Bioethics Forum Essay
Natural, Medical, Political Childbirth
“It felt selfish to put my baby at serious risk by pursuing a vaginal birth,” writes Kristen Terlizzi in a collection of essays published recently in Narrative Inquiry in Bioethics. You can read Terlizzi’s full story here.
The idea of childbirth is weighted with contradictory expectations. “In listening to women, it became clear to me that part of the problem was that an idealized notion of the ‘good birth’—a vaginal birth as free as possible of medical intervention—had taken hold,” writes obstetrician/gynecologist Anne Drapkin Lyerly, author of the book, A Good Birth: Finding the Positive and Profound in Your Childbirth Experience. “The “good birth” ideal causes distress when mothers are unable to attain the nonmedicalized, imagined moment.
On the other hand, a medical system built around the baby’s safety—though aligned with what Terlizzi describes as “the universal top priority of motherhood”—can intervene in ways that are at odds with the health or consent of the mother. The mother, concerned above all with her baby, is expected to relinquish control on the altar of a healthy child, but she must also relinquish her right to grieve a traumatic birth experience.
Erica Morrell describes her unexpected—and unexplained—emergency C-section. Groggy from the anesthesia and disoriented to suddenly have her daughter in her arms, Morrell tried to come to terms with what happened. “At least you have a healthy baby,” she remembers a passing nurse saying. “I will never forget how bad that nurse made me feel in that moment,” Morrell writes. “I was no longer in control even of my own emotions. The hospital staff knew better.”
The essays illuminate many things that society often expects of a woman and, in turn, blames her for. Whether she insists on a natural home birth with a midwife, brings a birth plan to the hospital and refuses some treatment, or consents completely to the advice of her doctor and the hospital, she falls short in some way. Why did she not trust her body to birth the baby naturally? Or why did she not value her baby’s health sufficiently to agree to a C-section?
The narratives circle around a central theme of power, and the give and take of that power forms a political dance. Lyerly explains how different players assert control, a response, she says, to a natural feeling of fear: “For obstetrics it is reliance on technology, mastery of techniques in assisted and surgical birth, and mistrust of the birthing body. For midwifery it is insistence on the normalcy and safety of birth, an emphasis that the body was ‘made for birthing’.”
Farah Diaz-Tello had hoped and planned for a home birth attended by a midwife but, after laboring at home she was transferred to the hospital. Diaz-Tello remembers feeling a “vague, animal fear” during her C-section, “exacerbated by little things like having a nurse holding the surgical drape claustrophobically close to my face.” She could see a reflection of her body, “lying in a pool of blood” in the lights above the stainless steel operating table. “And there was my midwife,” she writes, “the formidable woman with decades of experience catching babies, reduced to pleading with the young male anesthesiologist not to replace the IV in my elbow because I wanted to breastfeed. He did it anyway.” As they had entered the hospital, the author remembers, her midwife warned her that they were “now on their turf and their terms.”
Many of the narratives have this taste of violence and the conspicuous absence of consent. Bioethics has historically contributed to “this lack of regard for mothers,” argues Raymond De Vries in his commentary, “by framing the moral problems of birth in terms of maternal-fetal conflict, where the autonomy of the mother is weighed against the obligation of beneficence to the baby.” He writes:
“As long ago as the late 1970s, the application of principle-based ethics to obstetrics led to the framing of many moral problems in maternity care as conflicts between mother and fetus (Leiberman, Mazor, Chaim, & Cohen, 1979). In their 1987 opinion, “Patient choice: Maternal-fetal conflict,” the ethics committee of the American College of Obstetricians and Gynecologists (ACOG) reified the idea that mothers and their babies are adversaries (American College of Obstetricians and Gynecologists (ACOG) Ethics Committee, 1987). Twelve years later, the committee replaced the term maternal-fetal conflict with “maternal-fetal relationship” (American College of Obstetricians and Gynecologists (ACOG) Ethics Committee, 1999; Harris, 2000), but, as we see in these essays, this way of thinking about mothers and their babies continues to influence what happens in maternity units.”
When a physician is guided by the concept of “maternal-fetal conflict,”—a concept, De Vries notes, “that no mother could have conceived”—a mother’s birth plan looks like both a nuisance and a threat to the baby.
Conversely, Lyerly writes, “the claim that women’s bodies were ‘made for birth’ has taken its own sort of toll. The narratives here reflect the widespread tendency for women to blame themselves when birth does not go as planned.” She notes several stories in which the women apologize to their partners after birth, or feel guilt and frustration at what they perceive as their body’s failure.
There is a desire, throughout the stories, to collaborate. The mothers want the comfort of a doctor and hospital technology nearby, acknowledging that some intervention is often necessary. Terlizzi writes that it’s “ironic that a cesarean is what almost killed me, when a cesarean is also responsible for saving both my sons’ lives and mine.”
Most of the mothers did not desire complete autonomy during childbirth. They were scared but determined, and they requested help from experts to guide and protect them. They did not think to demand respect because they expected it. They came to appointments with their birth plans to join forces with their doctor, not to stake out territory. And of course, as De Vries notes, they never imagined their intentions could be perceived as conflicting with the well-being of their child. And so of course they were shocked when they were ignored.
The essays call out for a middle ground on which mother, midwife, and medicine can all stand. They ask for an acknowledgement of the existential, biological miracle taking place—a mother’s difficult endeavor, and her need for assistance by the parties she chooses, collectively motivated by a shared desire for a healthy child.
Mary Click is the communications coordinator for Narrative Inquiry in Bioethics.