Posted by: emjb | November 22, 2006

Informed consent requires being informed, dammit.

I was reading the blog of a doula who’s training to be a midwife, and in one post, she mentioned that one of her clients was birthing with a particular OB practice she was familiar with. She knew two of the three doctors were good ones, but the third…well, she’d heard things.

I recently took on a new doula client. I struggle so hard with my clients to help them with the informed consent stuff. I want my client to know that the OB practice she has chosen includes two amazing OB’s who I’d be delighted to birth with myself, but also one physician who (nurses report surrepticiously) is almost single-handedly responsible for the hospital’s not insignificant c-section rate and abusive horror stories from teenage and other under-served mothers. I can’t tell her this.

It took me aback. I’d been reading her blog for awhile, and she was a very pro-natural/homebirthing/woman-centered birth kind of person–or seemed to be. None of which explained why she would let her client who had specifically hired her as a doula, risk birthing with an OB who might lie to or coerce her into interventions she didn’t want.

Especially as she went on to say:

I fear for my hospital birth clients more often than not. I have been sifting through why that is, why I just can’t relax. I am aware that part of my anxiety springs from my own experiences birthing within the American medical model and also the births which I have attended as a Doula. I’m thrilled that my clients love their primary OB. I worry myself sick that her doctor won’t be on call when she presents at the hospital and that the nasty one will. It’s a sick, twisted lottery which defies acceptable explanation. But it’s how things are done here. I can’t share this with my clients and it leaves my heart heavy and my stomach sour. I hate that so frequently my role, intended to be that of dedicated support and love for the laboring women, so often requires me to stand witness to some awful, awful abuses of women and their babies.

So..she sees a woman vulnerable to abuse walking into a possible bad situation. But yet she feels that she cannot say anything to warn her, or prepare her for it. I don’t understand this. If you saw a friend about to go out with a guy who had a bad reputation for slapping women around, wouldn’t you tell her? Shouldn’t you?

So in the comments I asked her. Was it a legal issue? Why couldn’t she tell her client? Was that ethical?

She responded:

…Why can’t I tell her? Because I have no right to, and it’s not part of my job description. I have no first hand evidence too substantiate my claims, just hearsay from doula friends and nurses who work with the doctor in question. Furthermore, I plan on one day working with women in this community as a midwife, so I walk a very fine line as a doula in hospital birthspace. Frankly, I represent all doulas and all midwives when I am in that space, when my clients invariably share that I am a student midwife. If I found myself in a situation where I was seeing something completely unacceptable happen and/or my client was being abused, I would absolutely speak up in her defence(and probably find myself in a whole lot of trouble)and devil take the consequences.

And I still don’t understand, really. I can see that she fears retaliation if she breaks the code, if she passes on a rumor…even if she tells the client it may just be a rumor. I get the feeling there are consequences for breaking the protective silence around patient abuse that nurses, midwives, and doulas witness, apparently. That’s the only sense I can make of her post. She has to choose whose side to be on, and being on the woman’s side is too risky. Even for a doula, who might be a midwife there someday.

And that is deeply, horribly wrong. Who will be on her client’s side, if not her doula? How are patients supposed to know about doctors with bad reputations if no one will speak out? It’s too late when you see the abuse already occurring–the unwanted exam, the pitocin turned up surreptitiously, the scapel poised to cut. It’s too late, because the woman’s will has most likely already been broken, she’s already been convinced she can’t do it, she needs those interventions, the baby will die or she will die, and it will be all her fault.

I am sympathetic to the blogger’s position, but I can’t say I agree with it. It is a very hard thing to risk your career before it even begins, and I won’t be arrogant enough to say I wouldn’t struggle with what to do either.


If I were her client…I would feel utterly betrayed. I would feel there was no hope of fighting the system so long as those in the know refused to stand with me. What good do the doula’s tears do, if she won’t help in any meaningful way? Why have a doula or a midwife at all…what good is all this claptrap about natural, respectful birth if the fear of the hospitals and the doctors always keeps them silent when they should speak out, for God’s sake??

I’ll tell you how I feel–how I felt about my midwives, who let me walk into that meat grinder of a hospital without a word of warning. It’s a stab in the back. It’s worse than nothing, because if I had never trusted them in the first place, at least I would have known and accepted the abusiveness at the beginning. Being betrayed by someone you trust is much worse than simply being hurt by someone you already knew was hostile to you.

I hesitated to post this, because I want to understand. I want to be a midwife myself one day. I fear I’ll alienate a midwife blogger I respect.

But you know what? Fuck that. I don’t give a rat’s ass about some midwife’s career or fears of retaliation. Either be on the side of your clients or don’t, but don’t you dare let vulnerable trusting women walk into a war zone without so much as a scrap of knowledge to arm them against what’s coming. And then have the gall to feel sad when they get hurt! I mean, what the hell do we expect to happen here?

I don’t go around starting internet fights, and this isn’t really one. She’s certainly not the only midwife I’ve seen have these kinds of fears dictate how she acts. And it is a system that punishes those who speak out–that’s part of the reason it’s gotten so bad.

But speaking out, being an ally of the women giving birth, is the only–the only–way to make it better. One thing that feminism has taught me is that you can keep asking nicely till the sun burns out, and you’ll be ignored. It’s not till you start making trouble that things begin to happen.

Being a natural birth advocate of any kind, in our current system, is a political act. It is an act of defiance. And there’s no use doing it half-assed–in fact, if you do, it gives cover to the bad guys. We will not change this system with gentle throat clearing and heartfelt pleas. We will change it when we stand up, call people on their bullshit, and starting making a stink too big to ignore.



  1. I agree that people should be called on their bullshit, but do you really think it’s necessary to get a pregnant woman involved when all she is there for is to have a baby? Do you think that just because the politics of birth are important to you and me that they are important to her as well? If the rumors in question were substantiated, well then take your wrath to the person who has committed abuse, not to an innocent woman about to give birth. What right do we have to turn her delivery room into a battlefield? And, if we really made that much of a stink, do think we, as doulas would be welcome in hospital delivery rooms? And what of midwives? We have to maintain solid rapport with the medical community–those same doctors are who we depend on when emergencies happen. We can’t afford to consider them the “bad guys.” There are many ways to deal with this issue rather than scaring a client, spreading rumors and pointing fingers. This is a sensitive issue and should be dealt with accordingly. We, as doulas and midwives will never make the impact we want in this world if we barrel head-on into accusations and rumors. Although I feel passionately about women taking back the childbirth sphere, I know that we need to do it with dignity and diplomacy as well as passion.

  2. Aimee, I respect your response; doulas are truly in a no-win situation in a hospital birth (especially), which is why I don’t really hold it against my doula that she wasn’t able to do as much for me as I’d hoped. She didn’t have any power there.

    I guess what I think is, that many (most?) women’s births are already a battlefield–not because I wanted them to be, but because our society is in a fierce struggle over what rights a woman has to birth as she chooses, and with people who will not take advantage of her vulnerability. Hard to be more vulnerable than during labor.

    I just hear so many stories about horrific OB practices, from moms and healthcare workers, that I feel not saying anything is putting women at real risk.

    My .02.

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