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Once more on medicalisation: exploring the relationship between childbirth

experiences and early motherhood in East London by Deborah Talbot

Abstract

The medicalisation thesis argues that medical science has diminished people’s ability

to cope with pain, suffering and death (Illich 1976). In the arena of childbirth,

medicalisation is seen as disempowering women to the extent that they struggle with

the challenges of motherhood (Oakley 1979, 1980). This article will explore the

medicalisation thesis as applied to childbirth, through data arising from qualitative

interviews with mothers in Walthamstow, East London. It will argue that childbirth

matters for women, and the way in which they give birth – whether it is highly

interventionist or not, whether they feel in control or not - has long-term

consequences for their emotional, psychological and physical health, their

relationships and their babies. It will also propose that various localised systems of

support are key to women’s adjustment to motherhood, whether they have had

traumatic, difficult or good births.

Keywords: iatrogenesis, traumatic, natural childbirth, post-natal depression,

community.

Introduction: childbirth and the transition to motherhood

Carrying, giving birth to, and caring for a child is still one of the biggest

transformations for women, in their lifestyle, movement, physical constraint,

identities, sense of self and emotional scope (Elliot et al. 2009, Thomson et al. 2011).

Wolf (2001, p.5), for example, talks about the experience as one of death and

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confronting ones mortality, whether this is the death of a former self and mourning for

its loss, or the actual biological memory of the strong association of death with

childbirth; in short, women are confronting the 'deepest questions possible'. Cusk

(2002) focuses on the sense of (or actual) subjugation experienced by new mothers, an

experience that Stadlen (2007) argues we are unprepared for. While in previous

generations, women were groomed for childrearing, or perhaps more generously were

around, and were expected to care for, babies from an early age, many contemporary

women in the West are brought up under the guise of freedom and equality, only to

feel its absolute loss in pregnancy, birth and early childcare. Moreover, very few

women have the opportunity to be around babies and learn childrearing practices

(Oakley 1980, Stadlen 2007). Childbirth, experienced for the first time, can be said

therefore to express a sense of rupture, both in identity and in the level of suffering

and pain.

What role does childbirth play in this important moment of transition? As Oakley

(1980) rightly pointed out, the ‘medical model’ poses this question as a purely

biological one, the criteria for success being low infant and maternal mortality; to

manage this, births have become highly medicalised. Childbirth is in fact one of the

areas Illich (1976) uses to express the idea of clinical, social and cultural iatrogenesis,

meaning that medical interventions can be counterproductive for health. Illich argues

that medicalisation has implications for our ego formation, encouraging dependence

and helplessness. The woman is decentred in the medicalised birth (Martin 2001),

raising questions of the impact of this on their sense of self. This causal relationship is

of particular importance for the consideration of childbirth explored in this article.

What is the impact of the ‘medicalisation of childbirth’ on women, including their

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ability to mother? What implications are there for society in understanding childbirth

as a complicated interrelationship between the biological, psychological and

emotional process?

Seemingly we as a culture remain confused as to whether childbirth is a normal or a

medical event (Day-Stirk 2005, Scamell and Alaszewski 2012). Should labour take

place at home, in birthing centres, or in a hospital ward? Should women try and

experience pain as a developmental experience or take any pain relief going? Should

we adopt a system of planned cesareans or try and cut the overall rate of emergency

and planned c-sections? Should midwives or obstetricians dominate professionally?

What are our rituals of childbirth (Lomas 1966) and what should they be? As Oakley

noted, the concerns of the medical professions and mothers to be are different. As

already noted the former is concerned with mortality, while the mothers she

interviewed were concerned also with what she calls ‘quality of life’ issues, meaning

their emotional and psychological wellbeing. Teijlingen (2005) also notes the

confusing divergence between what he refers to as the ‘medical’ and ‘social’ models,

ones that do not address one another. Midwifery sits uneasily between these divergent

concerns, and indeed, as Teijlingen (2005) points out, opinion lies on a continuum

between the two positions.

More recently the medicalisation thesis has found its way back into sociological

discourse after some years of absence (Coxon et al 2014), through a critique of the

concept of risk and risk management (Scamell and Alaszewski 2012). Again while the

medical model seeks to eliminate risk, in the course of which interpreting it as purely

physical risk, there is a case to question risk in childbirth as more diverse and

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inclusive of concerns such as the emotional and psychological wellbeing of the

mother, the father, both parent’s identity transitions, and the baby and his or her

development. This latter thought has more in common with what Breen (1975, p.25)

describes as a 'bio-social' approach (see also Rossi 1977), that pregnancy and birth

and all it entails marks a women's development, much as adolescence does. Reiger

and Dempsy (2006) also address the ‘crisis’ of childbirth in our risk adverse culture.

They refer to childbirth as a ‘biopsychocultural’ moment, and, in perhaps what is a

reference back to Illich, suggest that birthing can be understood as performance, one

that requires overcoming challenges (for example, the psychological nature of pain)

and which requires support to do so. Risk therefore is more ambiguous than the

medical mode suggests and can be judged from different and competing perspectives,

with medicalisation posing its own risks for the woman, including physical ones

(Martin 2001, Rothman 2014). It suggests a need to understand childbirth in all its

biological, psychological and emotional complexity.

The symbolic and emotional importance of the birth has been indicated in several

research studies. Dahlen et al (2010), for example, in their research with first-time

mothers, found that women themselves felt that childbirth was a significant moment

and that they felt empowered or disempowered depending on the type of birth they

had had. Storytelling about their birth helped to both facilitate social networks and

resolve their feelings about the birth (Callister 2004). Simkin’s (1991, 1992, 2006)

research found similar distributions of satisfaction and dissatisfaction that were

related to feelings of empowerment and control, and argued the role of the caregiver

was critical in the kind of birth women experienced (Eames 2004, Baker 2010). Not

surprisingly perhaps much research has focused on negative experiences of birth and

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the impact of depression or trauma for women (Fenech and Thomson 2014). The

inclusion of ‘birth trauma’ might require some comment, as its consideration is fairly

new, as most psychiatric problems following birth are classified as post-natal

depression (Birth Trauma Association 2014). Birth trauma is not considered a

distinctive psychiatric condition from post-traumatic stress disorder, and the Birth

Trauma Association (BTA) considers it a normal reaction to a ‘threat of death or

serious injury’ to themselves or others (that is, their baby). Symptoms might include

nightmares and flashbacks, cognitive difficulties, avoidance of stressful situations,

anxiety and depression (BTA 2014).

Fenech and Thomson (2014) conducted a thorough review of the trauma literature and

found that birth trauma had long-term consequences for women’s sense of self and

their relationships. ‘Birth trauma’, they argue, ‘changes women forever as their past,

present and future selves become lost ideals’ (p.191). Birth trauma is linked feelings

of losing control, problems with bonding and relationships, struggling with feelings of

failure, and these feelings are generally linked to medical intervention of some sort:

having a hysterectomy following birth (Elmire et al. 2011), a C-Section or operative

vaginal birth (Gamble and Creedy 2005, Fenwick et al. 2009, Herishanu-Gilutz et al,

2009, Birthrights 2013). But they can also be linked to generalized self-reported

negative experiences (Waldenström 2004, Stadimayr et al. 2006, Mercier et al. 2012)

or what Simkin (2006) perhaps describes as feelings of dissatisfaction, which might

not be associated with specific medical interventions but a lack of support.

Less researched seemingly is the impact of trauma on babies. So far it has been

understood that a traumatised mother may experience bonding and attachment

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problems (Steen et al. 2013), leading to an emotionally negative impact on the baby.

Cassels (2013) found that empathy was lessened in children born in hospital and

under epidural, although the reasons for that not established. Emerson (2001),

however, reporting on his therapeutic work with children of birth trauma, found that

trauma produced babies prone to crying, with poor feeding, restlessness, and

resistance to touch. Children who had had traumatic births had feelings of incapability

and neediness. Like practitioners in the profession of osteopathy (Rosen 2014) and

psychotherapy, it was discussed as a separate trauma to that of the mother.

Feelings of power and control seem central to women’s experience of the birthing

process. Dana Breen’s (1981) case study of Barbara, illustrated the processes by

which women become disempowered and how differently women feel when they are

in control; this has long-term consequences for how they feel as mothers and how

they feel towards their children. Early research, such as that conducted by Breen and

Oakley (1980) very much located feelings of powerlessness as being a product of the

‘medical model’ of over-intervention making decisions for women, with women

feeling as either ‘victims’ or ‘victors’. Did they relinquish control to doctors (and

midwives, under the chain of command of medicine) or were they triumphant over

labour? That Scamell and Alaszewski (2012) found in their research that the process

of birthing was dominated by risk-assessment so that midwives were ‘unable to

articulate and defend normality' (p.210) is alarming, and illustrates how the medical

model is reframed in the contemporary context as a struggle to define what is normal

(Gould 2000). Kehily (1914) reported that in her research on modern motherhood,

women were preoccupied by risk and safety in childbirth and therefore felt unable to

make autonomous decisions. Naomi Wolf’s personal account of her two births is

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instructive, however, in that is not so much the level of medical intervention –

because both her births ended in C-Sections - as the feelings of control and respect

shown throughout that was important.

In popular narratives it has been argued that women have too high expectations of

their birth, encouraged by birth plans. However, Cook and Loomis (2012) conducted

research on the influence of birth plans and whether these constructed impossible

expectations, and found that it was not so much that birth plans were altered in the

birth, but the degree of change from the plan and how much women felt in control of

the decision making were critical in terms of how much women felt disappointed and

affected by their birth. Again, it was not so much that women experienced medical

intervention; rather it was how this was done and whether they felt in control and

treated with empathy and sensitivity. This tallies with recent thinking about respect

and dignity in childbirth as being more important than setting up a dichotomy

between medicalised and natural births (Bowser and Hill 2010, Birthrights 2013,

McConville 2014).

From the literature therefore we know that experiences of childbirth has a

psychological and emotional impact and needs to be considered as a complicated

interrelationship between the biological, psychological, emotional and socio-cultural,

although here there is much research yet to be done. What is missing is a need to

make a connection between childbirth as a symbolic event for the mother-to-be and

the experiences of first time and early motherhood (that is their recollections of the

first years of their children’s life)? It is this causative relationship that adds weight to

the need to rethink the role of medicine within childbirth, gives it social import, and

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brings into focus Illich’s more radical and wide-ranging critique of the impact of

medicine on the ego. The research that forms the basis of this article is based on a

small sample, and makes for an uneasy elucidation of causation (much like the

challenges faced by Oakley over three decades ago). It aims to point the way to the

need for further research to be done.

Methodology

The research on which this article is based was a sample of twenty-seven women and

mothers in Walthamstow. The original aim of the research was to explore mothers’

feelings about risk-taking in their children’s lives. Because of the author’s own

experience of birth trauma and the transference of anxiety onto ones offspring

however, a substantial part of the interviews and findings focused on women’s

pregnancy and birthing experiences, how this prepared them for motherhood and they

way they negotiated fears and perceptions of risk. Because the research connected the

experience with the aftermath in this way, the causative relationship between birthing

experience and motherhood emerged from the women’s own narratives. In order to

assess the likely impact of other causative influences (such as work and life stresses) I

also asked the women about their months of pregnancy. Also important were the

women’s narratives about themselves, their identity and view of their own

personalities. It should be borne in mind that establishing causation between birthing

experience and motherhood is a multi-causal struggle (Oakley 1980), yet in many

ways my own findings seemed to starkly represent a causal relationship particularly

when ‘good/great’ births and traumatic births (Simkin 2006) were considered. My

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own data however, should be seen as a small sample; one that points to the need for

more research and policy change.

The mothers were selected on the basis of whether they had children under five.

Oakley (1980), Simkin (1991), and Dahlen et al. (2010) have all argued that the first

birth is the most significant moment of transition in women’s identity as a mother.

Although many of the women interviewed had more than one child, it was perhaps the

first that remained most significant in their stories. For many of the women

interviewed there was a significant gap between the first birth and the interview, and

research has suggested that while women do retain long-term memories of childbirth

they are more fluid and detailed when nearer to the moment of birth (Simkin 1991,

1992, Talbot 2013a). It was certainly the case in this research that those women who

had given birth more recently focused more on the pregnancy and birth than mothers

who had older children, but stories of birth were nevertheless very present.

The research took a person-centred approach to the women’s narratives (Miller 2005),

that is, non-directive, participatory and respectful of women’s expressed subjectivities

that replicated the way that women wanted to talk about their births (Callister 2004,

Dahlen et al, 2010, Talbot 2014). The sample was drawn from online networks local

to Walthamstow, such as Walthamstow Parents Online (one that I had set up and now

discontinued) and the Facebook site WFParents (a pseudonym). Drawing a sample

from online networks is commonly seen as limiting representation. However, broadly

the sample consisted of the working middle-classes and working-classes (and

arguably there is not much distinction between the two in a high-cost area such as

London), the sample was fairly ‘international’. All had settled in Walthamstow and,

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bar one, had been there a fairly long time. Two of the sample had lived in

Walthamstow but had then moved to Chingford and Highams Park (about 10 minutes

drive but culturally very different). Who wasn’t represented? The urban poor and

marginalized, most definitely, and also the most wealthy, but that doesn’t alter the

relevance of the causal relationship examined (Oakley 1980, Ribbens 1998). It is a

point to be observed and to define the scope of future study. Ethical approval for the

research was granted by the Open University’s Human Research Ethics Committee.

Volunteers were sent an information sheet and consent form. About a ten potential

participants did not respond after this point. Participants were sent a report of the

analysis and invited to comment, and were invited to attend dissemination events.

Thus the research adopted the technique of respondent validation. However, while the

women said that they had enjoyed reading about the research, and some even talked

about emotional catharsis, none raised questions or reinterpretations of it, so there

were limits in terms of a validation method (Barbour 2001). Participants were offered

a nanny, and about half of those interviewed took advantage of this, often expressing

relief at having been given a break. As Holloway (1998) and Talbot (2013b) found,

geography is important in the formation of social attitudes. That the sample was

drawn from the London locality of Walthamstow and its locale was important

particularly in understanding networks of support available to women.

The research is also biographical (Ribbens 1998). The idea for researching in this

field, and the rationale for the questions I have asked, arose from my own birth

trauma, which was a long and disastrous induction followed by emergency C-Section,

and preceded by medical problems in my pregnancy and work-related stress. This has

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implicated the research throughout in an outsider/insider dilemma often presented as

an ethical conundrum for research with regard to ethics and validity (Kvale 1995). I

am close to the story some women are telling, so naturally narratives of trauma both

attracted my attention and engaged with my own story (although I was the only one

who had had multiple traumas of life, pregnancy and birth). Yet is was also

illuminating and inspiring to hear stories of the ‘good’ birth (Simkin 2006), and

comparing the two both led to personal revelations and research insights. My own

experience and the emotional ‘soaking’ I re-experienced with every interview and

analysis of the interviews dictated the presentation of the research as somewhat

emotionally engaged. I have through this research entered the terrain of what

academia likes to call ‘public engagement’, by working with the dignity and rights

activist group Birthrights, which has stimulated further critical reflection. I would take

the view therefore, like ethnographic thinkers such as Becker (1967) and Hammersley

(2000) that partisanship can enhance research and scholarship, if those perspectives

are made visible.

A note on terminology: I have referred to traumatic births as those who reported that

they experienced trauma and that it had had noted consequences. On the other end of

the spectrum I have referred to women who had ‘good’ births, those who reported

their births using words such as easy, without problem, short, and that it felt

empowering in some way. That does not mean they did not experience some

problems, particularly the home birthers where only one said they had supportive

care. Like Oakley’s (1980) findings, the numbers of women experiencing the good

birth were few, with the majority encountering some sort of difficulty either with the

process of birthing itself or the support available. Somewhere in the middle I have

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referred to the women who problematized their birth in some way. They lie on a

spectrum but did not identify themselves as having experienced birth trauma as such;

mostly they pointed to the problems that they had experienced, that it was emotionally

troubling and that it had had some impact on the way they thought about motherhood.

Other had what might be described as natural births but they were interfered with in

some way perceived to be ruinous (for example, being transferred from a birthing unit

to the labour ward at the last moment). This in some way correspondents to Simkin’s

(2006) distinction between good, great, disappointing and traumatic births, but is

probably more messy that this. Often the interpretation of ones experiences depended

on the presence of some kind of political thinking about it.

The presentation of data has been grouped into three substantial areas. Firstly, that

there was a considerable rupture in narratives of pregnancy and birth. In addition,

there were significant differences in the narratives of women who had experienced

trauma and those that had experienced the ‘good’ birth. Second, the birthing

experience had significant consequences for feelings about motherhood and for

babies, in the women’s accounts. Third, that support is critical although it should not

be only articulated in terms of support by the medical profession; support can be

thought about as medical, familial, and community-based. The conclusion will reflect

on the findings both in terms of understanding the importance of labour as emotional

and psychological, as well as physical, and that this has consequences for

understanding the social relevance of childbirth.

Research findings

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Narratives of pregnancy, birth and trauma

Nearly all interviewees, although there are some exceptions, said that their

pregnancies were good and enjoyable, regardless of the aches, pains and sickness.

This was regardless of whether the women had self-disclosed birth trauma. As is

common, many of the women had had second pregnancies by the time they were

interviewed, and women often reported being less fascinated and more tired than with

their first. Here some of the women describe their first birth:

...It felt like quite the natural thing to be pregnant and to be expecting him and the

pregnancy was fine, was quite exciting, fascinating to be pregnant...(2 home births,

both natural deliveries).

...The pregnancy was ok, I was quite sick for the first 3 months and then I was fine. I

had quite a lot of back problems though...(First birth back to back – where the back of

the baby’s head is facing the mothers spine causing greater pain, long labour,

ventouse and forceps).

...it was quite fun I thought, yes I mean I enjoyed, I slept badly and got a really sore

back and all those things but I still really enjoyed it, yes for me it was just really a

positive experience...(birth by induction and forceps, broken coccyx – tailbone - and

bladder trauma).

It is interesting that the women felt that despite the normal problems associated with

their pregnancies, it was felt to be an enjoyable and interesting experience. This

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contrasted with narratives of birth. Many of the women I interviewed described the

birth in fairly extreme terms. The following was typical:

...had a homebirth with my first child but it was a very, very traumatic labour and

delivery and that was very difficult, it felt like I had been kidnapped and tortured

basically for 24 hours...(Mother who had two home births, both natural deliveries,

and the first had felt unsupported).

...it’s like you feel like you’ve been through a car crash, you feel like, you know,

you’ve been run over by a truck because you’re absolutely exhausted, physically and

emotionally.. (Mother who had an induction after being ten days overdue, baby

delivered by ventouse).

...I think I was the palest I’ve ever been in my life and it just wasn’t myself at all. I

remember one of my first trips out, and just feeling really vulnerable...and like, I’ve

got to go home now, like the world was just too much. Urm, I think I was, yeah,

physically really broken...(Mother describing traumatic first birth ending in C-

Section).

The language used by the women was very powerful and extreme - car crash,

kidnapped and tortured, broken – and suggestive of a severe rupture. Obviously birth

can feel like quite an extreme experience, physically, psychologically and

emotionally; one associated with great change and as already noted (Wolf 2001)

difficult feelings of death and dying. It is possible that the strong language being used

by women to describe their birth is a symbolic representation of the transition from

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one self to another (Thomson et al. 2011, Wolf 2001) in which the birth amongst

becomes the prism for those complicated and transforming events (Kehily 2014). To

what extent though might the extreme language used by these women indicate a

cultural lack of orientation to the realities of childbirth, or a reaction to

medicalisation?

In the cases where births had been reported as either traumatic or ‘good’, there were

alternatively very strong negative and positive feelings about the birth and it seemed

related to the degree of medicalisation. It is worth reporting on numbers here,

although as a small-scale qualitative study this can be by no means generalized. Self-

reported traumatic births – by which I mean they were referred to as traumatic and

were seen as having lasting consequences - accounted for three of those interviewed.

Those who had reported (on the whole) ‘good’ births accounted for six of the women

interviewed (and three of those were home births). The following are some examples

of the traumatic and good births viewed through the prism of medicalisation or its

absence:

…I felt like I’d been tortured…I had a failed induction that lasted 4 days, a failed

epidural [anesthetic injection in the back which stops pain from the back downwards]

so I couldn’t walk, repeated and painful cannulas [a tube inserted by needle into the

body to deliver medicines and take blood], ended by an emergency C-Section…they

just did every medical procedure going..(Induction, emergency C-Section).

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...in the end I gave birth naturally, so it was very painful beforehand, but then

afterwards I felt very good, fantastic, I just recovered within a few days...(Long labour

and gave birth in high risk department).

...It just seemed like the thing to do, so I did. And it, it was nice, I felt afterwards sort

of powerful... I felt that I’d done something really powerful, and wonderful, and she

was so alert when she was born, I knew I’d done it right (Home birth, natural birth).

These are just examples of the narratives used. In general, women expressed the idea

that ‘autonomy’ (being free from interference) and control allowed them to have

better births. Both Breen and Wolf write in different ways about how women can

experience a better birth second time around by being able to exercise more control,

even in the outcome may or may not result in a vaginal delivery. This is expressed in

the mother’s accounts:

...he, it was a vaginal birth, and it was great...I pushed and pushed and pushed, and

out he came, and I was just like so proud of myself. Ah hah you don’t know anything,

I mean obviously they were brilliant and everything, but it was just like feeling so

triumphant. ... I could feel him coming out, it was amazing, you know, it really was. I

felt so good (Mother discussing second birth by vaginal delivery after first with

forceps).

...I felt really empowered, going through labour and getting fully dilated, and trying

to push him out... I feel really proud of myself for urm, for going through all that kind

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of thing...(Mother discussing birth of second child, which because he was too large

ended up in a C-Section).

From these accounts having a vaginal birth was an aspiration and associated with a

sense of achievement. The women who sat on the ‘extremes’ mostly experienced

good first pregnancies but their feelings about birth differed. With some exceptions

(for example a diabetic mother who could not avoid intervention as the birth had to be

highly managed), this depended on whether their birth had been highly medicalised or

not. For those that experienced good births, it is interesting that the language

corresponds to the sense of power and self-determination summed up in Oakley’s

(1980) depiction of her interviewees as ‘victors’ who had triumphed over their labour.

For the majority however, the experience was narrated as problematised but not

described as traumatic, with some key points highlighted as particular problems.

These included:

• Questions over the necessity of inductions

• Over-monitoring, internal examinations, forced labour on back

• Pain relief pushed on them and not explained, or denied

• Being turned away from the labour ward despite very long labour at home

• Being subjected to stressful transfers from birthing units to labour wards

• Unsympathetic home birth midwives

• Variable midwife care

• Consultants lacking in empathy

• Being turned away from ICUs

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• Poor communication (lacking in empathy)

• Awful post-natal experiences: bad environments and told to shrug off

experience

• Woeful post-natal care in the community

• Ignorant health visitors

• Untreated physical and emotional scars

That so many women described problematic experiences described above is troubling.

While one might expect childbirth to be physically shocking as has already been

explored, many of the comments relate to an absence of ‘dignified’ care, which has an

association with medicalisation as an concept (Birthrights 2013). Most of the

complaints listed here pertain to issues of poor communication, risk assessment and

the birth environment, issues that the dignity campaigners have highlighted as issues

and indeed midwives are themselves aware of, and which pertain to the neglect of the

critical emotional, psychological and symbolic importance of birth for women

(Birthrights 2013) and the importance of control (Oakley 1980, Fox and Worts 1999).

The responses are also concerned with the birth environment, and, although not a

dominant theme of the research, women who birthed at home (with a supportive

midwife), in birthing centres or even in one case a high-risk unit, had a better

experience than those in the labour ward. All had poor experiences to relay of post-

natal environments – including a lack of support, noise and a lack of privacy, poor

breastfeeding support, and the imposition of traditional visiting hours – that added

insult to injury for those forced to stay longer because of surgery.

The impact of birthing experiences on early motherhood

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Assessing the impact of birthing experiences on motherhood – meaning ones identity

transition, emotional and psychological stability – has an uneasy causation as has

already been noted. In many ways Oakley’s (1980) study wrestled with this

empirically in a way that has not been replicated since. In many ways ones birthing

experience is a product and springboard to a range of contextual issues, from

relationship problems to mental and physical health prior to pregnancy (Thomson

2011). Is it absurd therefore to pinpoint the experience of childbirth as central?

However to claim difficulties of causation and complexity is to deny the importance

of women’s subjectivities in terms of the relative importance they give this moment,

because ‘for most mothers childbirth is not a trivial event’ (Oakley 1986, p.2) and as

Simkin has argued (1991, 1992) memories of childbirth alongside its perceived

importance are retained long after the birth, and into older age. This perspective came

out strongly in the research findings.

In the narratives of the women interviewed a fairly familiar pattern emerged of a

relationship between traumatic or difficult labours and negative psychological and

emotional consequences including their adjustment to motherhood. That is, they

struggled with some aspect of motherhood, whether this was having an unsettled or

colicky baby, residual feelings of trauma or suspected depression, feelings of failure,

fear of not bonding well. Perhaps significantly for this study, some reported feeling

more feelings of anxiety about their children. Some said they wouldn't consider

having another child after the experiences they'd had (Fenech and Thomson 2014).

The following were typical of all of these points:

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… I think I had a lot of unresolved stuff though about perhaps feeling that I’d failed,

or, urm, that if only I’d, if only I’d tried harder, or, or done it better, that I would

have had a normal delivery (Mother describing aftermath of birth which was painful

labour, C-Section and hemorrhaging).

…I had extreme anxiety and I think what was post-traumatic stress…I no longer knew

who I was, what I’d been, that I was competent and capable. I kept on saying that I’d

died, I’d died…I didn’t know why no-one could understand me...it was like my mind

was a thousand pieces of glass littering the floor…(Range of medical procedures

under induction and emergency C-Section).

...I felt like my body had let me down…(Induced at 10 days overdue).

Central to some of these points are a sense of disassociation from their bodies and

their identities, and strong feelings of failure.

Significantly mothers who had had a C-Section or instrumental birth were more likely

to report that their babies were colicky or unsettled (Emerson 2001) and many sought

help from cranial osteopaths:

...the weeks afterwards I felt he was really unsettled, I think a lot of people think that,

everyone talks about colic don’t they, but he was, he really cried a lot and I think that

was to do with the ventouse...(Son born under induction).

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Those who had had in their eyes good births tended to find the transition to

motherhood easier: better adjustment to the new identity, easy babies, easier to

maintain some connection to their old mobility and lifestyle. One mother for example

talked about the impact of giving birth in hospital in 20 minutes and a fairly short

labour:

I always felt that having such a easy positive start made the first few weeks so easy...

We weren’t really, I mean we were tired because we had a baby crying all night, but

it seems to be a different level, and you know, we tried in those first couple of weeks to

do all the things that a lot of the milestones, like going on the tube with her, and going

in the car, and both of us driving with her in the back, so it was done, and we were

ready for the next bit. And then B went back to work, you know it wasn’t a big deal to

get on the tube, or it wasn’t a huge thing. I mean it still is, 'cos the logistics of getting

a baby between feeds and nappy changes and sleeps and bags and you know,

suitcases load of stuff you carry around into the car is still a mission. But it’s the

mental block of doing its gone... she’s been a very, very easy relaxed kid. And I think

I mean you don’t know, one plays against the other, but it certainly helps.

Here the mother makes strong interconnections between the short and unproblematic

birth and her own sense of fearlessness, confidence, strength and vitality, and also her

babies personality and her sense of being bonded to her. This sense of confidence was

also reflected in the other mothers who had had ‘good’ births. Two of the mothers

who had had good births commented however on their sense of exclusion from the

dominant narrative of trauma:

  22  

I’m the woman who has to keep her mouth shut to be honest with you. Utterly

uneventful, on both fronts …its difficult to explain but you know, you know, you don’t

want to be the smug one... I think when women are vulnerable, in those first few

months after having a baby, you don’t really want to go on about how great your life

is. Cos you don’t want to detract from the fact that they’re having a crappy time and

they need to get it out you know…(women who had had two relatively easy births)

... none of the kind of horror stories really. Urm, which then made me feel a bit

guilty. I remember I went to one parent group, we lived in Hackney when he was

born, and was kind of, just felt quite excluded because I didn’t have a blood, guts and

gore story to say...I feel like, there’s a lot of assumed, people assume negativity, all

the kind of default discourses were negative ones. And actually that hasn’t been my

experience...and then finding that a little bit excluding, so that was the kind of only

weird thing. Urm, which probably meant that I just hadn’t really bothered with

parenty groups and things like that…(Two home births)

These two women had had uncomplicated and in the words of one ‘great’ births, and

both felt a greater sense of ease, enjoyment and relaxation about being a mother.

However, they also felt excluded from, or unrepresented in, mothering communities.

It is possible that as outlined in the literature above birth tends to be interrogated

through the prism of trauma and understanding birthing through the lens of the good

or great birth (Simkin 2006) is equally important for understanding how birthing

impacts upon motherhood.

  23  

Understanding that there is a relationship between the good birth and an enjoyment of

mothering does not mean to say that traumatic births always lead to a problematic

outcome. In many ways, those that had traumatic stories to tell had also spent a great

deal of time reflecting on aspects of parenting, love, bonding, and how they are

raising their kids. This is also true of some of the mothers that had easier births. I

would argue that whether ones birth was traumatic or not, this kind of reflection bode

well for their relationship with their children; far from trauma threatening the bonding

process, the shock of it may well prompt deeper thought about ones actions, self,

identity and relationships. This sits with, for example, Breen's thoughts about

motherhood being part of a process of development (Breen 1981). Those open to

reflecting on it, or it was in some way facilitated (Simkin 2006), ultimately had more

settled sense of selves, and relaxed relationships with their children.

One way this process of reflection was revealed was through dreams. As Breen (1981)

outlines, dreams are revealing during pregnancy and its aftermath. Wolf also argues

that dreaming 'seems to prepare the pregnant woman for motherhood' (2001, p.125);

the dreams consist of fears of neglect and a lack of care towards the baby, of losing

them accidentally. In this research, dreams assisted in not only understanding what

motherhood was, but also in the recovery process itself. One mother had this to say

about her dreams:

...I had many dreams about my daughter when she was first born. Many were about

me leaving her somewhere because I was preoccupied, ones where I was not paying

attention to her very frequently and she turned into a fax image or a doll. I think I

understood after that that unless I poured myself in her, physically and emotionally,

  24  

she wouldn't grow. She has turned out to be very high needs [spirited] so I suppose

that is true. I also had a dream that she crawled back up the birth canal and then was

rebirthed, if you like [this mother had had a traumatic birth ending in C-Section].

Oddly it was odd that it was only after that she felt like mine, and I felt a lot better.

Often the greater soul searching involved provoked political involvement, a career

change or a resolution to stand up to medical staff for later births (Zadoroznji 1999,

Wolf 2001). This process might also be a reflection of the specific locality this

research was conducted in. Walthamstow in the interviews was noted as being more

left-field, community-orientated, with high levels of attachment parenting techniques

and breastfeeding in the mothers interviewed, regardless of their social class

(Holloway 1998, Talbot 2013). The specific location of this research illustrated in fact

something very important about the birthing process and the post-natal healing

process: the importance of support.

The critical importance of support

Critical to the experience one has in the birthing process, or afterwards whether this

be recovering from a traumatic experience, trying to breastfeed, trying to learn how to

care for ones baby and adjust to motherhood, is support (Baker 2010). However, the

nature of this support merits further exploration. Research in midwifery journals for

obvious reasons has focused on what midwives should or should not be doing (Eames

2004, Hunter et al. 2008, Lyburg and Severinsson 2010). However, if we consider that

birthing has not just physical but a broad ranging lifestyle, emotional, psychological

and identity transformative consequences for women, are midwives really able to hold

  25  

this in its entirety? This research in fact suggest that they do not need to (Baker 2010)

albeit how they are is important (Lyburg and Severinsson 2010). As outlined above

women did tend to reflect on the attitude of their caregivers but these were largely

concerned with the need for minor adjustments of behaviour and communication;

small acts of kindness in terms of practical and emotional support (Wolf 2001,

Birthrights 2013) were remembered and noted by the women interviewed:

...they were saying I’m sorry sweetie, come on, we’ll just you know, stroking me,

because I felt like a child. I said I have no strength any more, I just you know, I was

just so fragile basically. And what they did, they looked for an Italian nurse in the

hospital, to basically come and give me a bit of comfort.. (Mother who was herself

Italian, describing her experience of midwives in the high-risk department).

….Because I had a C-Section my milk took 6 days in the end to come on fully. There

had been a lot of fussing in the hospital with positions and so forth, which was very

stressful, but once I got home and was expressing a bit but not feeding, a midwife,

very experienced she was, just gently told me I needed to sit up more so my boobs

would be in a better position. It worked, I was so happy I cried and thanked her

profusely. I still get tearful now when I think about that, she doesn't know what that

meant to me...(4 day induction and C-Section).

The fact that women remembered these small acts of kindness suggest that emotional

care is critical to the birthing process (Prochaska and McGuinness 2014), and these do

not need to be extraordinary. However, the women interviewed also noted the crucial

importance of a female presence (Odent 1999, Pascali-Bonaro and Kroeger 2004),

  26  

supportive partners, the presence of their family or friends after the birth, and

critically the very organized and widespread parenting networks of Walthamstow,

whether it be NCT groups, online forums, friendship groups from parks and

playgroups (Talbot 2013), to their experience of birthing and its aftermath. There

have been massive social changes and dislocations to traditional family and

community networks in the UK, and it is often expected that institutions will bear the

burden of those transitions; however, this research illustrated that networks can be

formed in spite of the fragmentations of family and community (Talbot 2013). The

purpose of social support in this respect was that it allowed for non-judgmental

reflection; and it was certainly the case that, whether women had a good, a difficult,

or a traumatic birth, processing the experience with other supportive mothers had had

positive impacts for them and their relationships. It is equally concerning therefore

that two women who experienced a ‘good’ birth experienced a sense of dislocation

from other mothers.

However, the research also found that there were connections between networks and

being ‘middle-class’ and/or British. As Oakley argues of class it is notoriously

difficult to define in the context of conducting research on attitudes and behaviours,

and this is particularly so on the London context (Talbot 2013). However, those with

less money could not necessarily access support networks such as National Childbirth

Trust antenatal classes and groups, and other kinds of support, such as doulas (paid

birthing advocates) and alternative therapies. Critically resolving problems such as

tongue-tie that significantly impacts upon ones capacity to breastfeed often required

private assistance because NHS waiting lists were too long; eleven women had babies

with tongue tie, a few more who had problems breastfeeding that might have been

  27  

related. Not all could afford the private medical fee to get their babies tongues

clipped.

It was noteworthy that those interviewed who had migrated from another country felt

less connected to the community than English or Irish interviewees, particularly if

they had come from very close-knit communities and families. Important also were

the absence of therapeutic groups (Stadlen 2007); only one interviewee sought help

from a therapist for her traumatic experiences. Yet research shows that women do

have a need to talk about their birth story (Callister 2004, Baxter et al. 2014). It seems

urgent to consider the kinds of support mothers, fathers, midwives and other medical

personnel might need in order to be able to fully engage with the emotional and

psychological significance of childbirth and allow them the space to process their

experience.

Conclusion

In summary, this research has demonstrated that from the standpoint of women’s own

narratives about their births and lives as mothers, there exists an important and under-

explored relationship between childbirth and experiences of motherhood. Those who

had traumatic births, whether they expressed it in those terms or not, tended to

struggle more with aspects of motherhood, whether this be strong feelings of failure

or cognitive dissonance, than mothers who had had the ‘good’ birth.

The research also demonstrated the critical importance of support, and the time and

space to reflect on ones experience, as significantly affecting the long-term outcomes

  28  

of experiences of motherhood. In addition, the kind of birth one has is related to the

degree of medicalisation on the one hand, and feelings of control on the other,

particularly where there has been either a good birth or a traumatic birth. However,

women can be offered a sense of control even when medical intervention has been

high. Further, that many women cited issues of lack of respect and ‘dignity’ as being

important.

This is suggestive of the need to consider childbirth as a complex interrelationship

between the biological, the psychological and the emotional, and one that has

profound social effects where these matters are not considered. Women’s sense of

themselves, their emotional and psychological health, and their relationships can be

significantly affected by the kind of birth they had. Similarly, the social, meaning in

this case social and community support, can aid the process of healing and the

transition to motherhood.

While there have been important strides made recently in terms of reflecting on the

relationship of childbirth and post-natal depression and trauma (Fenech and Thomson

2014) and attempts to find a new language of care in the concepts of respect and

dignity (Bowser and Hill 2010, Birthrights 2013, McConville 2014), more needs to be

done to, not just reform, but revolutionise the way we think about birth.

Acknowledgments

To Nicky McGuinness, who conducted a review of a range of midwifery literature

included in this article, funded by the Centre of Citizenship, Identities and

  29  

Governance (CCIG) at the Open University, and to Elizabeth Prochaska of

Birthrights, who is making a stand on respectful care.

References

Baker K. (2010). The importance of effective support during childbirth. British

Journal of Midwifery, 18, 10, 665-668.

Barbour, R.S. (2001). Checklists for improving rigour in qualitative research: a case

of the tail wagging the dog. British Medical Journal, May  5,  2001,  322(7294),  

1115–1117.

Baxter J.D., McCourt, C. and Jarrett, P.M. (2014). What is current practice in offering

debriefing services to post partum women an what are the perceptions of women in

accessing these services: A critical review of the literature. Midwifery, 30, 2, 194–

219

Becker, H.S. (1967). ‘Whose side are we on?’ Social Problems, 14, 239-47.

Birthrights (2013). The Dignity Survey 2013: Women’s and midwives experiences of

UK maternity care. London. Birthrights.

Birth Trauma Association (2014)

http://www.birthtraumaassociation.org.uk/what_is_trauma.htm Accessed 28th March

2014.

  30  

Bowser, D. and Hill, K. (2010). Exploring Evidence for Disrespect and Abuse in

Facility-Based Childbirth: Report of a Landscape. USAID_TRIaction Project,

Harvard School of Public Health.

Breen, D. (1975). The birth of a first child. London. Tavistock publications.

Breen, D. (1981). Talking with mothers, about pregnancy, childbirth and early

motherhood. London. Jill Norman Ltd.

Callister, L.C. (2004). Making Meaning: Women’s birth Narratives. Journal of

Obstetrics, Gynecology and Neonatal Nursing, 33, 4, 508-518.

Cassels, T.G. (2013). The long-term effects of birthing interventions on childhood

empathy. Midwifery, 30, 4, 471-5.

Cook, K. and Loomis, C. (2012). The impact of choice and control on women's birth

experiences. The Journal of Perinatal Education, 21, 3, 158-168.

Coxon, K., Sandall, J. and Fulop, N.J. (2014). To what extent are women free to

choose where to give birth? How discourses of risk, blame and responsibility

influence birth place decisions. Health, Risk and Society, 6, 1, 51-67.

Cusk, R. (2002). A life’s work: on becoming a mother. London. Fourth Estate.

Dahlen, H.G., Barclay, L.M. and Homer, C.S.E. (2010). Processing the first birth:

journeying into ‘motherland. Journal of Clinical Nursing, 19, 13-14, 1977-1985.

  31  

Day-Stirk, F. (2005). The big push for a normal birth. Midwives, 8, 1, 18-20.

Eames, C. (2004). Midwives’ role in preparing women for birth. British Journal of

Midwifery, 12, 7, 447-450.

Elliot, H., Gunaratnam, Y., Hollway, W. and Phoenix, A. (2009). ‘Practices,

identification and identity change in the transition to motherhood’ in Wetherall, W.

(ed). Theorizing Identities and Social Action. Basingstoke, Macmillan Palgrave.

Elmire, R., Schmied, V., Wilkes, L. and Jackson, D. (2011). Separation, failure and

temporary relinquishment: women’s experiences of early mothering in the context of

emergency hysterectomy. Journal of Clinical Nursing, 21, 7-8, 1119-1127.

Emerson, W. (2001). Treating caesarian birth trauma during infancy and childhood,

Journal of Prenatal & Perinatal Psychology & Health, 15, 3, 77+.

Fenech, G. and Thomson, G. (2014). Tormented from ghosts from their past’: A meta-

synthesis to explore the psychosocial implications of a traumatic birth on maternal

well-being. Midwifery, 30, 2, 185-193.

Fenwick, S., Holloway, J. and Alexander, J. (2009). Achieving normality: the key to

status passage to motherhood after a caesarean section. Midwifery, 25, 5, 554-563.

  32  

Fox, B. and Worts, D. Revisiting the critique of medicalised childbirth: a contribution

to the sociology of birth. Gender and Society, 13, 3, 326-346.

Gamble, J. and Creedy, D. (2005). Psychological trauma symptoms of operative birth.

British Journal of Midwifery, 13, 4, 218-224.

Gould, D. (2000). 'Normal labour: a concept analysis'. Journal of Advanced

Nursing, 31, 2, 418-27.

Hammersley, M. (2000). Taking sides in qualitative research: essays on partisanship

and bias. London. Routledge.

Herishanu-Gilutz, S., Schattner, E. and Kofman, O. (2009). On becoming a first time

mother after an emergency caesarean section. Journal of Health Psychology, 14, 7,

967-981.

Hunter, B., Berg, M., Lundgren, I., Olafsdottir, A. and Kirkham, M. (2008).

Relationships: the hidden threads in the tapestry of maternity care. Midwifery, 24, 2,

132-137.

Holloway, S. (1998). Local childcare cultures: Moral geographies of mothering and

the social organization of pre-school education. Gender, Place and Culture, 5, 1, 29-

53.

  33  

Illich, I. (1976/1995). Limits to Medicine (Medical Nemesis: the Expropriation of

Health. London. Marion Boyars.

Kehily, MJ. (2014). Methods and mothers: a review of research methods for

understanding motherhood as a changing identity Birthing and Motherhood Seminar

Series. Open University Camden, 29th January 2014.

Kvale, S. (1996). Qualitative InterViews: an Introduction to Qualitative Research

Interviewing. London. Sage.

Lyberg, A. & Severinsson, E. (2010). Fear of Childbirth: mother’s experiences of

team-midwifery care – a follow-up study. Journal of Nursing Management, 18, 4,

383-390.

Lomas, P. (1966). Ritualistic elements in the management of childbirth. British

Journal of Medical Psychology, 39, 3, 207-213.

Martin, A. (2001) The Woman in the Body: A Cultural Analysis of Reproduction.

Beacon Press. Boston.

McConville, B. (2014). Respectful Maternity Care: how the UK is Learning from the

Developing World. Midwifery, 30, 154-7.

Mercier, J., Brannigan, C. and Green-Jervis, C. (2012). The legacy of a self-reported

negative birth experience. British Journal of Midwifery, 20, 10, 717-22.

  34  

Miller, T. (2005). Making Sense of Motherhood: A Narrative Approach. Cambridge.

Cambridge University Press.

Oakley, A. (1980). Women confined: towards a sociology of childbirth. Martin

Robinson. Oxford.

Oakley, A. (1979/1986). From Here to Maternity. Harmondsworth. Penguin Books.

Odent, M. (1999). Is the participation of the father at birth dangerous? Midwifery

Today. http://www.midwiferytoday.com/articles/fatherpart.asp. Accessed 27th March

2014.

Pascali-Bonaro, D. and Kroeger, M. (2004). Continuous female Companionship

During Childbirth: A Crucial Resource in Times of Stress or Calm. Journal of

Midwifery & Women’s Health, 49, 4, 19-27.

Prochaska, E. and McGuinness, N. (2014). Researching respectful care in childbirth.

Birthing and Motherhood Seminar Series. Open University Camden, 29th January

2014.

Reiger, K. and Dempsey, R. (2006). Performing birth in a culture of fear: an

embodied crisis of late modernity. Health Sociology Review, 15, 364-73.

Ribbens, J. (1998). 'Hearing my feeling voice? An Autobiographical Discussion of

Motherhood' in Ribbens, J. and Edwards, R. Feminist Dilemmas in Qualitative

Research: Public Knowledge and Private Lives. London. Sage. 24-38.

  35  

Rossi, A.S. (1977). A biological perspective on parenting. Daedalus, 106, 2, 1-31.

Rothman, B.K. (2014). Pregnancy, birth and risk: an introduction. Health, Risk and

Society, 16, 1, 1-6.

Scamell, M. and Alaszewski, A. (2012). Fateful moments and the categorisation of

risk: Midwifery practice and the ever narrowing window of normality during

childbirth. Health, Risk and Society, 14, 2, 207-221.

Simkin, P. (1991). Just Another Day in a Woman’s Life? Women’s Long-Term

Perceptions of Their First Birth Experience. Part 1. Birth, 18, 4, 203-210

Simkin, P. (1992). Just Another Day in a Woman’s Life? Part II: Nature and

Consistency of Women’s Long-Term Memories of Their First Birth Experiences.

Birth, 19, 2, 64-81.

Simkin, P. (2006). What makes a good birth and why does it matter? International

Journal of Childbirth Education, 21, 3, 2-4.

Stadlen, N. (2007). What mothers do, especially when it looks like nothing. New

York. Jeremy P. Tarcher/Penguin.

Stadimayr, W., Amsler, F., Lemola, S., Stein, S., Alt, M., Burgin, D., Surbek, D. and

Bitzer, J. (2006). Memory of childbirth in the second year: The long term effect of a

  36  

negative birth experience and its modulation by the perceived intranatal relationship

with caregivers. Journal of Psychosomatic Obstetrics & Gynecology, 27, 4, 211-224.

Steen, M., Jones, A., and Woodworth, B. (2013). Anxiety, bonding and attachment

during pregnancy, the transition to parenthood and psychotherapy. British Journal of

Midwifery, 21, 12, 844-50.

Talbot, D. (2013a). The medicalisation of childbirth: emotion, care, coping. Research

report. http://www.parentingandtheurbanexperience.co.uk/the-medicalisation-of-

childbirth-emotion-care-coping/. Accessed 27th March 2014.

Talbot, Deborah (2013b). Early parenting and the urban experience: risk, community,

play and embodiment in an East London neighbourhood. Children's Geographies, 11,

2, 230–242.

Talbot, D. (2014). Exploring the relationship between birth experiences and early

motherhood. Birthing and Motherhood Seminar Series. Open University Camden,

29th January 2014.

Teijlingen van, E. (2005). A Critical Analysis of the Medical Model as used in the

Study of Pregnancy and Childbirth. Sociological Research Online, 10, 2,

http://www.socresonline.org.uk/10/2/teijlingen.html.

Thomson, R., Kehily, MJ., Hadfield, L. and Sharpe, S. (2011). Making Modern

Mothers. Bristol. Policy Press.

  37  

Waldenström, U., Hildingsson, I., Rubertsson, C. and Radestad, I. (2004). A Negative

Birth Experience: Prevalence and Risk Factors in a National Sample. Birth, 31, 1, 17-

27.

Wolf, N. (2001). Misconceptions: truth, lies, and the unexpected journey to

motherhood. New York. Anchor Books.

Zadoroznyj, M. (1999). Social class, social selves and social control in childbirth.

Sociology of Health and Illness, 21, 3, 267-89.