Episode 143 - Declining Medical Recommendations
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
Mel:
[0:24] Welcome everybody to this episode of the Great Birth Rebellion podcast. Today we are talking about what happens to you if you choose to decline a recommended procedure or any recommendation during pregnancy, labor, birth or afterwards. What happens when you say no to something that your care provider offers to you or recommends to you. And if you've been listening to this podcast for a while, you know that there are lots of options available to you throughout your maternity care and that despite what is usually on offer, you can choose not to accept some of the management options during your pregnancy, birth and postpartum. Women have an absolute right to choose to accept or decline any medical recommendations. There is no law stating that women have to accept medical advice, even if their preferences appear to endanger themselves or their babies. So legal and social rights are in favor of women's autonomy, and you are the authority in your decision making in the eyes of the law, but also in the eyes of hospital policy.
Mel:
[1:41] However, in reality, women experience a lot of difficulty when they decline medical care because there's a power imbalance and while on paper you have the right to decline, in reality women don't feel that it's that easy to do. So let's talk about that and let's talk about what will happen to you if you decline.
Mel:
[2:03] That's what this episode is about. and also super quick reminder that this podcast is completely free to you the listener and I thank you for being here of course while this podcast is free to you it's not free to me to provide it I love making these episodes and I will continue to do it forever for as long as people will listen but to you the listener if you've gotten something out of it anything out of this podcast and that you felt the benefits of the podcast, consider wearing the Rebellion and heading over to thegreatbirthrebellion.com and purchasing some merch. You can wear it or use it. We've got top quality totes and t-shirts, carefully selected thermal mugs and drink bottles.
Mel:
[2:51] And even if you don't use it, maybe you can gift it to your care provider, make your partner wear it, put some on your baby shower gift list into your birth bag wherever it is you're going purchasing merch is a grassroots way of supporting the work of this podcast and all the profits are reinvested into the podcast it's easy to order online and if you're overseas the international postage can be a little bit of a killer but if you order over a hundred dollars worth of merch the postage is equivalent to local postage so just grab a few extra things for your friends instead of paying the postage. And so purchasing and using podcast merch directly supports the ongoing work of this podcast and it gets the word out so more women and maternity care workers discover the message of the Great Birth Rebellion.
Mel:
[3:44] Imagine the impact of wearing a Great Birth Rebellion shirt to work if you're a care provider or to your antenatal appointments or your birth. It really sends a strong message that you are informed and ready to advocate for yourself and your clients.
Mel:
[4:00] So all the details are in the show notes below. You can purchase at thegreatbirthrebellion.com. Now let's get into this week's episode. What you might expect to happen if you say no thanks to some routine maternity care or testing or screening or treatments. What might your care provider's response be if you decline something? So what happens to you will be different depending on the place in which you're giving birth or whether or not you know your care provider. The experience will be different if you know your care provider and you are in a birth location that you have consciously chosen and it will be different again if you're giving birth in a public hospital with standard care where you don't know the person caring for you in labour. So there are definitely going to be midwives and other maternity care providers and birth workers who might feel bothered by how hard-hitting this episode is going to be. You might feel like I'm aiming this dialogue and the comments at you. Please know that my intention is to give women listening an understanding of what they're up against if they want to have a birth within the system where they are fully in control of their decisions and what happens to them. If you're listening as a care provider and feeling offended.
Mel:
[5:22] That's work for you to do that's on yourself this podcast is written with women in mind who are receiving care so there's a very good chance that I haven't considered the feelings of midwives obstetricians and birth workers as I write this I am most definitely hyper focused on what I want to share with women I won't be apologizing for your feelings in this episode if you're a care provider and feeling like this episode is too much it wasn't written for you it's written for women the other comments I'm sure I'm going to get after this episode is that I am trying to frighten women and that I shouldn't be doing it because then they'll be extra scared to come to the hospital I'm not trying to frighten women I'm trying to let them know what they are up against so if this frightens you then maybe you do have something to be scared of consider that.
Mel:
[6:15] The only motivation that I can think of to withhold this information would be because we don't want women to know this is how the system works so that we can hoodwink them at the end and they're not prepared to defend themselves. That's the only reason I can think of as to why we shouldn't share the information
Mel:
[6:32] that I'm about to give you in this podcast episode. So this episode is an opportunity for women to hear and understand the psychology and the setup of the maternity care system and understand why when you decline care recommendations a simple and straight no is often not effective and you might need other strategies to help navigate these situations particularly if you're in labor because of how the system is set up. So I'm here to tell you how the system works so that you can navigate it to get the things that you want out of your labor and birth.
Mel:
[7:11] So let's recap how the maternity care system works. And I know this isn't going to apply to everyone. You might be out there, you're planning a home birth or a hospital birth with a private midwife who you have chosen and who gets you. You might have found your way into a publicly funded home birth program or midwifery care program where you know your midwives, you might be able to access your chosen obstetrician who listens to you and respects your decisions. If this is you, you are about 30% of the Australian birthing population who have been fortunate enough to access continuity of care with a chosen care provider in a location that you have chosen.
Mel:
[7:57] But if you are in one of these models, then many of the experiences that I'm going to share today might be somewhat diluted for you. You might be protected from some of the things that I'll be talking about today on this episode, or you might not be.
Mel:
[8:13] So stay tuned because still I think everyone should be aware of the systematic way that the maternity care system works. So the number one protection for your autonomy during your maternity care is if you receive continuity of care from a known and chosen care provider hands down the research says that you are going to be the most satisfied feel the most heard feel most in control of your decisions and ultimately feel less trauma and more autonomy in your experience this episode is still for you of course, if you are the 30% of women who've managed to get access to one of these gold standard maternity care options, there are going to be strategies in here for you, but you are least likely to feel completely disenfranchised and feel the impact of what happens to women when they say no to a recommended procedure or test or screening in a hospital setting.
Mel:
[9:10] So now for the rest of you, the 70% of you who only have the option of routine maternity care through a fragmented public system where you don't know your care provider. Or maybe you do have continuity of care but you didn't get to choose who that was with. So this sometimes happens in rural locations for example where there's only one care provider option. It might be a shared care GP they could be fabulous they might not be that great and but they are only option.
Mel:
[9:42] So you are really going to want to put these strategies in place if you are the 70 percent, that I'm going to be talking about today put these strategies in your back pocket because you're the ones who are most likely to feel pushback and pressure and coercion if you choose to go against medical recommendations. So let's talk about that. How does the maternity care system work? And this is for everyone, but particularly those women who have not been able to access continuity of care. You're the ones who are going to have to advocate for yourself harder than the rest. So the way the maternity care system works is that everything is focused on efficiency, keeping the flow of women coming in and out, maximizing output, so getting the babies out of their mothers, up to the postnatal wards with their mothers, and then out the door.
Mel:
[10:41] The maternity care system is designed to streamline this process as best as possible so all the staff know their place and function and they're tasked with not only looking after you but ensuring that the system works. Now I don't want to sound crass but the way it's been described by other authors before me and you know it becomes obvious and it will become more obvious as the podcast goes on is that the system is set up a little bit like a factory and hospital systems were developed at the peak of the industrial revolution so it's no surprise that we can apply a factory-like model to maternity care systems. So in a factory there are set entry points and conveyor belts that keep the flow going and there are clear processes that occur along the line all the way to the exit point where the product leaves the factory. So in this case, the woman and her baby are the product.
Mel:
[11:43] However, what also can become obvious through this episode and for women who have experienced the worst of maternity care is that the baby is more likely to be seen as the product by the system than you are as the mother. So if you are encountering care that seems like it's not very caring, consider the possibility that your care provider is prioritizing your baby as the product, I'm using inverted commas, your baby as the product over you as the priority.
Mel:
[12:19] So as I speak here, just please know that the system is bigger than the staff. I'm not saying that individual staff work this way or even endorse the system, but the system that governs the staff, including midwives, obstetricians, pediatricians, special care nurses, all of them, that the system is set this way and they come into that. They're expected to uphold that system. And the issue with a factory-style approach to maternity care is that anyone who deviates from the set path or who wants to get off the factory conveyor belt becomes a problem. This woman now requires individual care. She's declined the standard care, the conveyor belt care. She's hopped off the usual path and now requires managing, again, adverted commas, managing differently to the women who have elected to accept the standard care that is offered in the maternity care factory.
Mel:
[13:21] Some maternity care providers love this. They love it when women challenge the system and they choose their own path. They love caring for these women because they just love seeing a woman in her power with her own autonomy. but others will get very frustrated by this and
Mel:
[13:38] they will apply resistance to your choices and your autonomy. They want you to stay on the conveyor belt, stop causing a problem, stop disrupting the factory conveyor belt, stop disrupting the system.
Mel:
[13:51] However, the law is on your side. You have a right to get off the standard care pathway but the system doesn't really have a set process to deal with this they would prefer that you took the path of least resistance and follow their path for you follow the way that their system is set up now the fundamental issue with this systematic factory approach to maternity care is that it's a one-size-fits-all model and it struggles to provide opportunities for women or midwives to individualize the care for the individual woman's needs. So midwifery programs and home birth programs and private care providers such as obstetricians and midwives can do this better because they're not part of a very fixed system. The model that they work in allows some flexibility with time and with strategy. The autonomy of the care provider is more respected. They can make decisions that are based on the woman's individual needs rather than based on the factory expectation and the conveyor belt expectation of the one size fits all model.
Mel:
[15:00] So the first point I want to make is that although legally, and even it's written into policy, you do have a right to choose or decline any option available to you within the system. But if you choose the one that goes against the usual expectation within the hospital, you will, or your midwife will, encounter some pushback.
Mel:
[15:21] Not always. Some of you are listening and thinking no I said no and everyone was cool with it you know that doesn't happen in my hospital that doesn't happen where I gave birth it could definitely be that way but I'm giving some worst case scenarios here so that at least you know that saying no won't always be easy or acceptable in a hospital setting I desperately hope it is I desperately hope that in this episode I'm completely wrong and that you out there whenever you say no or you choose to change the path of your care that your care providers are accepting and help you get everything that you want that would be amazing the problem is is that that's not reality for the vast majority of women so that's where I'm going with this episode I will definitely be talking in worst case scenarios so just be aware of that as you're thinking no that's not how it is in fact saying no is so abnormal and I dare say it's unacceptable in a hospital setting that many hospitals have a specific policy of what to do if a woman declines the recommended pathway so it's not as easy as.
Mel:
[16:39] Saying no and the midwife just going okay no problem there is actually a written process and a policy that your care provider is expected to follow in the event that you say no to something that is usual practice.
Mel:
[16:53] So just think on that for a minute. They had to write a policy of how we're supposed to care for women when they decline recommended care.
Mel:
[17:05] What that implies is that you've gone outside of the usual practice and we need a process for dealing with that. A new conveyor belt in the factory to deal with the women who chose a different path, who chose their own path. So if you don't believe me on this, you'll see a number of examples that I've provided in the resource folder for you to have a look at. So if you've been following along in this podcast long enough, you'll know that there is a resource folder which contains the research papers that I use to create every single podcast episode. It's easy to get onto. You just join the mailing list and every week you will get a link that gives you the resources for each episode. All the backlog is in there. So if you sign up, you'll get all the previous episodes resources. Resources so I've put those policy documents examples of those in the resource folder for you to have a look at but in practice it can actually be a different thing so you might read those policy documents and they're they're not bad you know they do uphold the right of women to say no and to make their own choices and you'll see that many of them have those words in there.
Mel:
[18:15] But the words say one thing and in actual reality the culture of the workplace where the care where your care provider is working often is different to what the policy might say so let's ask this question why if I say no to something is there going to be some resistance and the answer to that is that there is a power imbalance between you and the system. The hospital venue is not your territory. You don't own that. You're out of your power zone.
Mel:
[18:52] It's assumed that because you came there to have your baby that you will submit to the type of care that's been offered in that facility. There's a basic assumption that because you are physically in the building that you are a willing passenger on the factory conveyor belt.
Mel:
[19:08] And the hospital system and possibly your care provider believes deep down that they are the expert over you, that that is the best place and the safest place for you. and they'll assume that they know what's best for you and your baby. So if you choose against what's on offer, against what the experts are saying, then you're perceived as choosing the option that's not the best and not the safest. Of course, this isn't true because women are really clever and very capable of making decisions that best suit their individual needs. But to refuse a suggestion of an appointed expert in the room sends a message to them that you don't believe that they know what's best for you and some people who bring ego to the birth space get offended by this they genuinely believe that you're choosing something that's more dangerous so when you challenge someone who's in power and who has authority this creates resistance because of the inbuilt power imbalance. The system is designed to elevate the care provider to a position of expert and that simultaneously disenfranchises the woman and reduces her power and
Mel:
[20:25] her control and autonomy. And I know it sounds really harsh. I mean, there are some fabulous midwives and obstetricians who work in a way that buffer women from this.
Mel:
[20:35] But I can tell you that these care providers are bearing the consequences of trying to give women their power back in the system. They are facing the resistance that women would normally face. And they're putting themselves in the firing line by advocating for the women under their care. And we know this. This is not me just throwing my opinion out. The research is telling us that these care providers who want to provide woman-centered care who are on the side of the woman they're so tired and exhausted by putting themselves in that role because they're trying to protect women and in doing so they're burning out and they're experiencing moral stress because they're constantly trying to balance the needs of the system against the needs of the woman so if you have been the beneficiary of a midwife who has individualized your care and helped you navigate the system you were in the presence of a person who was working twice as hard at their job because they were working for you and they were working for the system. Some midwives and obstetricians only work for the system. Others are balancing the two and the battle that they're having on your behalf is to ensure that they are rebalancing the power imbalance that is inbuilt into the system.
Mel:
[21:56] So saying no is hard because you're not respected as the authority at your birth and so no the word no is only meaningful if the person you are saying no to actually respects you as an equal but as it stands there is a power imbalance within the maternity care system so your no is less meaningful so my first point is don't assume your no to mean something you saying no could just be seen as a hurdle to your care provider something they're going to have to work out how to get around and how to overcome it's it's not necessarily if you say no that that's going to be respected because there's a power imbalance, you saying no can be a trigger for a process that we call the escalation of care there are escalation of care policies however they may not be a policy written around this in a hospital but I can tell you that if your initial care provider is not accepting of you saying no or they feel like you're making a decision that's against hospital policy or against their personal opinion about what you should choose they will escalate this circumstance and I'm going to use an example of vaginal examinations during labor. So here's what I mean when I say escalate, the escalation of care process.
Mel:
[23:24] And you can apply this to any scenario. I'm going to just choose a scenario here just to tell a story. So let's say that in this circumstance, you've gone into hospital in labor and you're planning a VBAC, a vaginal birth after cesarean. Again, just as an example, a case study. In the hospital factory, if you're planning a VBAC, you go down the VBAC conveyor belt, which only goes for about 8 to 12 hours. And this production line issues you with a continuous CTG for fetal monitoring. On this particular conveyor belt, you may or may not be allowed to use water for pain relief depending on the hospital and depending on your care provider. You'll be given an IV cannula for just in case and your progress will be tracked by regular four-hourly vaginal examinations. This is just some of the things that will be offered to you on the VBAC conveyor belt. But because the VBAC conveyor belt has a time limit, if you haven't had your baby by the time you get to the end of the conveyor belt, you'll be moved to another conveyor belt, maybe the operating theater conveyor belt. So let's say you're on the VBAC conveyor belt and you say no to the four hour levodinal examinations, which are used to check the dilation of your cervix. So that's our scenario. You've said no.
Mel:
[24:48] Now, the person caring for you, probably a midwife if you're in the public system, is the bottom of some kind of workplace or structural hierarchy. And yes, hospitals work under hierarchical model. This is no secret. And when you say no, there's a process where maybe they'll have a conversation with you about it. Sometimes midwives will say, look, I'm going to go out now and I have to tell this person and here's what's going to happen. But just know that you don't have to agree to this they know the escalation process.
Mel:
[25:23] And they are going out of the room to inform the next person in charge the next person on the hierarchy it might be a senior staff member who's supervising them or the team leader for the day or the educator whoever's next in line they'll let them know that they tried to offer you a vaginal examination and you said no. This next person in charge will most likely assume that either the offer of a vaginal exam was not made in an effective way, maybe not with the right information or the right amount of persuasive force or the wrong words and then they'll come in to talk to you. Now this is the first stage of escalation. What's happening here is a second person is coming into your birth space to come and try and convince you to take the vaginal examination. This is the start of the escalation process for women who decline routine standard care. So if you want something different than what is on your particular conveyor belt. And I know there are midwives listening to this knowing that they would accept the no and advocate for the woman.
Mel:
[26:33] When they go through the escalation process and I know there are midwives out there who if a woman says no they will go to the next person do some kind of fancy footwork to reduce the impact of the escalation process you might have a great midwife who's willing to advocate for your decision to decline a vaginal exam but you can't assume that that's going to happen you need to be prepared for the scenario that you will trigger the escalation process and that someone is coming in to try and convince you to take the vaginal exam. This means that possibly a stranger is coming in to interrupt your labor flow and talk to you while you're trying to labor. They're going to interrupt your space again, pull you out of the labor zone by making you engage with them and having another discussion about the thing you just discussed with the previous care provider. And this is not what your brain wants to do. Your brain wants to stay in the limbic system which is the part of your brain that governs the effective flow of labor.
Mel:
[27:37] Every time you have to talk to someone you get drawn out of the limbic system and into the frontal cortex of your brain and that's where your decision making skills reside. Where the parts of your brain are that help you string together a thought or some words or make a decision. This part of your brain is supposed to be dozing while you're in labor low activity in the in the prefrontal cortex your limbic system is the most important part for labor but every time someone comes in and wants to talk to you you're being drawn back into your conscious prefrontal brain and out of the labor zone.
Mel:
[28:19] And this can absolutely impact the progress and the events of your labor. So these interactions are impactful and the job of the people around you and your support person or your doula or your midwife, your partner, your robust friend is to protect the space around you so that no one comes in and pulls you out of your limbic system and your labor zone. And so any strategies that you employ to keep taking back your power, you also want to be conscious that you want to minimize the interruption in your labor as much as possible yes hold on to your power yes get the things that you want but also avoid too many confrontations where there's numerous people coming in and pulling you out of your labor zone but this is exactly what will happen when this new person comes in to convince you to accept the vaginal exam.
Mel:
[29:10] And if you hold your ground with this person then the escalation process continues and the other people that come in might be doctors they might be another midwife in charge and they start putting pressure on you with increasingly more coercive language until you finally relent until you give up the fight and let them give you a vaginal exam just to get them off your back. Honestly this is not my opinion and it's not even just my experience although I've seen it play out in front of my eyes time after time. This behavior is recognized and upheld by the research when we ask women what happens to them when they decline care and again you'll see all the papers for this in the resource folder.
Mel:
[29:56] What happens to women that they've told researchers and they've collected these stories is that this escalation process ensures and their care providers use coercive language to try and convince them to accept the medical care that they want to give the women. And women talk about this feeling like a constant fight, a constant battle in labor just to have their no respected.
Mel:
[30:25] Hospitals don't deny that there's this escalation process. Some of them don't even realize it's a problem. But there are a few things that you can do. instead of saying an outright no you can do some things that might soften or dilute this escalation process or you can prevent it from being triggered altogether so if you are robust and okay with conflict and confrontation and you're ready for this fight in labor you could say no I don't want that and don't send anybody else in to have this conversation you could say that but honestly it gets people's back up and so if you confidently stand in your power in a situation where the power imbalance is already not in your favor.
Mel:
[31:15] Then you've got to expect some resistance. So you might want to play the game a little differently in the interest of protecting your labour space. If you feel strong and capable of an outright no, please go ahead. If you are confident in your support team and that they can protect your space for you, you can do that. But lots of women aren't comfortable with that and they don't want to play it that way during labour. Some women prefer a more subtle and strategic methods to keep control and power and that's completely fine if it's you you don't have to go in there overtly fighting to keep your power in an aggressive way you can prepare with strategic strategy it's still powerful because you're going to keep control of your choices but it's going to be strategic and subtle and that's where you keep your decisions that are in the labor space and play the system a little bit for your own benefit because when they use coercive strategies and language and even when they escalate they're trying to apply pressure to you and play you in a way that gets you to play along with their plan what you want to do is make them go along with your plan so.
Mel:
[32:36] Here are a few strategies that you can use to keep hold of your power and hopefully avoid triggering an escalation process so that your birth space is protected so the first strategy I call protecting your time bubble so please know that in the system that a real limitation of the factory process and of the conveyor belt is that there is a limitation on time so once your labor starts to progress beyond the time that the system is comfortable with maybe you've gotten to the end of your 8 or 12 hour conveyor belt you're going to be recommended different things to try and manipulate your body to conform to the time expectations that that system that hospital that factory has so the biggest power strategy you can you can employ is to protect your time bubble and buy as much time as you can in the least intrusive way possible so one strategy if we use the vaginal examination example instead of saying no I don't want one this conveys your desires but it doesn't give your care provider any information about your future plans or preferences and your care provider knows that during the escalation process when they refer this on to the next person in the hierarchy the making of a future plan is really important to the next person in the next stage of the escalation.
Mel:
[34:03] Process they're kind of less interested in your know and more interested in.
Mel:
[34:09] Knowing well when will you accept this thing that we've offered.
Mel:
[34:13] So to get around that expectation. So instead you could say something like, yes, I hear that you are offering me a vaginal examination.
Mel:
[34:22] Now, I don't want one at the moment, but I'll reconsider in a few hours. And the other way you can go about this is to find out if this intervention, any intervention, is being offered routinely. So is this something you offer every woman at this point? Is this a routine vaginal examination? or are you concerned about something is this an extra one and so understanding is this urgent or is this not urgent is this just routine on the conveyor belt is this the normal strategy will help you as you make your decision but this phrase of yes I hear that you're offering me a vaginal examination now it says yes I heard you I hear what you're offering I don't want one at the moment okay you've conveyed your preference but I'll reconsider in a few hours and now you've given them the plan they're not giving you a plan they're not going to say hey we'll come in in one hour you've given them the plan they know you heard them you received the information you conveyed your message and you've told them what the next steps are going to be the fact that you intend and to revisit the decision later. Although it doesn't mean much to you, it means a lot to the people who are working in the maternity care system.
Mel:
[35:41] No one knows what you might want in two hours. Not even, you might change your mind. You might want it in an hour. You might want it in two hours. You might want it in four hours. But it at least conveys the message. I'm not completely closed to this. I will reconsider it. And it can actually dilute the escalation process where the midwife and the system might be completely happy with this. That even if it is discussed outside of the room with another midwife and that your care provider says, hey, she says in two more hours. The other person the next person who's escalated to might say great no problems we'll reconsider then so you've immediately given yourself a time bubble more time for your body to work and function you won't have the the challenge of the escalation process where people are coming in and interrupting you and interrupting you because you've given the terms of the next two hours at least and just remember also if you really don't want to be interrupted in labor and I completely understand that. No one should be interrupted in labor. But if you don't want to have this conversation, then consider having your partner, your support person, or your doula to have this conversation on your behalf. So this strategy of asking for more time, it can be employed over and over and over to protect your time bubble. But there is another important element here, and it's The use of the word yes versus the use of the word no.
Mel:
[37:07] Now, I posted a reel on Instagram about this a while ago on social media, and I received the most disgustingly phrased feedback from a few very angry women. A small number of women sent me the most hateful comments I've ever experienced on social media, and this post was about the use of the word yes.
Mel:
[37:32] So I'm going to focus on the psychology right now of using the words yes instead of no. And I'm not going to go into full detail, but again, the paper that I'm referring to is in the resource folder. But there's MRI science that shows that when you use the word no compared to yes, a different part of the brain lights up in the people hearing the words. And these different parts correlate with different emotional responses in the person who's hearing it and also different reaction times from the person hearing the word. A yes placed at the front of your sentence puts your care provider into a different emotional state than if they were to hear the word no straight up and it opens the door to a slower more calm and open conversation. Now, I'm not suggesting that this yes implies that you'll definitely be accepting a vaginal examination. The yes is simply placed as a strategic way to control the collective nervous system in the birth room and to keep it calm while you expertly and strategically navigate the power dynamics in the birth room.
Mel:
[38:51] So this phrase yes I hear that you're offering me a vaginal examination now, I want I don't want one in the moment but I'll reconsider in a few hours completely dilutes the escalation process because you've kept the conversation non-confrontational it's still relational respectful you've given the care provider your plan and of course it's possible that the escalation process will still ensue and you may need to get your support people to intervene and request that no more people come into your room to discuss the vaginal examination. Sometimes nothing works and you may need to be really clear. I have said I will reconsider in two more hours and I don't want to be asked again until then. So you decide whatever the terms are. You may actually decide I don't want another vaginal examination. So you could say yes I hear that you're offering me a vaginal examination. I hear that this is part of your usual routine practice with women who are planning a VBAC and I hear that you have concerns about my progress. However, I really don't want another vagina exam and I don't want to talk about this unless you have specific fears for me or my baby. So you can be really clear on your terms. But if you start with a yes.
Mel:
[40:08] There are literally different parts of your care provider's brain that light up. And the yes word invokes less emotions of anger and it encourages a slower response to your words, whereas no was correlated with negativity and a different part of the brain lights up when we hear the word no compared to the word yes, regardless of what follows. So I'm not suggesting the yes is, yes, I will take your vaginal exam. It's just there to calm the collective nervous system and protect your labor and birth space to prevent too much of the escalation process interfering with your labor process. It's a strategy. It definitely is. And I'm not denying here that I'm giving you tools to play a sort of game. Some people will say the system's not a game. Yes, it is. If you've ever experienced it, you'll know there are particular strategies that will help you get the birth you want in a hospital setting.
Mel:
[41:21] So that's strategy one, protecting your time bubble. The second strategy is to claim your territory and don't ask for permission.
Mel:
[41:33] Assume that you own the space and use it however you want to use it move things around turn lights on and off manipulate the space to suit your purposes set it up the way you want it get your gear out that you've brought don't ask for permission to use the space in the way that you want to use it when you manipulate the space in the room to suit your purposes you also subtly claim ownership and power over the space. And then you'll see that instead of you asking permission for what you can do, can I use the bath? Is it okay if I change the bed? Is it all right to put this here? You'll see that your care providers start to get the message that you own the space because they'll start asking you for permission. Is it okay if I move this a bit? Is it all right if I turn the light back on can I put this here so in a very subtle way non-confrontational way you can start to express that the understanding that you own the power in this space by using the room as if you own it it's your territory.
Mel:
[42:44] So a few things you can do to own the space, first and foremost, start asking for things that are going to help you with positioning. So ask for floor mats, bean bags, they might have birth slings or something that hangs from the ceiling, different chairs, birth stools, pillows, blankets, soft things that create a space where you can get comfortable to move around in different positions, however you feel most comfortable. You can manipulate the bed to create a more comfortable space as well so the bed can be changed you know the front and the top can come down and change into more of a big chair or something that you can kneel on hands and knees or where you can rest over the top of the bed on your knees you can change it that way another way to completely dominate the space is to use the bed as a storage space so raise it all the way up they're usually electronic just work out the remote.
Mel:
[43:41] Raise it all the way up, put your bags and equipment on it and it means you can use it to lean forward on when you're laboring but it also makes it harder for care providers to suggest that you know just hop up on the bed for something. They're a lot more resistant to use the bed and again I'm not going to harp on it but there's a lot of literature written about the power of the bed and how when women are on it again that implies that the care provider who's standing above you has more power than you do on the bed and the power when you're on the bed the power lies with the person who has got free movement around the bed and who's sort of up and looking over you.
Mel:
[44:23] So if you can dismantle the power that the bed has in the room and over your birth, then again, that's you claiming and owning the territory of your birth. And if we go back to the circumstance and example I was using earlier of the VBAC, you might be told that you're not allowed to use the birth pool, for example. But that's okay because that's a rule for your care provider to follow. The policies are not written for you. So if your care provider says, look, our policy doesn't allow women who are having a VBAC to get in the pool, the policies aren't there to control you. The policies are there to control care providers. The policies are for your care provider to follow, not for you. So if you want to get into the water, don't ask for permission. Don't ask, can I get into the water?
Mel:
[45:19] Just turn the bath on and get in there and it's up to the midwife to deal with your deviants I say that tongue-in-cheek but you have gone against a policy but it's your prerogative it's your right to use that room as you want and need it because you've claimed ownership of that space because you're the woman you're the one who has the autonomy and the choices in this scenario so use the space as if you own it so final words for when you go and you start declining medical recommendations so these could be during pregnancy where you have more capacity to have robust conversations so you might feel stronger and more capable when you're not in labor to decline things and that's okay but final words are to remember that everything that is on offer to you is just a recommendation that the policies are not for you to follow therefore your care provider to follow you are offered just whatever is routinely given to all women because that's the conveyor belt that you're on so maternity care is provided in a systematic and uniform way that's determined by the conveyor belt that you've been put on in the maternity care factory but.
Mel:
[46:33] If what is offered to you doesn't suit your philosophy or it doesn't suit your needs or preferences, the law and actually policies are on your side. They're really specific about woman-centered care and respecting women's rights to choose to decline or accept interventions or recommendations.
Mel:
[46:54] You're allowed to decline medical recommendations and medical care. Just know that there will likely be a reaction to this. And you might have a care provider who's comfortable with women having authority over their choices and they're comfortable with women declining options and maybe it'll be a complete non-event for you maybe this whole episode bears no resemblance to what it is that you might experience in the system but I can bet there are women out there who've already had a birth experience who the penny is dropping for and so you know you might even encounter midwives or doctors who are so on your side that they give you tips on how to navigate the system and they give you insider knowledge and strategies on how to get around the little policies and things that don't suit your needs but you might have a care provider who expects you to follow their recommendations and then the consequences of you declining care will be this coercive language and pressure that is designed to scare you into making the decisions that they want you to make they'll apply so much pressure and the intention is for you to just give in.
Mel:
[48:07] So if you take nothing else away from this episode, that's what I want you to know. That there is a power imbalance in maternity care and maternity care system.
Mel:
[48:16] And your care provider intrinsically has more power than you do by default. They're positioned as the expert and many of them will think that they know better than you. And they own the space that you're in. Unless you're in the fortunate minority who has other options. But for many of you it would be your job to prepare yourself to hold on to your own power and use the strategies that will prevent confrontation and interruption in your birth space to allow your body as much opportunity to labor as possible while you strategically navigate these power dynamics so that you can get the birth that you want. Sometimes you will have to go into your birth prepared for a fight and in addition to the two other suggestions that I gave earlier protecting your time bubble and owning the territory you can make this fight more powerful by having people with you who can advocate for you such as a robust and confident partner or friend or a doula has who has your interests at heart you can also take with you a private midwife in the hospital, which again is all of these protective barriers around your autonomy can help you choose the type of care you want, have your no, be more powerful and avoid the coercive behavior of the escalation process for women who decline medical recommendations.
Mel:
[49:45] To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com follow me mel @melaniethemidwife on socials and the show @thegreatbirthrebellion all the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
©2025 Melanie The Midwife
