On the penalties you pay for believing in women

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On the first day of my first obstetrics rotation as a medical student, I got to attend a birth.  I was assigned to shadow one of the staff obstetricians. We waltzed in unannounced to the room of a labouring woman, who was pushing, feebly, ineffectively, with her feet in stirrups, legs encased in drapes.  The doctor turned to me and rolling his eyes said, “At this rate, we could be here all day.  Nurse, get me a pair of forceps.” And then, for what seemed to be no reason at all, other than impatience, he pulled the baby out.    It was awful and I remember feeling terrible for everyone….the mother and her baby, the nurse who had to “obey” and for myself for having to bear witness to this thing. 

 What did I do with those feelings?  Did I report this behaviour to the proper authorities?  No, I certainly did not.  It was clear to me that this was how it was going to be, that shocking things like this were – shockingly – forbidden to be viewed as shocking at all.  The way everyone else around me was acting it seemed to be the expected norm.  The staff doctor was my boss, and he was at least in part responsible for my grade during that rotation.  I was in no position to complain.   

To be fair to the obstetrician, as a student, I didn’t understand everything that was going on.  It could have been that there was some other reason to deliver the baby that way that I didn’t fully appreciate.  Maybe the fetal heart rate tracing wasn’t optimal.  Still.  I’ve had many other experiences of the same kind in my training and beyond, enough to know that this kind of casual approach to violent events is commonplace.

By looking at me and speaking to me in that way, including me as a sort of a peer… “we could be here all day” ….. I was being asked to take sides.  It was as if I was being groomed for something.   Grooming can be quite flattering.  You don’t want to speak out because you are afraid of being humiliated.  This doesn’t change the fact that you are complying with the abuse of women. But you are complicit in an act of oppression for the same reasons everyone complies with oppression, because you are weighing the risks and the benefits of non-compliance.   You are performing complex calculations in your head, below the level of your cerebral cortex.  Who would have known the brainstem can do this kind of math? 

It’s a survival mechanism though.   We need to suppress this information from our conscious selves to function in this system.   We are helped to suppress our empathy in so many ways.  In the hospital setting we make the patient seem “other” than ourselves.  The patient gets a hospital gown and an arm bracelet to segregate and anonymize her. The patient I described in that story above didn’t even have a name.

We do these things in part because at times we have to do horrible things to people in the name of helping them….for example, most days I’m cutting into the flesh of women which could—perhaps even should– be repulsive and frightening but I have learned not to think about it in that way. It is easier to think you are cutting into a piece of some sort of material and not, you know, an actual woman.   

The problems happen sometimes when the patient seems too much like us.   As long as the patient comes from some sort of difference:  age or race or socioeconomic class, it’s okay*, but then, someone comes along and bam—-all of a sudden we have trouble.  For example, I once had a lot of problems staying out of grief with a dying woman who –though not related to me—happened to have the same last name, and children around the same age as mine.  (For the record, staying connected to her as she died was a transformative event in my medical life, which is to say, my actual life.)

And then there are the very scary things that happen.   Like when patients bleed to death and babies die.   After half a dozen or so of these sentinel events as they are called, we start maybe exhibiting some of the signs of post traumatic stress disorder.  We shut off even more.  We abuse patients, for better or worse, we are perpetrators.  We become that obstetrician that I followed on the first day of my obstetric rotation.

Not much is written about the perpetrators of violent crimes. They aren’t usually the ones seeking therapy.   I read a book recently called The Birth Wars by Mary-Rose MacColl, which highlights the terrible relationship – the war – between midwives and doctors in Australia where tragic outcomes for women and babies have become a sort of collateral damage.  She doesn’t offer us any solutions but it seemed to me, since she called it a war, we can maybe learn something from the studies of soldiers who have been in combat.  I think the comparison is apt because they are both perpetrators and victims.

Judith Herman, who wrote the book Trauma and Recovery about the survivors of violence, political terror and sexual abuse, writes that every soldier has a threshold of resilience that can be exceeded fairly quickly:  most “tours of duty” exceed this threshold.  And given a horrific enough event,   no one is immune from the consequences of traumatization.   Judith points out that the trauma of combat takes on greater force when the soldier can no longer rationalize it in terms of some higher value or meaning.   Doctors like me feel a little bit this way when we question the evidence behind our practice.

There is a solution.  Herman also writes about the healing power of connection.  And so it is the connection that provides the recovery. It is disconnection, in some cases perhaps a merciful act of the brain to minimize memory of horrific events, which becomes the problem.  

Therapists say that when we make connections, whether it is in our relationships or in our professional lives, we can talk about anything.  What they don’t seem to talk about is the cost of connection.   Each of us needs to weigh in that cost.   If you disconnect, it seems that you will probably pay later: depression, anxiety, PTSD.   With connection, you pay now:  anger at everyone who makes the system suck for women. Anger at yourself for not being able to change it.

For me, one of the penalties in believing in women is to live alone in a world of wounds.  The choice is to harden my shell, or to make believe that the consequences of intervention and obstetric “scare” are none of my business[i].   I can’t seem to do either one.

 

*******

I am in the operating room, about to do a caesarean section.  The baby is exceedingly premature.

A paediatrician stands waiting to take him away.   The baby is breathing on his own, and very vigorous, and so, I say to the mother, go on, reach up and touch him, it is really important; they may not let you hold him for a while.  She reaches up and grabs his little foot in her hand, and afterwards I am sewing up her skin she is still looking at her hand and marvelling at the warmth of him, and how wonderful his skin felt. “He was hot as, cuz he came from inside me, and his skin was so freaky, soft,” she is saying.   But the anaesthetic technician has just noticed her fingers are covered in blood and amniotic fluid.  Frowning at me over the top of the drape, he hastily puts on gloves, and gets a bunch of tissues to wipe it away.  

 

 


[i] Aldo Leopold described this wounding from the view of an ecologist living a world of exploitation of the land, in his book, A Sand County Almanac  Oxford University Press 1949

*(of course, this is NOT even remotely okay)

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23 thoughts on “On the penalties you pay for believing in women

  1. Elizabeth Allemann

    Thank you. This is Truth. I have also seen this and walked the path you describe. May you find peace and joy.

  2. Alison I recall the birth of my daughter, in 1976, a ‘normal’ birth, but with only a Catholic GP present with no empathy whatsoever. As soon as my beautiful daughter was born, I still remember putting my hands out to touch her – in the trauma I’d forgotten why I was even there. I was but a child myself. Said GP told me off in no uncertain terms, I wasn’t to touch her until she’d been checked over.

    We health professionals can so make or break the experience, in our ignorance or in our passion to be there for women. Hurrah for obstetricians like you.

    I’ve seen the best and the worst of midwife/obstetrician relationships in 25 years as a midwife in UK and NZ. When it works well, and respect is on both sides, and we’re each there for the woman, it is magical and the best job/vocation in the world. But when it doesn’t …

  3. Dr Alison, thank you. I have never seen nor heard the obstetrician’s side of the birth story – let alone such a sensitive, strong, thoughtful obstetrician such as you. Thank you so much for what you’re writing. Your voice is so needed.

  4. The story of the forceps had me completely unglued. I’ve been at those births. The woman in your story may remain forever nameless to you (and certainly to me). But I feel as if I know her, and you, too. I’ve been that nurse, being asked to provide a piece of equipment or do some other task when I know it’s going to result in the doctor doing something that I can’t justify in my own mind. At some point, I had enough expertise to know when the doctor was more interested in the clock than the fact that a human being was being born.

    In the case you described, I only wish that the woman had done what one of my patients did. She screamed, “WHAT ARE YOU DOING?” The doctor said he was using forceps. The woman screamed, “OH NO YOU’RE NOT”, withdrawing her body as best she could, and extending her leg in a forceful motion. I don’t recall the obstetrician ever getting the forceps out so eagerly thereafter. She was my hero.

    I cannot imagine how difficult it is to feel like you’re in charge if you’re lying on your back, spread-eagle, But she somehow mustered the willpower to indeed be in charge. I never forgot that.

    On the sentinel events: Shortly before dawn, I left a laboring multip (about 6 cm) for a few minutes–5 minutes at most. When I went back into the room, a massively prolapsed cord and thick mec were in the bed, and the woman was lying there, silent. With no doctor on the unit, I held the head off the cord, and when the doctor came, the mother gave a few pushes, and delivered a dead baby, whom we could not resuscitate. That was more than 30 years ago, but I remember it as if it was yesterday, and I can see that baby clearly in my mind’s eye. My lower lip is quivering just writing this. (But, as you say, I could separate myself from it when it occurred.) Nine years later, she arrived at the hospital, in labor with her next baby, and one of the nurses was kind enough to tell me, “She asked for you, Marie.” I was glad I could take care of her the second time, but that first time will stay with me forever.

  5. Jean

    Thank you for this post. Many years ago I watched a male physician reduce a cervix. I was new, but the feeling that I was watching an assault will forever be with me. This experience helped shape me into the passionate patient advocate that I am today.

  6. Beverley Walker

    Yes I have seen all of this and have not remained silent and was eventually with maturity able to report and become part of an audit team which came up with solutions. Gradually woemn came off their backs and were able to walk about kneel etc. but again the backlash came and the more birth noralised the more it became surgical assault and battery o women. This is the reason home birth has risen in popularity and that is fought tooth and nail by the meidcal hierarchy.

  7. I see these assaults too often myself as both a labor and delivery nurse and a doula. I advocate for my patients, buy them time, give them options, tell them they can say “NO” to the assaults and do my best to give them the experience they seek with their new baby. It is a tough job and I love what I do. I stay at the bedside because I find value in helping them have both a healthy baby AND a good birth experience. Thank you for this article, I understand totally.

  8. Mawt Pearson

    Thank you for your powerful story. It makes me feel as though we are not alone in the desire to care, truly care for women. I thank you for your courage and strength and implore you and all other birth workers to never disconnect or lose sight of the reason we do what we do. I want to make it a positive one for women. I work for them and not the clock or an institution. It matters. X

  9. Maureen O'Reilly

    Thank you for posting this Rikki. As another midwife I can relate well to this post. The book about ‘The Unfortunate Experiment’ in the 80’s recorded similar situations which resulted in a much higher level of informed consent for peope in our health system. But what’s happened? Are we all burning out ; working on tight budgets; getting older; gen X having different values and expectations or what? The disempowerment I observe in my work seems to be invisible to others. I am certain that NO one consciously intends their work to be anything but safe and correct but at times my gut and intuition tells me it’s not. My usual contribution to advocacy is to tell women and their families that they are the boss of themselves and to ask, challenge and seek more information if things don’t seem or feel right to them. I do my best to always ask if what I am doing or suggesting is ok with them

  10. Alison, this is so powerful, and so very important. Thank you so much. For the past 11 years we have supported women healing from a traumatic birth. We have heard so many stories from women in our support groups : blurting their painful stories out between sobs and often shaking as they speak. We are often the first to hear their stories…sometimes years after the event. We just want you to know that every question you ask about the care you are offering, every time you can make that connection (yes, I am aware there is a cost for you) with the woman, every time you are able to acknowledge that this is an emotional journey towards becoming a mother…it matters. We work, at our end, to empower birthing women so that they can understand the importance of taking responsibility for their own care, and being able to advocate for themselves and get their needs met. So that they understand the benefits to them when they create a team around them of people all dedicated to support them in this massive journey. We’ve seen these women and couples go into very challenging situations, and emerge empowered, with support from some excellent health professionals who kept them central, and with support from their own understanding of the importance of keeping themselves central to the care, and making sure that happened. Women need to know about the issues that face health professionals like yourself…not to be able to make excuses for them…but to be able to understand that this is a two-way street, and that they have a role to play in getting their own needs met. Thank you for everything you are doing – these are very important conversations.

  11. Thank you Alison, for bringing attention to the clinician’s experience of trauma at challenging birth situations. Have you seen ACOG’s video: Healing our Own: Adverse Events in Obstetrics and Gynecology? It’s only available to ACOG members, I think. Also, as part of the National Partnership for Maternal Safety, there is a support bundle being created for women, their families and maternity clinicians after a severe maternal morbidity: http://www.safehealthcareforeverywoman.org/maternal-safety.html Please contact me if you’d like to learn more (morton at cmqcc dot org)

  12. Isabel Camano

    No words can describe how I feel after reading this. Thanks Alison for being so brave as to expose all your fears and feelings. It has made me realise how much you inspire my day-to-day “battle”…although I hope (almost beg) that in many cases you and many others, hopefully myself too, satisfy the expectations of the families which we have had the honour of sharing special moments with.Many times we are just mere observers, many others we can change the way they observe and just a few we really change outcomes…lets’ hope that we learn more to observe and let nature do or if we do, let’s hope it’s just when it’s really needed.
    Isabel ( predator, soldier and friend)

  13. We should never under estimate the effects of that first touch,smell,taste of our own baby. I used to be a family Doctor in Britain, delivering babies at home, now I only deliver sheep. This morning a young inquisitive pregnant first-timer sniffed at another ewe’s lamb, licked it and in an instant was hooked –‘That’s my baby’. She became distraught when I had to pen her up away from the lamb. We’re not very different: I remember sniffing the top of my first child’s head when she was handed to me, of feeling her skin with my tongue and the overwhelming realisation that I couldn’t live without her. When the (incidentally male) midwife came to bath her I very nearly floored him ( which would have been embarrassing – Local lady doctor punches town’s first male midwife )

  14. In 1985 when I was a student midwife I witnessed an obstetrician pinch a woman’s labia with sponge holders to see if the pudendal anaesthesia was effective prior to putting forceps on the baby. she howled. her labia bled. sentinel moment.

  15. Jessica Jordan

    Alison, your expression of thoughts and ideas from your heart, through the lens of an obstetrician, really gives me great hope about the care that women and their families have, can and will receive within the tertiary setting. It is really easy to become disillusioned when in constant ‘learning mode’ we observe practices that are disempowering and abusive to the woman. Midwives, nurses, doctors, managers, we all participate in this violence. Your writings identify the thoughts and ideas of many and encourage us all to walk on the righteous path, honoring the sanctity of the birthing process and acknowledging our role in preserving this sanctity, no matter what intervention required, or the outcome.

  16. Hi Alison. This is a tremendously powerful and insightful post. When I was a medical student, I lost count of the number of times I saw someone above me set a bad example by the way they treated patients; with indifference or occasionally contempt. There were, of course, also inspiring and wonderful clinicians whose example I still try to emulate.

    When I used to teach medical students in the UK, I would point out to them that the motto of the British Medical Association is “With Head and Heart and Hand”. I told them at medical school we were very good at teaching them how to use their heads: with facts and figures and knowledge. We were very good at teaching them how to use their hands: technical skills and procedures. But we were very poor at teaching them how to use their hearts: with compassion, a sense of morality and ethics, and a desire to share in the patient’s experiences. I urged them not to allow their intrinsic caring natures to be ground out of them by the casual daily cynicism they would encounter on the job.

    You are not living “alone in a world of wounds”. Some of us are right there bleeding alongside you.

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