Why don’t midwives respect women’s choice for medicalization of birth?


Midwives have a fraught relationship with maternal autonomy.

They tell themselves they are committed to 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. They glorify women’s agency.

Her baby, her body, her choice! And that includes epidurals, 39 weeks inductions and maternal request C-sections.

Until the moment a woman chooses an epidural, an induction at 39 weeks or a C-section without medical indications. They oppose those decisions and they rationalize their opposition by insisting that women have been hoodwinked by the structure of contemporary maternity care.

I’ve been writing about and puzzling over midwifery hypocrisy on autonomy for more than a decade. I recently came across a Master’s thesis that offers a compelling explanation: it’s the difference between succeeding waves of feminist philosophy.

Choosing Surgical Birth: Personal Choice and Medical Jurisdiction was written by Alexandria Vasquez, now a sociology faculty member at Mills College.

Vasquez seeks to understand whether a woman’s choice of C-section without medical indication is a choice that is worthy of respect. Midwives and other healthcare professionals have made it clear that they are NOT respectful of such decisions, going so far as to mandate psychiatric assessment for any woman who makes such a request.

Think about that for a moment: the same midwives who argue that women’s decisions to choose a medically contraindicated homebirth or refuse even lifesaving interventions in childbirth MUST be respected also insist that women’s decisions to choose surgery SHOULDN’T be respected and can be understood as psychiatric disability.

Vasquez argues that it reflects the difference between second wave and third wave feminism.

Second wave feminists argue that the intervention of medicalized childbirth has led many women to experience more pain, confusion, and ultimately less control over their own birth. Second wave feminists maintain that the pathologization of childbirth has created a rationalized, technocratic order where women’s bodies are seen as predictable machines as opposed to natural beings… To second wave feminists, the consequences harm all women as it has become customary for any woman to give birth in a hospital setting with unnecessary medical intervention…

In other words, midwives — as second wave feminists — believe childbirth interventions are only chosen as a result of the structure of contemporary maternity care. They deny that women choosing medical interventions in childbirth are exercising moral agency. Hence these women’s choices for interventions can and should be ignored.

In contrast:

…[T]hird wave feminism argues that the [second wave] perspective idealizes natural childbirth… [T]he valorization of natural childbirth fails to consider childbirth as a burden on women, and not something they have to believe defines their very being…

…[T]hey believe medicalized childbirth has proven beneficial for expecting mothers by providing less painful, more manageable, and lower stress births for those who seek out this alternative. In this regard, they contend that a woman should have full autonomy in choosing what mode of childbirth is best for her and her unborn child, and to take away or criticize this right is oppressive rather than feminist.

In the view of third wave feminists, women who choose interventions in childbirth like maternal request C-sections ARE exercising moral agency and are NOT victims of an oppressive structure of maternity care.

How can we reconcile these two perspectives? We can acknowledge the existence of structural pressures while understanding that they are not the only explanation for women’s choices.

We can analogize to the decisions women make to have children.

No one would deny that there is tremendous structural pressure to have children. Baby girls are given dolls to prepare them for the role of future mothers and girls of every age, from every ethnic background and economic stratum are encouraged to imagine futures that include children.

We recognize that women who are child-free by choice have resisted that pressure. They have exercised moral agency in the face of major structural constraints; their decisions are worthy of respect.

But — and this is the critical point — it does not mean that women who choose to have children are not moral agents or that their decisions are not EQUALLY worthy of respect. Just as we should never force women to have children against their will, we should never denigrate the choice to have children as merely the result of societal pressure.

The same principles ought to apply to childbirth interventions. We can acknowledge that there is structural pressure to medicalize childbirth. We can respect the moral agency of women who reject medicalization. But that does NOT mean that women who do choose to have childbirth interventions are not moral agents or their decisions are not equally worthy of respect. Just as we should never force women to have medical interventions against their will, we should never denigrate the choice to have medical interventions in childbirth as merely the result of structural pressure.

Her baby, her body, her choice! And that choice includes epidurals, 39 weeks inductions and maternal request C-sections.