A Doula's Call For A 'Culture Of Consent' During Childbirth

I gave birth seven years ago in a Boston-area hospital where I generally consider the care to be excellent. I arrived near the end of my labor, my cervix almost fully  dilated. After an hour of moving freely around my hospital room, my midwife and labor nurse said, “It’s time for you to get into bed now.” And then they said, “Let’s have you get onto your back.”

Even though I had read the medical research that found that lying supine carries risks to a fetus -- which is why pregnant women are advised not to sleep on their backs -- I behaved like any woman in the suggestible state of labor: I did what I was told, though it went against my instincts and my preference.

Very quickly, my baby’s heart rate went down, as the weight of my nine-months-pregnant abdomen pressed on my vena cava, the large vein in the back that returns the blood to the heart.

My instincts kicked in. I jumped up off of my back, and repositioned myself on the hospital bed, on my hands and knees. My daughter’s heart rate instantly returned to normal.

“There’s not enough time for you to change positions. You need to get onto your back,” the midwife said — even though I had already changed my position. In the suggestible state of labor, I did what I was told. Again. And my daughter's heart rate went down again.

The midwife told me she would need to cut my vagina, a procedure known as an episiotomy, to get my baby out faster. She went ahead and cut me without my full permission. She used some local anesthetic so that I didn’t feel it, but my body and my brain still knew what had happened.

Even though my birth had gone normally until that point, it ended in a way that left me feeling out of control and violated.

For the last seven years, that memory intrudes every time I think about giving birth to my daughter. I share it now to pose this question: Does maternity care currently function within a culture of consent?

At Boston University, professor Eugene DeClercq and colleagues have, for 16 years, been conducting a very important national survey called "Listening to Mothers." It has found that after giving birth, over 50 percent of women were unable to correctly identify the potential side effects of major medical procedures such as Cesarean section or induction of labor.

Almost one in four mothers said they did not fully understand that they had the legal right to clear and full explanations of any procedure during childbirth, and that they had the right to accept or refuse any procedure.

As a doula myself, I have witnessed births at nearly all of the hospitals and birth centers in the Boston area over the last two decades. Unfortunately, my doula colleagues and I have witnessed caregivers performing a variety of actions on people in labor without their fully informed consent, including the following:

• vaginal exams;
• administration of the drug Pitocin;
• episiotomy;
• insisting that women get onto their backs;
• diagnosing a stalled labor and recommending a C-section, without fully offering the patient the option to wait (for an otherwise healthy mother and baby).

For decades, childbirth advocates have proclaimed the importance of informed consent in maternity care. Also for decades, the feminist movement that I’ve been a part of my whole adult life has been discussing the critical importance of consent in our sexual lives.

However, it has only been since last October that we’ve watched as a nation while famous men like Harvey Weinstein have been implicated in sexual abuse of their employees, and the Me Too movement began. A national crisis and conversation has been unfolding about the need for a culture of consent.

What is the definition of a culture of consent? One definition is that it is a culture in which a person’s right to make her own decisions about her life and body — to decide “yes or no” — is normalized. And an absence of “no” does not equal full and free consent.

This is most obvious in certain situations, such as when one person is seen as holding a position of authority over someone else, or when one of the parties is in a highly vulnerable state, or when one party doesn’t understand what is about to happen.

In maternity care, this translates into a moral obligation for caregivers in a position of authority to obtain fully informed consent or refusal from a woman in the vulnerable state of childbirth.

A first step toward creating a culture of consent in maternity care would involve adding one simple sentence to many conversations. If a doctor says, "I’m here to give you a vaginal exam," or a midwife says, "I feel that I need to cut an episiotomy right now,” they can follow that by saying, “You have the right to say yes or no.”

That simple sentence embodies the spirit and the critical importance of informed consent in any area of health care.

But childbirth is often a crisis situation, you may say. Obstetric medical staffs are not Harvey Weinsteins; they want mother and child to do as well as possible, and sometimes their expertise may need to trump consent. I would respond that while that is true, there are also occasions when providers make medical errors in their own decision-making. And a patient who is conscious still has the right to say no.

Conversations about consent culture are happening with the most intensity on college campuses, in Boston and around the country. My wish is that young people who are in medical school today would bring these principles to the care they provide the next generation of childbearing women.

Perhaps someday, my daughter will experience her own pregnancy and birth. I want it to be normal for everyone involved to know that during any point in the process, she has the right to say yes or no. To get to that point someday, it needs to start happening now.

Ananda Lowe lives in Somerville and is co-author of "The Doula Guide to Birth: Secrets Every Pregnant Woman Should Know."