Episode 204 - Advocating for Yourself in the Maternity System
[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. In 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.
[0:25] Hello, and welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and I've been a midwife for over 18 years. As a result, I'm an insider into how the maternity care system works. Largely all over the world, you'll find that although there are some differences.
[0:46] The basic premises of maternity care are similar, and all of the strategies that I'm going to talk about today for self-advocacy in the maternity care system will have some relevance to you wherever you are in the world. I would like to personally thank the sponsor of this podcast because that means that you get to listen for free. Poppy Child from Pop That Mama is a doula and hypnobirth practitioner, and she's a sponsor for today's podcast. Poppy has an online course, hypnobirthing course it's called the birth box and it's already helped thousands of women i get behind the work that poppy is doing in the birth box it's practical strategies to help you get ready for labor and birth but also the challenges of parenting and with my code if you type melanie in at the cart you'll get 25 off so if you're preparing for birth go check it out you will be so glad you did. The link is in the show notes. Type Melanie at the cart and get 25% off. Thank you Poppy for sponsoring this podcast so that everybody else gets to listen completely free.
[1:56] Let's get started on today's episode.
[1:59] Now in this episode I will be sharing the strategies and tools that you can use as you interact with the maternity care system so that you can effectively advocate for yourself and have your choices and preferences respected. Not everyone is going to have the benefit of their own care provider who they know trusts and who they know is listening to them. So if that's you and you're not sure who's going to be caring for you throughout your maternity care or your birth, you may need to adopt some self-advocacy strategies to make sure that your preferences are heard and that you have the type of maternity care that you're hoping for. Now, universally, when we think about how do you create a maternity care system that benefits women, it's all about looking at research where women have expressed the most satisfaction out of their pregnancy, birth and postpartum experiences.
[2:57] And when you look at that literature, the women who have the most sort of satisfying experiences with the maternity care system are the ones who have continuity of care. And what that means is that you know either your midwife or your chosen care provider all the way through your pregnancy, birth and postpartum. So I will say if you've got that model of care, if you've been able to choose who your care provider is going to be and you trust and love them, then you are already in a really good situation with regards to your position as you self-advocate within the maternity care system. Not everybody has the privilege of choosing their care provider. So I'm really thinking about you women out there who might be in a situation that you didn't choose where you need to self-advocate because you don't have somebody who's on your side.
[3:49] So today I'm going to share actionable and practical and identifiable strategies that you can use to advocate for yourself during pregnancy, birth and postpartum as you interact with the maternity care system. And if you're sitting there listening to this thinking, I don't understand why I need any strategies, then you need this episode more than anyone because what you don't realize is that you're going into a maternity care system that isn't necessarily interested in exactly what you want. They want to give you the care that they believe is best, but you want to receive the care that you believe is best. So this episode is about how to get the care that you believe is best for you and your baby and not get swept up in accepting what somebody else believes is best for you.
[4:40] So let's kick off with actionable strategies that you and your support people can use. Another really big element of self-advocacy is who you have with you. We're going to kick off with actionable strategies. But before I explain anything further, the first thing to understand about the maternity care system, and this can be mitigated if you've got your own care provider that you've chosen and you're going to a location of your choice, this can be mitigated. But you've got to understand that there is a power imbalance in the maternity care system where your care providers and the institution itself will often assume a position of power in that professional and client relationship. This is something that's spoken about all across the field of medicine and maternity care. This is not a new brand new idea that I'm just coming up with. There is an identified inherent power imbalance within that relationship.
[5:40] And often the maternity care system will assume a hierarchical power higher than the woman herself. And despite this assumption, there is a lot of governing documents that state that you as the woman are the ultimate boss. You have the ultimate decision-making capacity.
[5:59] Your authority is paramount and your autonomy is protected by law. And all of the documentations and policies that you'll read if you happen to get access to the policies of the hospital or location that you're giving birth at they'll all talk about you as being the boss of your care that you are the ultimate authority and that decisions should be based solely on what you want however what you'll notice is that regardless of policy and language around woman-centered care and client autonomy or patient autonomy, what you'll find is that embedded in the culture of maternity care is that you're not considered to be the most powerful person in the room. And so now you are forced to consider how are you going to advocate for yourself and hold on to your power in the birth space and through your pregnancy and postpartum. And women get confused because they think before going into this situation, they think that their choices will be respected in the maternity care system and then they get a shock in situations where they aren't respected and they don't realize that sometimes they'll actually have to fight.
[7:14] Strategize, negotiate and advocate for themselves just to be heard and just to get the type of care that they want. This can take women by surprise. So this episode is about removing that element of surprise to make you realize that there is some really easy strategies that you can use to prepare for this possibility that you might have to advocate for yourself if nobody else around you is. And there are some of you out there listening who are like, oh, that didn't happen to me. I had great care providers who didn't put any pressure on me and that's great. However, I know for sure that there are a large percentage of women listening now who have had to learn the hard way that you might need to fight for what you want in the maternity care system. And those women are listening, you are listening to this in order to get ready for the next time you need to engage with the maternity care system. And the other argument I hear all the time is women shouldn't have to prepare to defend themselves in the maternity care system or someone will say, hey, all the stuff you talk about, you're scaring women.
[8:22] So I need to tell you, I am in no way trying to scare you or overreacting about what you could encounter in the maternity care system. I acknowledge that not every woman encounters this. I'm just helping you to know what you need to be prepared for just in case. I'm in no way trying to scare you. I'm just explaining the reality of how it actually is. I'm not making up scary stories. I feel like I am just shining a light on the reality of what goes on. So if this scares you, that's actually on you to discover why are you scared and what can you do to resolve your fears. If you feel scared by this episode, it's not because I'm scaring you or making up scary stories. It's because I've given you information that you find scary. So for many women, the realities of the maternity care system are scary. And today I'd like to share some ways that you can prepare yourself to not feel scared and for you to be prepared because potentially maybe you're scared because you don't know what to prepare for or what to expect. So this episode is all about preparation. This episode is for you if you're feeling frightened about what you're about to go into.
[9:39] So you can resolve your fears and concerns by getting ready with strategies, the ones I'm going to speak to you about today. I sincerely hope that you do not need to use any of the strategies that I'm going to talk about today I hope that when you talk during your pregnancy birth and postpartum that your care team genuinely listens to you and does their absolute utmost to give you the type of care that you want to receive but if you find yourself in a situation where there's a stalemate or a conflict I'm hoping in this episode to give you the strategies that you'll need to navigate that So you're the one that comes out on top.
[10:17] You and your baby come out on top, not the interests of the system. So here we go. Point number one.
[10:26] You need to own your role as the boss of your birth. What you need to realize is actually all of the legal structures that exist around you, all of the documents that exist around your care in the maternity care system, position you as the boss of your body and of your decisions. The problem is, is so many women assume that they don't have power in the maternity care system and they don't realize they need to hold on to it because the inherent cultural structure within the maternity care system is designed to kind of siphon away your power and to subjugate you so that the clinicians hold the power and the institution hold the power. However, if you acknowledge and realize that you are the boss, your behavior within the maternity care system will instantly change because you're making the assumption of authority. You are the authority over your own body, your own baby, pregnancy, birth and postpartum. No one can legally do anything to you without your consent. Even if you or your baby are in a situation where one of your decisions means that you or your baby could be seriously injured or disabled or die, you still have the right to make those decisions within the maternity care system. That is how far maternal autonomy goes.
[11:50] In the legal structures around maternity care. You have a right to bodily autonomy which is protected by law and no one can do anything to you without your consent. Nonetheless you will experience scenarios that feel as though you are trying to be coerced to make decisions that are not completely yours. And so in these scenarios and it'll be a consistent theme throughout this whole episode, I suggest that you start to script sentences and write down possible phrases that you can use on repeat to make sure that your message is heard and that you keep reminding yourself that you are the boss in these scenarios. So certain strategies for reminding yourself of what authority and autonomy you have, you could say, and these are just ones that I've scripted. I would encourage you to script anything that feels right for you and how you would normally talk and how you would normally think but for me I've written down my right to make decisions about my own care is protected by law.
[12:55] I am the boss of my body. Another one is this is something you could say to a care provider if it's feeling overbearing and you've exhausted your other strategies. This thing that you are doing now is coercive. You're trying to make me change my decision because I didn't choose what you think I should choose. Now, this really points out a clinician's behaviour towards you. I hope you do not need to use that one, but it's entirely possible that you might need to. And again, another one that can be really straightforward, this interaction does not meet the legal standards for valid consent. And here's where I want to talk to you about valid consent, because the law says that nothing can be done to you without valid consent. And a valid consent is considered voluntary, informed, a specific agreement given by a person with legal capacity to make a decision, that's you. If you're well and you're not mentally impaired or anaesthetized or unconscious, you are a person with legal capacity to make a decision, which must be current at the time the action is taken. Consent must be freely given without coercion and cover the specific procedure or treatment being performed. So the key elements of a valid consent are that you, the individual, has capacity, the ability to make the decisions, and most adults have that.
[14:22] That consent is voluntary, that the decision must be made freely without pressure or undue influence from professionals, friends or family. Now, I'm just going to stop for a second on the voluntary part because the real crux of a lot of informed consent or consensual procedures in maternity care centre around this freely given without pressure and voluntary consent and freely given without coercion.
[14:52] What you'll notice if you've ever been in the maternity care system either as a care provider or as a woman, coercive tactics are embedded within the maternity care system. Even little things like, I hear it every day, if you don't have this test we will not allow you to get in the water during your labour and birth. What you need to know as a woman is that that's coercive. They're trying to say, you must take this if you want this. They're using strategies to coerce you into making decisions that they think you should make. And then if you don't make the decisions that you, they think you should make, that will withdraw privileges. Whereas in fact, if you're walking into a public hospital, you own that space. You're the woman with bodily autonomy. Your tax money has paid for this service to exist. The people who work in there are public servants and their whole intention is to give you care that is both safe and appropriate for you.
[15:54] They cannot withdraw and withhold certain privileges from you because you are the boss in this scenario. You're right to bodily autonomy and to make decisions and to use what the space, however you want to use, is embedded in law. But women don't realize this and care providers may not even realize that their language is becoming coercive. And we saw this in recent legal situations where the woman who arrived at hospital wanting to be admitted and wanting for her midwife to be called to the hospital so that her care could commence at the hospital was told, we will not call your midwife until you agree to have a vaginal examination. She did not want a vaginal examination and care was literally withheld, including pain relief until she agreed to a vaginal examination this was taken all the way through court recently and the finding found that the woman experienced assault as a result of that an unwanted coerced vaginal examination neglect because she wasn't given the care that she deserved and.
[17:09] It was found in this case that her consent was not voluntary and that it was coerced. And this is not legal consent and it's considered medical assault. If somebody gives you a procedure you didn't want or the consent was invalid. So the next step for the elements of a valid consent are that it's informed. So you need to be given sufficient information, including the risk benefits alternatives in order to make a decision. You may or may not get all of that information. and part of what I'm going to talk about today fills this gap in the informed consent process. The consent must be specific and directly apply to exactly what's happening in that scenario. You need to be informed of and not coerced into every single little procedure. It's not blanket consent. And also the consent must be current, so directly related to your circumstance. So those are the five elements of valid consent. And every healthcare provider needs to abide by these. But these are the issues that usually arise in maternity care, which require you to advocate for yourself.
[18:18] So that's the first thing is to firstly understand that you are the boss of your birth your right to bodily autonomy is protected by law and that you have the right to a valid consent process before anything is done to you and if that consent process involves coercion and that consent is not freely given it's considered a form of medical assault and coercion
[18:42] is not acceptable in maternity care. However, it's rife. It happens all the time. So the next one that I want to talk to you about is about you inherently as a person in your personality. And this is about people-pleasing behavior. Now, if you're in the maternity care system and you are trying to advocate for yourself and you already know that you have people-pleasing behaviors, that's not going to serve you. So there My point two is that there is no room for people pleasing in maternity care. So this is the time to recognize if that's you and to work through your personal people pleasing behavior. Because a people pleaser, if you're not sure if this is you, a people pleaser is someone who acts out of the intention to satisfy and please others often at the expense of themselves. And that's the biggest deal, is that it's often at your expense.
[19:40] People-pleasing behavior is characterized by the tendency to be unable to say no. And people-pleasers often excessively apologize when they do prioritize themselves or if they do something that they think will be uncomfortable to somebody else. People-pleasers feel that they have a responsibility over how other people feel around them and they seek to avoid conflict and confrontation. And as a result people pleasers will not do what's in their best interest in a bid to avoid conflict and confrontation and not make the other people around them feel uncomfortable. Now this can be a lovely trait in some situations and of course nice to express in some areas of your life but during pregnancy birth and postpartum there is no room for people pleasing behavior because your actions or your inaction will be to the detriment of yourself.
[20:38] It will be for the benefit of others. Everybody around you will be pleased, but you won't because of this inherent people-pleasing behaviour. So now is the time to identify if you're a people-pleaser and work out how to turn that off in the scenario of pregnancy, birth and postpartum. Now again, this is where some pre-written scripts and strategies can help you. If you struggle with simply saying no and this is something that one woman explained to me how she overcame her people pleasing behavior and trained her no muscles in her brain she said i used to just stand in front of the mirror and say no or no thank you or i don't want that practicing scripts where she is allowed to advocate for what she wants over doing what she thinks other people want her to do. And usually people-pleasing behavior is just a long-term habit or trait in you. And as a result, people who are people-pleasers actually haven't built the skills for conflict resolution to say no or to stand up for themselves.
[21:50] But these kinds of behaviors are learnt. You learn to advocate for yourself. But if you've traditionally not done that, you need to practice so that in the situation, in pregnancy, birth and postpartum, when you're required to advocate for yourself, you actually have some of those skills. As I'm saying this, I'm realising that I am absolutely not a people pleaser. And so I apologise to the people pleasers who are listening to this if I'm being completely insensitive. But my.
[22:22] Self-advocacy and saying no and not taking responsibility for other people's feelings are quite strong and robust which I guess is what often gets me in trouble but if you've identified yourself as a people pleaser you might have trouble advocating for yourself in the maternity care system so now's the time to identify that and start building some strategies for how to advocate for yourself and here I'm going to recommend again that you come up with some sentences that you can practice and repeat and build that muscle in your brain. A few that I've just built out here that you could adopt if you wanted to or come up with your own is try a few that are specific to your circumstances. So one sentence could be, no, I don't want whatever it is. I'm planning to do filling the gap instead. Can you please help me arrange that? Or the next phrase. I would like some time to think about that. Let's talk about it in my next appointment.
[23:23] Another phrase. Before I choose, I need more information. Where can I go to find more information?
[23:31] A simple phrase. No, I'm not interested in that. If we're going to get a bit, little bit more forceful, please don't ask me again. I've already given you my answer.
[23:44] Next phrase. Thank you for that information, I'm going to need 20 minutes to think about that. I'll let you know when I've made a decision. So these are all phrases that you can write down, practice on repeat so that if you ever need to advocate for yourself, you can have a selection of scripted responses that might feel easier to deliver than just panicking and freezing and accepting whatever's offered to you.
[24:11] All right, the next thing that I'm going to suggest when you're advocating for yourself within the maternity care system is think about why you're making certain decisions and don't make decisions in order to solve the problems of the maternity care system. And I'm going to explain this. We know that there are inherent issues within the maternity care system, issues that we didn't cause, that the staff in the hospital didn't cause. However, women are often held responsible for solving these problems, which takes the problem out of the hands of the hospital and keeps placing it on women. And this can go hand in hand with some of the people pleasing behaviour that we just spoke about, but it's a little bit more complex. The truth is that the maternity care system has limitations on resources, including time and staffing and space and beds. And some of the decisions that are made around your pregnancy birth. And postpartum are not necessarily in the interest of yours or your baby's needs. They are simply a response to these understandable limitations of the hospital or institution. But unfortunately, you're the one who's going to be disadvantaged. And it's the women who advocate for themselves who are going to be least likely to be disadvantaged by the limitations that are inherent in the maternity care.
[25:34] So you may be in a circumstance where you'll be asked to comply in a particular scenario because it solves a problem for the hospital, even if it's not in your best interest. And I want to give you a real life example of where I saw this playing out in my own clinical practice. It was a long time ago, but I had a client who was pregnant with twins and she was getting frequent and repetitive ultrasounds for the size. There was concern for the size of one of the babies which seemed to be growing less and progressively less and was smaller than the other twin. It came to a point where the suggestion was made that she should have a cesarean section to give birth to the babies because they felt that the discordance in weight was becoming too severe. The woman wasn't completely convinced that she needed to have the cesarean section but with the information that she had she decided she would have the caesarean section. Now because it was a planned caesarean we were told that all the planned caesareans in that hospital there was an a nominated midwife who was there to make sure that the women could keep their babies with them from the caesarean section they would go skin to skin they would travel together to the recovery ward the midwife would stay with them there so that the mum could have uninterrupted skin to skin with her babies there would be no separation and then they will go to the postnatal ward when she was ready.
[27:03] This was great news to my client because this was something she really, really wanted. And then on arrival, when we came for the cesarean, we were told, actually, they were short-staffed that day and that they had to deploy the skin-to-skin midwife back to birth unit because they just were limited on staff. And then everybody left the room. And my client said to me, I don't want to let, I want to keep the babies with me skin-to-skin. She said, what should I do? and I said to her today you are not going to solve the problem of the hospital it's their problem that they are understaffed and again it's it's unfortunate of course there are limited resources but why should this woman be the one who has to bear bear the brunt of the consequences of the hospital's lack of resources she was told there would be one there and because the hospital had limitations and their own problems, this woman was going to suffer. She wasn't going to get what she wanted. The hospital was going to get what they needed. They were going to deploy the midwife back to birth unit to solve their staffing issue. And I said to her, today, you are not going to solve the hospital's problem. They have to solve the problem themselves.
[28:18] So I suggested if she wanted to keep her babies with her, that was absolutely her right to do so. And that if she didn't want to hand the babies back over after they were put skin to skin in theatres, that it's well within her rights to hold on to her babies.
[28:34] So the decision was made by her that, yes, that's what she would be doing when the babies would be passed to her in the hospital after the cesarean section, in the theatre, sorry.
[28:46] That when it was time to hand them back over so that they could go to the postnatal ward with the midwife who was unable to stay, that she would just decide not to let them go. And I watched her advocate for herself in that scenario. and it played out just as I thought. The midwife said, I need to go now. I'm going to take your babies with me because this midwife was responsible for care of the babies. And the woman said, no, I want to keep the babies with me and I'm not going to let them go. And the midwife kept trying to put the problem back on the woman. She was saying, I need to go. I need to go back to the ward. And the truth is, is that was the midwife's problem. It's not the problem of the woman. And so that midwife had to call birth unit and say to the birth unit, hey, I can't go because the woman wants to keep her baby, which is completely fair enough. The women should be allowed to keep their babies in this scenario, two babies. And so the hospital had no choice but to solve that problem themselves. So the midwife stayed with us. The birth unit felt the impact of one less staff member. But guess what happens? When that happens, when the hospital feels the consequences of their lack of staffing, and it's not, anyway, I'm not going to get into the details of resourcing hospitals, but they had to solve that problem because the woman refused to solve the systematic problem of low staff levels.
[30:16] All I'm saying is don't solve the problems that if they're caused by something else. So another example that women encounter, for example, they want to have a water birth when they get to hospital. When they arrive and they say, well, there's no, your midwife who's caring for you doesn't have their water birth qualifications. Okay, well, that's the hospital's problem. And a phrase that you could say is, well, I intend on having a water birth. Can you find me a midwife who's capable of assisting with that? Let them find that solution. You don't have to adapt. You are the boss of your birth. And I've had people, when I say these kinds of things, they're really upset. They're like, that's not fair to the hospital system. Well, guess what? The hospital system is there to serve you as a woman and try and meet your needs. If they don't have the capacity for that, that's not your problem. That's their problem. That's a skill issue. That's a staffing issue. That's a funding issue. That is not a problem for the woman to solve. So have a think, why am I not being granted access to the thing that I'm asking for? Is it because the hospital's asking me to solve their problem? And so then you can start making decisions about if you're going to stand your ground and prioritize your needs or adapt to the needs of the maternity care system.
[31:39] Now the next point is all of this advocacy can get absolutely exhausting and it can be soul destroying and it can be like death by a thousand cuts. Women feel worn down by the necessity of having to constantly advocate and fight for themselves. It's absolutely exhausting. And so this is where it's really important to have recruited a robust and prepared support team. Now this could include a doula, your partner, a robust friend, anybody who you think will absolutely have your back. This is your ride or die. Whatever you say goes, absolutely they're on board. And I've seen this work so incredibly where the woman actually doesn't feel like she needs to fight for herself because everyone around her comes to her defense. And this can make you more robust in your maternity care and more able to continue to self-advocate and get what you want and not sort of resign yourself to just having the scraps of what's been offered. You'll actually have more capacity to fight for yourself.
[32:49] And I've spoken a lot on this podcast about the importance of a robust support team who's on your side and who's competent and confident. And I'll list all the episodes in the show notes that actually talk to your support people about how to be great support people and how to advocate. So the ones that I've got listed here, episode 173, 170, and 151 are great episodes to help you prepare your partner or support people. And I also have an all facts, no fluff guide that helps you and your care team work through the pain of labor, particularly if you want to avoid pain medication. Medication and I'm mentioning that here because in that guide guide to giving birth without pain medication there's a whole section for your support people and how they can advocate and care for you that's the reason I'm mentioning it here so I'll put the guide in the show notes below in addition to the episodes 173 170 and 151 and those are the ones that you can send to them I'll list them in the show notes something you need to remember is that when you're in when you're and you're laboring.
[34:04] Birthing and postpartum, that you are vulnerable and impressionable and you might have less energy. And this is really tricky if you're trying to also advocate for yourself when you're feeling this power struggle and some bullying and coercion and you just don't know what to do.
[34:23] This is where you start relying on your support people to help advocate for yourself. And again you can come up with some scripts that help communicate this to your support people and also your care providers and they can be really strong words I'm feeling exhausted with having to fight to get you to listen to what I'm trying to say, You could just tell them how tired and exhausted you are with this conversation. I am absolutely exhausted with having to fight for my own autonomy right now.
[35:02] Just come up with some scripts that convey that you've had enough. The scripts are your friend.
[35:09] Okay, the next strategy that takes a little bit more planning and preparation and that hopefully you would get to do before you're even that far in, that you're actually giving birth, is to choose care providers that you feel comfortable with and that you trust. This can eliminate a lot of the power struggles and the issues that even arise. You might not even need to feel like you need to advocate for yourself because maybe your care provider just provides respectful care and listens to you and you don't have to fight for what you want. But that all revolves around you making early decisions and accessing services where you are going to receive more respectful maternity care and be less likely to be coerced and having to fight for what you want. So choosing people that you feel comfortable to have conversations with, who you trust, who you feel comfortable saying no to, and who you feel like they will listen. This way, you'll find it easier to advocate for yourself because there'll be less fighting and less conflict. And the most likely place that you're going to find this is with continuity of care which is what I mentioned earlier in the episode all right we're going to move on to the next strategy.
[36:15] The next one is don't ask for permission remember this comes back to remembering that you are the boss tell them how it's going to be don't ask them what you can have so instead of can I get into the bath now the phrase is I'm getting into the bath or please fill up the bath I plan to get in it's not can I use the bath I'm planning on using the bath make that happen as my dear friend Kirsten Small says you don't need anyone's permission to use your own vagina let them know what you're planning and ask them how they plan to facilitate that now I'm going to repeat that again. Now this is a phrase from Dr. Kirsten Small, previous obstetrician, and she says you do not need anyone's permission to use your own vagina. Tell them what you are planning and ask them how they are going to facilitate that.
[37:15] All right, that is don't ask for permission. Just tell them what you're going to do and ask them, how are you going to help me get this?
[37:23] And as I've been talking the whole way through, the next strategy is to write and practice scripts for both you and your support people. What are some clear phrases that you can prepare and use and practice that will help you to advocate in scenarios where you maybe don't know what to do? You can go back to your script, choose the right phrase and go ahead with using that one. The next thing you can do, and you're already on track to do this, is you're listening to the Great Birth Rebellion podcast. And that is about becoming highly informed and educated so that you're prepared to self-advocate. One of the elements of consent is that you are informed because information means you've got everything, all the information that you need in order to make an informed decision and consent to the things that you want and don't want. The problem is it may be that your healthcare provider is gatekeeping some information and that they're only giving you information that they want you to have so that you make the choices that they believe you should make. Or they're giving you information that you're not going to have.
[38:31] That restricts itself to what they can offer you. They're not offering you everything on the menu. They're only offering you the certain things that either they want you to have or that they can personally offer you. But that's not all the information. That's gatekeeping information. And so you may need to take responsibility for gathering knowledge and information ahead of time so that if you're in a scenario where you have to make a decision where there's a fork in the road and you think, do I do this or I do that? If you've already put the time and energy and taken the initiative to become educated and informed yourself, these decisions become easier and clearer and you're not relying on external people every time, particularly if you don't necessarily trust them. You're not relying on them to give you all of the information. You're actually taking some responsibility over doing what you can to collect information that will help you make decisions as you go through your care.
[39:30] So that's the point of taking responsibility to become informed. And again, lots of people say, oh, that's not fair to make women do that. I agree. It's not fair, but we're in a scenario where the maternity care system may not have your best interests at heart and you have to self-advocate. And part of that is to be informed. So if you want to be able to consciously and successfully advocate for yourself, you need to take responsibility for gathering the information. And you're in the right place. If you are binge listening to the Great Birth Rebellion podcast, it is a great start into your journey of being informed.
[40:10] Now, the next way to advocate for yourself, for self-advocacy in the maternity care system, ask questions. So if somebody comes in and say, hey, we want to do this or we think you need this, go, okay, now it is an information-seeking exercise.
[40:29] Ask every single question you have. And if you're not satisfied with the answers, ask another question. If you still don't have all the information, ask another question. If as you ask these questions to that care provider, you're getting a sense that they don't truly even know what they're talking about or they're telling you things that aren't actually true and they're making up statistics and whatever it is they're doing, they might be getting angry with you. And this is something that happens if you repeat, if you repeatedly ask questions, you may observe the clinician getting repeatedly frustrated with you because they know that you're not just going to do what they say you actually want information before you make a decision and it's quite possible that they don't have that information at the top of their mind they may and I hope they do but my suggestion would be to ask all the questions that you need in order to gather the information that you require to make an informed decision if that clinician can't give you those answers it's okay to say something like it seems like you don't have the answers to the questions that I have can you find me somebody else who might be able to answer my questions.
[41:46] It doesn't have to be confrontational. It doesn't have to be aggressive. It's I need more information. Can you please find me somebody who can give me that information? And if they're giving you information that is of interest, say they're quoting some stats to you or they're giving you some information that you think, oh, I'd like to know the source of that, ask them, can you give me that research paper that you're referring to? Can you show me that policy that you're referring to? That's an interesting statistic. I'd be interested to know where that came from. And so you just keep asking questions until you have all the information that you need to make the decision that feels right to you. But please know that not all care providers will have the answer. And so you need to keep probing and asking, please, can you find somebody who can answer my questions?
[42:38] All right. So this kind of might go without saying, but I would suggest going above and beyond to be as polite and unemotional as possible as you encounter these interactions. And this politeness is going to make sure that the interactions don't escalate, that emotions don't bubble over. And you can offer sentences. Now, here is a psychological strategy. And again, I've gotten in trouble for recommending psychological strategies. Lots of cranky people emailing me saying, you can't suggest that. Yes, I can because it works. So when you're phrasing your sentences, there is a psychological hook in people's brain when they hear the word yes, they become calmer and more satisfied. When they hear the word no, that immediately puts a guard up. So when you're responding or having conversations, it's okay to start the sentence with yes. For example, yes, I'll think about that and let you know in a few hours. For example, if somebody comes up to you during labor and says, hey, we need to do this. And you're thinking, I need to have a think about that. Instead of saying, no, not right now. You could say, yes, I'll think about that and let you know in a few hours. The outcome is the same.
[44:07] Next, you could say, yes, thank you. I plan to continue as I am. it doesn't matter what they said before just start with the word yes yes I'll consider a vaginal examination in three hours but not right now yes I will get out of the bath when I feel ready honestly you're saying the same thing just put yes at the beginning instead of saying no, I will get out of the bath when I feel ready no I'll consider a vaginal examination three hours just put yes in front but say the same thing it just is a little bit of a strategy to keep the room calm in the best interest of yourself the next thing that you can do and this kind of goes hand in hand with becoming highly informed and educated is to write down your birth preferences or pursue this a birth mapping activity and this will help you be prepared with the information that you might need and come up with strategies as you come to those forks in the road for decision-making.
[45:10] Now, this one in particular is designed, this one I call expanding your time bubble, and it's specifically designed for when you're in labor, not during pregnancy or postpartum. It might work in those scenarios, but if I think about it when it's most powerful, maintaining or expanding your time bubble. Now, something you need to remember about the maternity care system is that it's obsessed with time. It wants everything to happen in a certain timeframe, a predetermined timeframe. And if your body doesn't perform according to their predetermined timeframe that they believe is the best timeframe, but probably isn't, then they are going to try and employ things into your labor that are going to speed it up and bring it back within their self-defined time parameters. So part of what women are always doing when they're engaging with maternity care, particularly in birth and labor, is trying to get a bit more time to just let their body function so that they can have their babies.
[46:11] And so this strategy of expanding your time bubble, basically, if they're asking you to do something that seems as though it's to speed something up, ask questions about, is this an emergency? Are myself or my baby in danger? Or are you just concerned because this is not happening in the time that your policy dictates it should? So ask a few questions about the urgency of the situation. Are me or my baby in immediate danger? What are your concerns? Why do you want to speed these things up? They might want to break your waters. They might want to do a vaginal exam. They might want to add oxytocin to your labor and birth experience. They might want to send you off for a cesarean section, whatever it is. If you're unsure and it's not an emergency, a strategy for how to keep control of what happens to you during labor and birth is to ask for more time. Expand your time bubble. So one example that I always use in this scenario is about the routine four-hourly vaginal examinations. So let's say you've had a vaginal exam four hours ago and your midwife or care provider comes back and says, right, it's time for your next vaginal examination. And you think, I don't really think I need it. I don't think there's any danger. I don't actually want it.
[47:34] And your timing, your phrasing could be, or your scripting around this could be, is thank you for the opportunity. However, I don't want a vaginal examination right now. I'll reconsider that possibility in two hours' time. So by then, you've pushed out to two hours. And once you get to that two hours time mark, if you think, I still don't want a vaginal exam, I actually don't feel like I need one, it's okay to say, I thought I might have wanted one, but I still don't. So I'll reconsider that opportunity in two hours. So this is all about expanding your time bubble, giving yourself more time for your body to just function instead of adhering to the arbitrary sort of limited timeframes that often you'll be offered in maternity care services.
[48:25] Now, you might find yourself in a scenario in the maternity care system where there becomes some argy-bargy, you've locked heads, there's no budging.
[48:39] And it may be that your particular requests are dismissed, that your desires are ignored. So now it's time to get a little bit more sort of, I don't want to say aggressive. We don't want to be aggressive. just a bit more robust so you could again this is about scripting say to your care provider please document that that my request has been denied that you could be any in this sort of phrasing that you have denied to provide what I would like document this in the notes and I would like to co-sign the document where you document how you declined to give me the thing that I wanted and ask if you can have a copy and then all the other thing you would do is ask for a second opinion so you could escalate this and say well I would like to speak to somebody else about this because I don't feel like you're listening to me.
[49:40] Again, another strategy. So come to the point in your script writing activity where you might write some things if they're absolutely not budging. What do you need to say in order to move things along? So please, I need to speak to somebody else about this. I don't feel like you're listening. Please document that in my notes that you have denied my request for whatever it is.
[50:12] Have some sentences like this that you can say that mean that that whole process is clearly documented in your notes and ask for a copy and ask to co-sign. This could be enough to actually have your whole scenario escalated to somebody else whose job it will be to make sure that you're satisfied with your care. I would hope that if you get to this point that somebody is allocated to your care who's more gentle and the power struggle is less.
[50:42] Okay, I could talk about this all day, but I'm going to stop there and give you a very brief summary of what I've just said. First thing, remember that you are the boss of your body. That law protects your autonomy and your decisions within the maternity care system. Although culturally, the maternity care system believes that they're in a power position over you, that's not what's written in law or hospital policy. Secondly, your care provider must obtain valid consent before doing anything to you and if that consent is achieved through coercion or putting on pressure or trying to persuade you, that's not valid consent. Number three, if you've identified yourself as a people pleaser, immediately you know that you are going to have trouble advocating for yourself in the maternity care system. So now is the time to start formulating some scripts, practicing standing up for yourself and saying no to things that are outside of your personal boundaries of what you want to do. This is the time in pregnancy, birth and postpartum where you have to advocate for yourself and baby. There's no room for people pleasing. The next point is don't make decisions in order to solve the problems of the maternity care system where they are advantaged and you are disadvantaged. Always make the choice that advantages you and leave the hospital system to work out their own problems.
[52:11] The next point after this, and this runs through all of the points, is to write down scripts, words that will help you and phrases that will help you to, that you can repeat, that you can refer to if you're in scenarios where you're advocating for yourself and you feel like there's no other strategy. Look through your list and see which phrases and sentences are going to be the best for that scenario and just practice and use them in the scenario. It's okay to just take your time with this. The next point is to recruit a robust and prepared support team that could include a doula, a private midwife, your own continuity of care providers, your partner, your support team, whoever it is that you can recruit to yourself to become part of your advocacy team. That goes hand in hand with choosing care providers that you feel comfortable with and that you trust and preferably who can care for you for your pregnancy, birth and postpartum. The next point is don't ask for permission. You are the boss. Just tell them what you plan to do and ask them how they're going to serve you.
[53:17] The next point is to become highly informed and educated so that when you come to decision points where there's a fork in the road and you have to choose one or the other, you feel confident because you've got all the information that you need. This goes hand in hand with asking your care provider as many questions as you need to get the information that you need. In the scenario where your care provider is unwilling or unable to fully answer your questions, ask them to give you a care provider who can fully answer your questions.
[53:49] Again, be polite and offer the yes in front of sentences that explain what the plan is. Yes, I'll think about that and let you know in a few hours. There was the strategy of expanding your time bubble, the strategy of just asking for some more time. I need some more time to think about that. I'll let you know in whatever time you decide. And if all of those things don't work for you to get to finally feel heard and to get the thing that you're advocating for, it's okay to escalate this and ask your care provider to please document that my request has been denied and ask to co-sign documents and escalate for a second opinion. If at all you can, if you're having a lot of trouble with your care team or the facility that you're at, it's okay to also opt out of that scenario and leave. I realize that that is not possible for everybody because resources and birth locations are scarce it's a privileged position if you can change care providers midway through your pregnancy but if at all possible if you have doubts it is okay to do that all right again as I said I could talk about this forever but that is in a nutshell some of the self-advocacy strategies that you could use.
[55:10] And adopt if you want to get the things that you want out of your pregnancy, birth, and postpartum without feeling like somebody's made decisions on your behalf so that you can feel confident that what happened to you is based on all of your own decision making and that you've made the choices that feel right for you and your baby. I'm your host Dr Melanie Jackson and I'll see you in the next episode of the Great Birth Rebellion podcast. 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.
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