Midwives’ and lactation consultants’ fraught relationship with maternal autonomy

My way or the Highway, opposite signs

Medical ethicist Susanne Brauer has written:

Obstetrics and midwifery are value-laden, value-producing and value-reproducing practices, values that constitute the social perception of what it means to be a ‘‘good’’ pregnant woman and to be a ‘‘good’’ (future) mother.

Similarly, professional lactation support is also value-laden, value-producing and value-reproducing.

There’s no better example of this behavior than their fraught relationship with maternal autonomy.

Midwives and lactation consultants sugar coat their paternalism by claiming that women who don’t follow their recommendations need more “support.”

If there is one thing midwives are sure of, it’s that they are committed to maternal autonomy. They believe deeply that women are entitled to choose place of birth, birth attendant, birth support, vaginal birth, refusal of procedures, refusal of pain medication and refusal of hospital policies (e.g. separation of mother and child after birth) that do not serve their needs.

Yet there’s another thing they’re equally sure of: some maternal choices are better than others.

Similarly, lactation consultants are committed to maternal autonomy: women are entitled to choose where, when and for how long they breastfeed. They are entitled to choose public breastfeeding, breastfeeding in Parliament or locations otherwise restricted to professional behavior, breastfeeding on demand and breastfeeding toddlers or older children.

Yet there’s another thing they’re equally sure of: the choice to breastfeeding is better than the choice to formula feed.

How do midwives and lactation consultants square their ostensible commitment to maternal autonomy with promotion of specific maternal choices? Ironically, they rationalize it with paternalism, a practice thoroughly inconsistent with maternal autonomy.

What do we mean by autonomy in a pregnancy/early motherhood setting?

From a legal point of view every medical intervention, including therapeutic, palliative, diagnostic and preventive measures, is potentially an infringement on the bodily and psychological integrity of the patient—regardless of whe- ther the intervention is medically necessary. Each inter- vention is therefore in need of consent from the (competent) patient in order to be legitimate (special cases are emergency cases and medical decisions concerning incompetent or unconscious patients). This is especially true for routine prenatal care where the purpose of medical intervention is diagnostic and preventive in nature, and not the treatment or eradication of disease.

How can we tell if a mother’s autonomy is being respected?

1. She must receive accurate information.

2. She must receive complete information.

3. She must understand the information.

4. She must have a real choice between options.

5. While it is appropriate for a provider to convey what her choice would be in a similar situation, the provider must not exert pressure to produce that choice.

There is a massive professional and lay literature on the many ways in which obstetricians have failed to respect mothers’ autonomy. To their credit, there has been tremendous progress over the years — offering new options that privileged, primarily white women demand — but there is plenty of room for improvement. Obstetricians have replaced their paternalism, the belief that they know best, with greater respect for patient choices.

Midwives have often presented themselves as more respectful of patient autonomy than obstetricians. They spend more time eliciting patient preferences, discussing fears and making plans. They are quite comfortable, often encouraging, in promoting women’s right to refuse conventional medical tests and treatments and have offered novel options — continuous labor support, homebirth, placenta preservation, etc.

In both theory and practice midwives are actually less respectful of maternal autonomy than obstetricians because they feel no compunction about injecting their personal preferences into patient care. An obstetrician might prefer a maternal request C-section for herself, but she has no problem respecting patient preference for vaginal birth; an obstetrician might prefer an epidural for herself but she has no problem respecting patient preference for unmedicated birth; an obstetrician might prefer every possible prenatal test for her baby but she has no problem acknowledging that some women want as few as possible while still being compatible with safety.

Midwives, in contrast, prefer unmedicated vaginal birth for themselves and tout it to their patients. Indeed, they go so far as to label their preferences as “normal birth” and run campaigns to promote it. They argue vociferously against “interventions,” including effective pain relief in labor. For most midwives maternal request C-sections are anathema.

Lactation consultants don’t even pretend to respect patient autonomy. They have created the Baby Friendly Hospital Initiative and promoted public health campaigns, legislation and restrictions of formula, all explicitly designed to privilege exclusive, extended breastfeeding over any other possible choice (formula feeding, combo feeding).

How do midwives and lactation consultants defend their blatant violations of maternal autonomy? The exact same way that obstetricians always justified their violations of maternal autonomy: with paternalism. They believe unmedicated vaginal birth and breastfeeding are better for mothers and babies and that justifies pressuring women into approved choices.

When you point out to them that they are emulating the worst habits of patriarchal medicine, they double down. Instead of reflecting on the irony that they are promoting specific choices instead of maternal choice, they ignore the issue of autonomy altogether. In their account the problem with obstetricians is not that they failed to offer women choices; but that they offered a single choice that was inferior to the single choice that midwives offer.

For example, they applaud obstetricians offering women the choice of VBACs after multiple C-sections or breech vaginal births, because vaginal birth is better. They decry obstetricians offering women maternal request C-sections because C-sections are inferior.

Midwives and lactation consultants have offered one innovation to the practice of ignoring maternal autonomy, however. Obstetricians were quite forthright in asserting that their education and training justified their paternalism. Midwives and lactation consultants sugar coat their paternalism by claiming that women who don’t follow their recommendations need more “support.” But support means helping each mother to achieve HER goals, not the providers goals. We have another word for that: pressure. Midwives pressure women to have vaginal births; they pressure women to refuse epidurals or they sabotage their efforts to get epidurals. Lactation consultants privately and sometimes publicly deride women who can’t or don’t wish to breastfeeding as lazy, ignorant and manipulated by formula companies.

Obstetrics has a long history of paternalism; but to the credit of obstetricians most now recognize this and try to do better. Midwifery and professional lactation support rest firmly on paternalism, the belief that midwives and lactation consultants know best. Sadly they refuse to recognize their own paternalism and therefore continue to impose it.

  • Amazed

    Not quite OT: My friend’s preterm baby has never been put on the breast. Never. Anyone cares to guess what she did today as her mom was making her a bottle and I was holding her?

    Do I hear “Tried to open your shirt and rubbed her nose against you in the search of a breast?” Because that’s right. That’s what she does to her mom when she’s hungry and it isn’t as if she had any experience pointing at breast being a food source. Almost as if it’s an instinct and not learned behavior. But feeding from the breast is an art and all this.

    And no, there was no nipple confusion in the aftermath either. She ate her milk with gusto. Fuck them idiots teaching new mothers that a single bottle means the end of breastfeeding and how baby will lose nursing progress.

    • Hannah

      My kid was FF from birth and did the same for… I don’t remember how long, but at least six months. And even now at a year old, when he isn’t feeling well or is really upset? He cuddles up by my boobs. Never had one, but still finds comfort in it.

  • EmbraceYourInnerCrone

    OT but not really as it has to do with maternal autonomy: Arizona woman denied prescription for Misoprostol –

    https://www.huffingtonpost.com/entry/pharmacist-denied-miscarriage-drug_us_5b2fa267e4b0040e2743f360

    The pharmacist refused to hand the prescription over to the other people working behind the counter as well. I think this is a horrible law, a pharmacist should not be allowed to decide which medications a person is allowed to get and which they aren’t, THAT is up to the person and their doctor.

    And for anyone who wants to say “Well they can just go to another pharmacy” Not everyone has a car, not everyone has another pharmacy available in their area. And even if they do, I should not have to explain my personal medical business to the pharmacist and everyone else within earshot. If the pharmacist has an issue because of medications that the person is already on that’s different.

    But you don’t get to say, for instance ” these are meds to help you fight HIV, I don’t think you should be able to get those” or “these are pills to help you with erectile dysfunction, I don’t think you should have those”. NO, no one elected the pharmacist judge of what people should do with their lives, they need the medication, their doctor wrote a prescription for the medication, fill the damn prescription.

    • EmbraceYourInnerCrone

      Unfortunately this type of pharmacist is not exactly unusual; https://nwlc.org/resources/pharmacy-refusals-101/

      This one is especially awful:
      “In Milwaukee, Wisconsin, a mother of six went to her local Walgreens with a prescription for emergency contraception. The pharmacist refused to fill the prescription and berated the mother in the pharmacy’s crowded waiting area, shouting “You’re a murderer! I will not help you kill this baby. I will not have the blood on my hands.” The mother left the pharmacy mortified and never had her prescription filled. She subsequently became pregnant and had an abortion.”

      The pharmacist should have been fired. You Do NOT blare your clients medical information or personal business all over the pharmacy with in hearing of anyone standing there.

      • The Bofa on the Sofa

        The pharmacist should have been fired.

        The pharmacist should also be charged with practicing medicine without a license.

        On what basis can the pharmacist claim the medication is not necessary? They have not even done a physical exam (as if they were qualified).

        If a pharmacist has an issue with a prescribed medication, they need to contact the doctor and express their concerns. Then the doctor should make the decision, and the pharmacist will be bound by it.

        (the whole argument that “business owners don’t have to sell things they don’t want” is also bullshit; pharmacists are granted special privilege by the state to sell controlled substances; with those privileges comes responsibilities; you want to “sell what you want like everyone else” you give up your pharmacy license)

        • guest

          As someone who has studied a lot of pharmacy law, I can explain exactly why this exists.

          Pharmacists have the right to refuse to fill a prescription. They use this right many times each day when catching medication errors, dosing errors, potentially lethal drug interactions, etc.

          In a few rare cases, this right is used when the pharmacist feels that he or she cannot fill a prescription without violating his or her personal ethics. This includes filling prescriptions for patients who wish to commit suicide, filling prescriptions to assist with a pregnancy termination, and filling prescriptions for birth control. In these cases, the pharmacist is supposed hand the task over to another pharmacist who is willing to provide care.
          Doctors and nurses also have this right to deny care on religious grounds.

          Unfortunately there are a handful of activist practitioners (mostly in Arizona) who refuse to refer the patient to someone else who will provide care. This is upsetting and an ethics violation, but it doesn’t mean that all pharmacists should be stripped of the core of their job – ensuring that patients have safe and effective drug therapies.

          Pharmacists, especially in a hospital setting, often have post-graduate training, and are in school and residency as long as physicians. They are specialists in medication and drug therapies. They are not “trained monkeys and pill counters” who follow instructions blindly, nor are they retail salesmen who must always make a customer happy.
          This isn’t the 1800s. Each Walgreens is not owned by a druggist. Pharmacists are salaried – it is the same as if a physician or nurse were on staff – and do not make money off of individual drug sales. They are medical care providers, not retail salesmen.

          • swbarnes2

            Pharmacists have the right to refuse to fill a prescription. They use this right many times each day when catching medication errors, dosing errors, potentially lethal drug interactions, etc.

            But presumably, they don’t outright refuse…they call the doctor to make sure the doctor hasn’t overlooked something.

            In a few rare cases, this right is used when the pharmacist feels that he or she cannot fill a prescription without violating his or her personal ethics. This includes filling prescriptions for patients who wish to commit suicide, filling prescriptions to assist with a pregnancy termination, and filling prescriptions for birth control.

            How does the pharmacist know the patient wants to commit suicide?

            And yes, we know that pharmacists can refuse to give birth control. Bit it’s obnoxious. If a patient and doctor agree that birth control is a legitimate medical need, the pharmacist has no right to override that.

            An in the original case, the pharmacist was absolutely wrong about the drug killing the fetus, because the doctor and patient knew the fetus was already dead. The pharmacist didn’t know that, but they the hell should they presume?

            I’m also confused how you can read

            Reports of pharmacies refusing to fill prescriptions for birth control—or provide EC—have surfaced in at least twenty-six states across the nation, including: AZ, CA, DC, GA, IL, LA, MA, MI, MN, MO, MT, NH, NJ, NM, NY, NC, OH, OK, OR, RI, TN, TX, VA, WA, WV, WI.

            from Crone’s link, and conclude that this is mostly not a problem outside of Arizona.

          • EmbraceYourInnerCrone

            This is also the kind of policy that allows Catholic hospitals to refuse to give emergency contraceptives to rape victims. After all, as one (former) Democratic(!) Senator once said, if they want EC it’s just a short ride to another hospital…

            You know what, one can keep one’s religion OUT of my health care, or go find another job.

          • guest

            “But presumably, they don’t outright refuse…they call the doctor to make sure the doctor hasn’t overlooked something.”

            You’d be shocked at how often physicians will refuse to correct an error when contacted. So yes, outright refusal is common. As in “I cannot in good conscience fill this prescription, because it would cause injury to you.”

            “How does the pharmacist know the patient wants to commit suicide?”

            Eight states allow medically-assisted suicide. I happen to work in one. Staff at each pharmacy have volunteers for each shift who are willing to prepare, dispense, and offer counseling on the medication for this. Those who have not volunteered are required to treat each patient seeking medically-assisted suicide with care, respect, and courtesy, and to make sure that the volunteer staff can fulfill their order in a timely fashion.

            “And yes, we know that pharmacists can refuse to give birth control. Bit it’s obnoxious. If a patient and doctor agree that birth control is a legitimate medical need, the pharmacist has no right to override that.”

            I agree. The pharmacist should comply with the law and with the duties of their profession. Once the prescription has been accepted, the correct course of action is to make sure that it can be dispensed to the patient in a timely fashion. That does not mean that the pharmacist in question has to personally dispense that medication.

            “An in the original case, the pharmacist was absolutely wrong about the drug killing the fetus, because the doctor and patient knew the fetus was already dead. The pharmacist didn’t know that, but they the hell should they presume?”

            I am not defending the Arizona pharmacist. I think that individual’s actions are a travesty, and that individual should face harsh consequences.

            I have had four missed miscarriages myself, two of which were resolved by D&Cs, and two with misoprostol. I also live in an area where I am dependent upon a Catholic hospital and clinic network for care. I have had an OB and a pharmacist refer me to other practitioners for care, because they would not participate in the termination of a pregnancy, even though the fetus was already dead. In both cases, they found another practitioner who was willing to work with me and did so in a compassionate manner. I respect their right to refuse when other options for care were available to me.

            “I’m also confused how you can read…from Crone’s link, and conclude that this is mostly not a problem outside of Arizona.”

            I did not conclude that at all. It is occasionally a problem in all states – with doctors, nurses, pharmacists, and all kinds of care providers – denying care to patients, shaming patients, etc.

            It is however MOST COMMON to see these reports and complaints of pharmacists denying care coming out of Arizona. That state is home to several church organizations that excommunicate members who provide birth control or pregnancy termination as part of their professional work. Also, several corporate retail pharmacy chains in Arizona are owned or managed by members of these churches.

          • In the case of the woman who was refused misprosol, retention of the already dead fetus (it’s correctly called a “missed abortion” in medical parlance) can cause sepsis in the woman, which can be fatal. That’s why doctors diagnose and pharmacists are not qualified to do so.

          • EmbraceYourInnerCrone

            I’ve had both a miscarriage/spontaneous abortion and the next year I had a missed abortion. For the missed abortion I got a D/C to remove the dead fetus, as a non-surgical option was not available at that time. If some ass had stood there and said “I have the meds you need but I can’t give them to you because of my religion, and I won’t let any one else here give them to you” I probably would have jerked him over the counter and gotten myself arrested.

          • sdsures

            That’s what happened to Savita. 🙁

      • kilda

        at a very minimum they should have been fired for the hipaa violation. don’t get me wrong, I think they should be fired for interfering in a patient’s prescription, but I don’t see how anyone could argue against firing them for the hipaa violation.

        • Pharmacists are not licensed to diagnose or prescribe. Those who do should have their licenses revoked.

      • Sarah

        This occasionally happens in the UK, as pharmacists there are also allowed to refuse to provide emergency contraception even if there’s nobody else on the premises to do it instead. All they have to do is give details of an alternative local provider, and they’re not obliged to take into account whether the woman has transport to get there etc. Sometimes it’s fine, I have about a dozen within walking distance, but sometimes it’s not.

        Inevitably, the delay in obtaining emergency contraception in some cases and the inability to do so in others must lead to more pregnancies than would otherwise occur if timely emergency contraception were provided. I’m always moved to wonder if these supposed anti-abortion pharmacists know how many unnecessary abortions their actions have led to.

        • sdsures

          I live in Salford, a suburb of Manchester, and a pharmacist at my Tesco refused my request for emergency contraception, claiming (lying) that he was not licensed to dispense it.

          I know he was lying because I have gotten emergency contraceptive from that exact pharmacy, and all they do is ask if you would like to step into the private consultation area (you can close the door) when you’re getting the pill and instructions on what to do with it.

          He wouldn’t even go into the room with me, after I’d described the above earlier occasion of getting the pill. >_< He just kept stalling and claimed we then had to go to a different pharmacy, which I KNOW is bollocks.

          GRRR!

          • Sarah

            You should complain.

          • sdsures

            They don’t care.

          • Sarah

            I’m astonished.

      • Abby Beastall

        They’re not even right, emergency contraception doesn’t kill anything anyway it just delays ovulation, so there isn’t a ‘baby’ and they are stupid as well as unprofessional.

        • Sarah

          Well there are people who think ‘life’ begins when sperm meets egg rather than when egg implants, and as I understand it emergency contraception prevents the latter. So while it’s irrelevant to me as I’m pro choice regardless, I can see that if you hold that view then you might see it as very early abortion (and this could be true if you were pro choice as well I guess).

          However, if the pharmacist does think that’s an abortion and is on those grounds opposed, then they shouldn’t choose to be in a job where prescribing emergency contraception is a pretty common requirement. There are a number of things I don’t agree with ethically, so I don’t take jobs where I’d expect to be paid a salary for not doing them. There’s a stonking level of entitlement there.

          And emergency contraception has been in existence since what, the 80s? You’d have to be getting pretty close to retirement age to have chosen the profession before realising this was a thing. The majority of pharmacists are going to have chosen the career and trained for it post-EC. Yet there are some who expect an ethical opt out of something they knew or ought to have known would be a part of the role!

  • BeatriceC

    OT: Shit’s getting real in San Diego. A group of protesters stayed after a march to an immigration detention center near the border. They’ve shut down entry and exit from the center at this point.

    https://www.facebook.com/BernieSandersBrigade/videos/2219493858067052/?comment_id=220628992085086&notif_id=1529803988363601&notif_t=event_mall_reply

    • Zornorph

      Good Lord, those were some crazy-ass people.

    • demodocus

      Kick some rhetorical butt, B.

    • Who?

      Not sure there is much point harrassing the people who work at the centre, most of whom are probably earning very little and have no opportunity to get a different job or influence the decision makers who instruct them.

      The President is on a crusade, pity help anyone in his road, until something shiny distracts him. Then pity help whoever is in that path.

      • The Bofa on the Sofa

        Not sure there is much point harrassing the people who work at the centre, most of whom are probably earning very little and have no opportunity to get a different job or influence the decision makers who instruct them.

        Of course they do. If they all refused to work, it would affect the entire process.

        “It’s just my job” does not excuse the people working for organizations doing bad things.

        • Daleth

          “It’s just my job” does not excuse the people working for organizations doing bad things.

          Exactly. It’s perilously close to the Nazi collaborators saying, “We were just following orders.”

        • “We’re just following orders”. Sound familiar?

          Oh sorry, hadn’t read the message below. Obviously great minds think alike.

        • Who?

          If they all refused work today, they would be out of work tomorrow. Given the unemployment queues in the US, they would be replaced in the blink of an eye by people with less training than them, and perhaps who meet the job description of wanting to be cruel to brown people.

          • The Bofa on the Sofa

            And then blame the next people.

            “It’s just my job” is NOT an excuse for supporting evil.

            The janitor at Dufenschmirtz Evil, Inc is supporting evil, too. Good people don’t do that.

  • Anna

    Ive noticed in NCB this automatic assumption that everyone wants drug free, VBAC, rooming in, skin to skin, to go home as early as possible etc and they seem to think the reason it doesnt always happen is because of teh evil system, teh evil Drs or women are “uneducated”. I think the reality behind low VBAC rates for example is a large perecentage of women are not willing to take the risk, a lot of women dont want to go home 4hours after giving birth! Some women dont believe epidurals are evil and inductions never warranted. NCB just cant fathom it! All the carry on about being “with woman” is garbage. They are only with each other and the women who want what they want.

    • CSN0116

      PhD-educated, in epidemiology nonetheless, with access to all the support and shit I want – I had elective cesareans, then VBACs (my choice) with well-timed epidurals, I refused skin to skin (one nurse even said, “I don’t know where to put the baby!” I had to tell her to put him in the warming bed, clean him, assess him, swaddle him, and then hand him to me), stayed inpatient as long as possible, put my babies in the nursery from 8 pm to 8 am every night (yes, at least one hospital in town still has a nursery), and never put a single one of my five children to my breasts, not even for a second.

      I knew what I wanted and nobody was going to fuck with it. Period.

      • 28Weeks+5Days

        Why did you go from elective c-section to VBAC? I’m scheduled for an elective c-section and am curious. Was it number of children? I’m only planning on two, which was part of my decision.

  • WonderWoman

    But both midwives and lactation consultants believe they’re doing all of it for their clients’ good. In their echo chambers they share the “science” that supports the choices they prefer and think that everybody else is uneducated about the benefits of vaginal birth and breastfeeding.

  • Mel

    That was one of the oddest things about the crazy LC compared to every other medical professional I encountered while Spawn was in the NICU and once we were out and about in the real world.

    The NICU nurses, neonatologists, medical specialists of all stripes, his primary care physician and Early On therapists treated Spawn as being one member of a three-person family – and that all three of us had needs that had to be met. The NICU nurses encouraged my husband and I to go on dates; the neonatologists looked at options for home feeding in terms of the amount of stress it would place on my husband and I. His doctors gave us options for care and therapies with the assumption that we would choose what worked best for us – and the Early On folks are all about providing support for parents of at-risk infants (which I found as helpful as their tips for helping my son.)

    The lactation consultants seemed to care about the production levels of my breasts; the rest of our tryad was inconsequential. I know one of the lactation consultants never learned my son’s name in 4 months. She also never learned to recognize my husband as my spouse in spite of him being present at more than 60% of our meetings.

    • demodocus

      As i said before, the most arrogant medical type I’ve encountered in years was a lactation consultant. Sigh.

  • Sarah

    You reckon LCs are committed to women being able to choose how long they breastfeed? That’s generous of you. I can’t see some of them being very supportive if a woman wanted to choose to breastfeed for 24 hours.

    • Mel

      I had the same thought 🙂

  • fiftyfifty1

    Typo? the second to last paragraph starts out with a weird half sentence.