highlights that the core problem is reproductive oppression and further:
“We believe that the ability of any woman to determine her own reproductive destiny is directly linked to the conditions in her community and these conditions are not just a matter of individual choice and access. For example, a woman cannot make an individual decision about her body if she is part of a community whose human rights as a group are violated, such as through environmental dangers or insufficient quality health care. Reproductive justice addresses issues of population control, bodily self-determination, immigrants’ rights, economic and environmental justice, sovereignty, and militarism and criminal injustices that limit individual human rights because of group or community oppressions.”