Obstetrics - Bastion of misogyny

Miso-what?

by Barbara Kruger

Misogyny (miss-odge-a-knee) literally means 'hatred of women' - but just as we understand that a paedophile doesn't really 'love' children, so the term misogyny has come to refer to having an inherent prejudice towards women, usually to their detriment.

I get that referring to obstetrics as a bastion of misogyny is a strong statement to make - Didn't huge numbers of women die in childbirth before maternity wards and hospitals and operating theatres? What is wrong with that? You don't become a gynaecologist or obstetric nurse unless you want to help women, right? How is that missy-, misod... hating women?

This has been a very difficult post to write. It is a real challenge to get the balance between describing the misogyny, if not outright abuse that women are experiencing under obstetric care, whilst acknowledging that there are many care providers who do not intend to practice in this way. I would like to put forward the idea that it is not every individual in the obstetrics industry that is consciously misogynistic (although some are), but that the institution of obstetrics itself utilizes deeply entrenched misogyny as its foundation. For one example, see here.

Therefore even those who are not personally invested in the practice of misogyny feel stuck in a system that cannot function without it.

If you are still a wary, let's try something. I found this site (among others) containing a list of the characteristics of a misogynist. If we personify the obstetrics industry, how many of the characteristics of a misogynist does it fulfill?
Before you read the list below - please remember this is not about doctors vs midwives or men vs women - I have seen internalised misogyny practiced and perpetuated by midwives and doctors, male and female. I believe we are dealing with a system that is inherently misogynistic, but is allowed to continue as such because women are told that the misogyny is for their own good. 

Characteristics of a misogynist:

•  Controls women by destroying their self-confidence
• 'Are you sure you don't need an epidural?' (x10)
• *checks dilation* 'You are only 3cm dilated.'
• 'Failure to Progress.'

•  Needs to ensure that women are always less powerful than he is
• Stirrups
• Lithotomy position
• 'My gynae said he/she will/won't let me...'

• Intimidates women by constantly finding fault with them
• 'Let's see if this naughty cervix is behaving.'
• 'This perineum is far too small - we'll need to do an episiotomy.' *head not even visible*
• 'Be quiet - You're making too much noise!'
• 'What size shoe are you?'

• Humiliates women in public and devalues their opinions
• *Calls the doula over to show her why the episiotomy will be necessary and why more time won't help by demonstrating how 'small' the mother's vagina is with his two fingers while she has full sensation and without her consent.* (Mother is on her back. Ends up cutting three times.)

• Must ALWAYS win in a discussion with or about women – all encounters with or about women are seen as a battle to be won.
• 'Well if you want to have a doula you'll have to find another gynae...'
• 'Well, you can either listen to me or you can have a dead baby.' - otherwise known as playing the 'Dead Baby Card'
• 'You know you can't trust Dr Google,' when a mother tries to present a peer-reviewed journal article on how delayed cord clamping may be beneficial.

• Blames women for failings that are in no way related to them
• 'Failure to Progress' is often more a case of 'Failure to Wait'. When a mom is strapped to monitors and not allowed to stand up and eat and be normal it is no wonder that labour stalls!
• 'We'll have to give formula because your milk hasn't come in yet.' *Less than 24 hours after birth.* Anyone who knows the least bit about breastfeeding knows milk only comes in at around three days after birth. 
• 'It seems your pelvis is too small to deliver this baby.' Said by the same person requiring the mother to be on her back in the position most likely to restrict opening of the pelvis.

• Blame women for his own failings and shortcomings
• 'The Caesarian rate is so high because women's pelves (pelvises) are getting smaller.'

•  Denies women's feelings and makes them wrong for feeling them
• 'It wasn't that bad. At least you have a healthy baby!'

• Makes jokes or derogatory comments about women and then ridicules any woman who gets offended or upset

• Belittles or ignores women's accomplishments
• 'It must have been the atarax.' *After mother reached 8cm from 3cm dilation in 3 hours through some Rebozo sifting, moving around and changing positions.*

• Has no remorse or guilt for the pain he causes women
• 'But I saved you!'

• Tries to keep women from doing things they are qualified to do
• Like being able to make decisions about what they do with their own bodies.

•  Selectively quotes authorities to substantiate his views and positions on women
• 'Cochrane Review? Pfft! I only trust the British Medical Journal on these matters.' i.e. the extent of his research is on how to do better surgery, not on how to avoid surgery to begin with.

• Will confuse issues by changing the subject, denial, word jugglery, lying, twisting the facts or acting as if nothing happened
• 'If you tear, it will be jagged and we will have to cut the jagged edges off and then sew it together.'
• 'Your baby will drown if you give birth in the water.'

• Is preoccupied with sex and is sexually controlling
• Ever heard of the 'husband stitch'?
• 'Don't you think your husband would rather you had a Caesarean?'

• He has problems with authority figures in general and women in authority in particular.
• Outspoken and experienced midwives (as opposed to obstetric nurses) in general and private midwives in particular are often seen as the enemy and are accused of giving women all sorts of crazy ideas.

• Has a Jekyll and Hyde personality - Nice to you in public, but cuts you down in private
• 'My gynae is very pro-natural.' *When I know his CS rate is over 85%*
• 'My gynae is very happy for me to try for a vbac.' *When I know the success rate of VBACs in that hospital is less than 5%*
• 'My gynae said I can have a water birth.' *When the midwife on duty says she's never seen this doctor allow a first time mom to deliver in the water.* 

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So before you start roaring at me in ALL CAPS saying that birth attendants aren't all like that, I totally agree. I know some truly incredible birth attendants and caregivers who have utmost respect for the birth process and birthing women. But they struggle in a system that does not represent these ideals. Read Dr Gauri Lowe's account of her obstetric training as a GP here: Thoughts on expecting natural birth service from your doctor...

Even though all the quotes above are actual quotes or situations I have heard / experienced / read, I understand that they do represent extremes, and yes, I understand that many individuals do not consciously perpetuate these misogynistic language and behaviour patterns, but until someone calls them out, the abuse will continue. A woman should feel safe and secure and supported no matter what her race or social class or education or risk category. 

Edited to add:
In describing obstetrics as the last outpost of misogyny, I don't intend to minimise other expressions of misogyny, both explicit and implicit, but I do feel that obstetrics is a particularly well guarded bastion of the ideology, because it is one of the most widely accepted and widely justified areas of misogyny. In short, 'It's for their own good.'

Further reading: 

Birth: A surprising history of how we are born by Tina Cassidy (On Takealot)
Dr Robbie Davis-Floyd (Anthropologist) - Articles on Childbirth and Obstetrics

Birthing Day...

When a baby is born, so is a mother. 

Photographer: Karen E

I always thought that was a cute, if not trite, little saying. Until I had my own babies.

I have come to realise that having children entails a massive core identity shift for many women - more so than getting married or a first menstruation or any other of life's transitional experiences. The shift often takes us by surprise in its nature and its magnitude. 

Ask any mother which she remembers in greater details, her wedding day or the births of each of children. Almost all the women I have asked have far more acute memories of the triumphs or tragedies of their birthing days than their wedding days. (I'm not sure of the equivalent life experience to ask about for women who haven't been married - if you have any ideas let me know!)

Three years ago my youngest daughter was born and even though we celebrate this day, the 18th of June as her birthday it was, as cheesy as it sounds, a birth-day of sorts for me too. 

I birthed my first daughter in a drug free natural birth in a private hospital in Pietermaritzburg. I was on my back doing purple pushing, but for most of the nurses there it was the most natural birth they had seen in many months - especially considering the number of nurses who came in to congratulate me with awed whispers of 'We heard what you did!' 

My gynae told me it was one birth out of a thousand and that totally freaked me out! To me it was a normal birth, an 'average' birth, an example of how most women could and did give birth but I have since discovered that there is far too much hospital policy, often not evidence based, and not enough support for moms (read: doulas) for this to be the norm.

It was an intense experience for me. I have never broken a bone or dislocated anything or had kidney stones or anything like that, so it was the most painful thing I had ever experienced. But I felt confident, I felt supported and at no point did I feel as though I was suffering. 

I learned a little more over the intervening years and chose to have a water birth at home for the birth of my second daughter. That was an utterly life altering experience. Here is a link to the full story: Eloise's Birth (will open in a new window)

I essentially had an unassisted birth with a midwife in the room. I had said to my midwife, Sr Arlen Ege, that I wanted to do as much myself as I could, unless I asked for help or unless she could see that intervention was necessary, and she gave me the gift of respecting my wishes. So I had an exquisite physiological birth after a week of on-and-off labour (check the link for more details) and it was a highlight of my life. 

I was high on endorphins and oxytocin for what seemed like weeks afterwards and I truly felt like I could take on the world! 

And so I firmly believe that when both my babies were born, new facets of who I am today were birthed at the same time. 

Photographer: Karen E

My babies showed me how to think of someone else before myself, how to nurture and how to love. They showed me reserves of strength and patience that I had no idea I had. They also showed me my limits and my weaknesses - and I have been able to grow through those times. They brought out the fierce mama bear in me - the wild woman who roars in the face of danger and hardship. 

They have also drawn out my softest tear-blurred gazes and inspired my proudest heart-busting moments. 

One thing that I adore about being a doula is that I have the privilege of walking alongside women as they make this transition. I get to witness the birth on so many levels!

So today everyone celebrates my daughter's birthday, and rightly so, I have had many of my own! But on this day I secretly celebrate my own birthing days, those hallowed moments of encountering the exquisite juicy rawness of human life. 

I give them gifts, as parents do, but no book or toy can come close to the gifts my daughters have brought me - the gift of becoming more fully myself, the gift of finding my calling, the gift of becoming a mother.

Hindrances to Natural Birth #52 : Tickets

Image courtesy of Arvind Balaraman / FreeDigitalPhotos.net

I'm pretty sure that if I were to ask you about some of the top hindrances to natural birth, 'tickets' would not be high on your list. Pitocin, lithotomy position, hospitals, a medical model of care, our culture of fear around birth: these are all pretty obvious. But I believe some of the real hindrances to natural birth may be somewhat more banal.

Labour is a shifty thing sometimes. One of the hormones that keep labour going - oxytocin - is considered to be a 'shy' hormone. It is not easily released under pressure. It is the hormone most intricately involved in lovemaking and released during orgasm. It is also the hormone that causes 'let down' or a fast flow of milk when breastfeeding. In short, oxytocin is the hormone of love, labour and lactation. 

Couples struggling to get pregnant who have to do the 'baby dance' on a particular day or even at a particular time will often attest that being 'forced' to make love on schedule kind of kills the vibe. 

Let's take it a bit further. Imagine you are in the middle of lovemaking and someone knocks on the door, peeks around it, and switches on the main light, just to check how you're doing. Are you there yet? Shall we check to see how far you've got to go? It seems to be taking some time. If you're not done in x amount of time we may need to help you along. I'll be back shortly. As you were. Toodles! 

Vibe. Officially. Dead.

Now that sounds ridiculous when applied to lovemaking, but the same hormone, oxytocin, is what induces and keeps labour going. 

So imagine: you are at the end of your pregnancy and your mom has booked her ticket from across the country, or across the globe, for the day before your expiration due date. She only has three weeks off work. The pressure is on. The clock is ticking.   

The thing is, when a pregnant mom has a perceived time limit within the labour process, her body is far less likely to release sufficient oxytocin to keep labour going effectively. On a larger scale, when a mom feels under pressure to go into labour to begin with, it actually makes it much harder for her to do so. 

And so she starts looking at induction options. Inductions can be helpful when there is a genuine medical need for them, but often then lead to a cascade of interventions as illustrated below.

There is lots I could say about inductions that would give some evidence for the diagram above - but that is a whole other post on its own! Let's rather look at some solutions to avoiding inductions altogether. Firstly, let people know that 'estimated due dates' are just that, estimates - there is about a 4-6 week window of 'normal'. I've got another post in this series looking at the notion of due dates as a hindrance to natural birth. I'll link to it here once it's up.


I know you get better prices if you book tickets long before the time and I know grannies-to-be would love to be around at the when babies are born - but I would really encourage you to find a way to not have time pressure around the time of your birth, especially if you are aiming to have a natural or low intervention birth.

Do you have creative ideas on how to avoid time pressure around your labour day? Please share them with us!

The doula as a witness

I love that I learn from every single birth I have the privilege to attend. Each family and each birth requires different things from me - different words, different actions, different energies. Part of the skill in being a doula is knowing when to use which words, actions and energies. 

At times I stand by as a quiet presence, at other times I am in constant contact. Some moms prefer silence, while others want distraction. I rub feet, hands, hips, legs, backs and shoulders, I stroke hair,  I whisper encouragement, I turn down the lights, I turn up the heat, I fill the pool, I bring cool washcloths, I hold the space, I keep everyone fed and watered - doing my best to remove any hindrances to the birthing mother. 

I do all these things, but I feel they are all secondary to my role as a witness.   Of anyone involved in the birth process this one is almost unique to doulas. Partners are present but the birth is their own birth experience too. The midwife, the nurse, the doctor - they have their own responsibilities that often involve papers, numbers and tools - they have additional concerns that I don't have to carry. I am able to be there - truly present - with all my energy and attention focused on the birthing mom. I know midwives who choose to be fully present with the birthing mother, but these are rare.

And so I often get to see the things that others don't. I witness a birthing mother glowing serenely through yet another wave; the gentle interactions between a mom and her partner; the dad's face as he marvels at what he and his partner accomplished. I witness the mother's triumph as her dreams and expectations are clothed in flesh.

I am there for the disappointments too. I witness the moment when the gynae orders a second caesarean section after a long battle for a VBAC. I am there when her wishes are disregarded and her body violated with impunity by those with greater authority than me. 

In those moments something in the depth of me rages.  I don't dispute the medical justification for their actions, but too often there is little to no acknowledgement of her desires, her struggles, her strength, her autonomy, her personhood. 

Something in me rebels at the idea of being complicit in a system that routinely disregards evidence-based care in favour of convenience, that favours policy over personhood.

While this system rolls on, someone has to mop up the emotional fallout after institution has done its work. While there is little I can do on my own to improve the care women get while giving birth in our birthing institutions, I can bring empathy - the ability to sense, understand and share the feelings of another - because I was there.  

So to all my doula moms, thank you for the privilege of allowing me to witness your journey...

I was there when you believed you couldn't go any further but you did anyway. I was there when you felt your body would split itself apart but you kept it together. I was there when you found and accessed that primal power deep inside. I was there when you pushed past exhaustion. I was there when your hopes were shattered, when your deepest healing was won, when your darkest moments were met, and overcome. 

I saw what you did. 

Your triumph. Your power. Your vulnerability. Your pain. 

I saw it all.

And I want you to know: you are magnificent, you are fierce, you are breathtaking. 

I know because I was there, and I remember. 

Debra's Testimonial

This was my first experience of a private hospital as a doula. I met Debra only a few weeks before the birth on the recommendation of a mutual friend, but we connected straight away!

Debra had an unplanned Caesarean birth after attempted induction. I'll be writing my story about this soon, but here is her story:

Not sure if you can see it here,
but mom is on the ball!

From the time we conceived, my husband and I read books, watched DVDs and sought advice from close friends and family. However, since none of our family were able to make the delivery or help us adjust to life after the birth, we still felt particularly nervous about whether we were always making the best choices for our family. 

This is where the famous Leigh joined our family of 3! I had never heard of a ‘doula’ or birthing ‘servant’ but from the day I met Leigh, she played an invaluable double role as both a passionate baby specialist and devoted friend. 

Leigh spent hours with us, answering our many questions regarding different natural birth pain relief options, emergency hospital procedures, breast verse bottle feeding… All our concerns were addressed. This made us feel confident and completely supported, knowing we could make well informed decisions concerning the safety and care of our baby Mpilo.

On the 6th of September Mpilo was due to be induced. Just in case he decided to arrive early, Leigh made sure we knew where she was at all times. Even if my contractions happen to start at 2am, she guaranteed to be there for us. What commitment! 

Armed with games, snacks, massage oils, stories and a medicine ball, Leigh was ready for anything that might occur on our special day. After 6 hours of trying to prepare for a natural birth, the doctor decided to conduct a C-section birth, due to my increasing BP and the circumference of Mpilo’s head. I would have panicked if Leigh was not there to speak with the medical team, offer us sensible advice and show compassion. 

During the C-section, Leigh talked me through the effects of the epidural, what the doctors were doing, how to recover from the procedure and took photographs, all while holding my hand. While I was in recovery, Leigh had already updated my husband on the success of the surgery, checked Mpilo was okay and organised for him to be exclusively breast feed.

The next day, Leigh was back to check on my recovery, to patiently answer more of my questions and help me effortlessly connect with Mpilo. Since then, Leigh continues to keep in regular contact with us. What a beautiful woman! What an amazing experience! 

Mpilo Samuel Nala, the name of our handsome baby boy, means ‘God’s desire is to give us abundant life’ (1 John 14). This is our testimony of His endless goodness to us. After sharing our baby journey with Leigh, our very own special doula, I would sincerely encourage every expecting mother to do as we did.

Did you have a doula for a caesarean birth? Would you recommend it?

For Love or Money?

Is this doula worth the moola?

Find it here.

So as I'm nearing the end of this doula course I'm contemplating the possibility that I get to earn money doing what I love. That is a very privileged place to be!

High School teaching, ballet teaching, lecturing Art History at three different institutions, importing amber teething necklaces and hazel necklaces - I enjoy all of these things. But, with ballet teaching for instance, I never started my own studio because something in me just knew that as much as I love dancing and teaching, it's not what really gets me up in the morning. If I did force it just because it was what I'd always done, I think it would have eaten me alive.

Working with bellies, birth and babies on the other hand... Now this stuff keeps me up at night! I will sit and read journal articles on the benefits of one birth position over another for hours, or sit with a mom while she labours for as long as it takes and feel more alive at the end of it than I did at the start.

But I read someone the other day writing about how she found a doula who 'isn't in it for the money, but does it from her heart' and while I understand her point, I get a bit frustrated that it's seen perceived as an either/or situation - you do it for the money OR out of your heart...

I'd love to be be able to offer my doula services for free, all day and every day. 

I'd love to be be able to offer my doula services for free, all day and every day. But when I am helping a mom in labour, I need someone to help look after my girls, and that sometimes costs money (or bribes). I want to do extra courses in hypnobirthing and aromatherapy and massage and breastfeeding (and and and) to be able to help my moms even more - but they all cost money and take time.

Furthermore, being a doula can be really inconvenient! For instance, I have a glass of wine with dinner sometimes, but when I'm expecting a mom to go into labour I won't drink at all, because I am quite sensitive to alcohol and I don't want my driving to be compromised and I think it's disrespectful to pitch up smelling like you've been drinking.

I can't organise holidays or travel too far away when I'm expecting a birth soon - or vice versa, I can't take clients due two weeks on either side of a holiday. If you think it's tough not knowing when you're going into labour, I have the buildup every time I have a birth! Don't get me wrong, I'm not complaining, I just think people need to know.

So I am in the situation where I will need to charge precisely because I love what I do. And you know what, I think that my time and skills, and my heart, are worth it.

Get the T-shirt here.

The stats back me up and the moms that I've already helped would agree, continuous care in labour makes a big difference! But, on the other hand, I do believe that every woman deserves a doula and I'm not saying that I won't ever take clients who can't pay, and I most certainly will do volunteer work as well, but in order to have the space and the finance to do that, I need to charge those who can pay for the service.

Perhaps I could offer discounted services for special cases, or barter my services for car repairs, or set aside a small amount per birth to put towards moms who aren't able to pay the full fee; I'm not sure, I'll have to see how it goes!

So what can you do to make doula care more accessible? If your medical aid doesn't already pay towards doulas (Fedhealth and Momentum do, and Discovery should be signing up soon) then write a letter to them saying why they should pay for doulas! If they do, write and thank them and let them know how much you valued your doula! We, the doulas and midwives, don't have as much clout as you do when it comes to getting medical aids to pay up...

If your hospital doesn't allow doulas as an additional birth partner, find one that does and give birth there and write to the original hospital and tell them why you aren't giving birth there. Or have a home birth and have as many doulas as you like...

Hospitals are very precious about their maternity wards as in the bigger cities women have a choice as to which hospital they want to birth at, and maternity wards bring in good money for hospitals, so if they are losing patients because they don't allow doulas, they would love to know about it! If they do allow doulas, write to them and thank them and let them know how much you appreciated your doula!

The same goes for medical aids that won't pay for home births and hospitals that won't allow private midwives. You as the paying client have the power to make a difference in these institutions!

Was your doula worth the moola? Comment and tell us about it!
Have your writtena  letter to your medical aid or your local hospital? Are you going to? Let us know!