Pregnancy is a time of excitement and trepidation, yet mothers have found themselves routinely facing ethical and moral judgments in relation to their behaviour when pregnant or later while breastfeeding.
With opinions from strangers, friends, and immediate family on our weight, our age, if we smoke, our diet, unintended or teenage pregnancy, our birth choices or our mental health, we ultimately are led to question almost everything we do as we grow and birth our babies.
Disappointingly, pregnancy and birth has not avoided this onslaught of stigma with many women feeling judged for their choices, actions or beliefs while pregnant and afterwards, which may create shame, guilt and intense culpability if something were to go wrong.
Stigma is a significant barrier for women who are looking for help, support and treatment, often avoiding medical advice for fear of being condemned. The adverse effects of stigma on our mental, physical, and behavioural health is well documented and can be particularly detrimental to maternal health. While stigma often grows as a social construct, in this instance the medical profession has a responsibility to help eliminate stigma attached to the compounding world of pregnancy.
What may seem like a test with answers we believe we are getting wrong, the first appointment a woman undergoes in her journey from conception to birth is the booking visit. It’s here our midwives create an understanding and picture of our overall health and our lifestyle in order to care for us and our babies while in their care. However, the process and questions can unintentionally provoke underlying feelings of shame, discrimination or inadequacy.
Geraldine Gannon, assistant director of midwifery and nursing at the Rotunda Hospital in Dublin, is very aware of underlying stigmas some women may encounter throughout pregnancy. She suggests maternal care has changed rapidly in the past number of years with efforts to eliminate bias or the belief that the medical profession is judgmental in its care and a change whereby the profession aims to empower women in decision-making surrounding their own health, pregnancy and birth. With changes to antenatal education, providing an inclusive environment and encouraging women to voice their concerns maternal health is changing across the board.
“We’re conscious that the booking visit may be a woman’s first encounter with the health service if it is her first pregnancy,” says Gannon. “It’s also our first opportunity to help women better their health. Every question we ask at these appointments is necessary and for an important reason. Every answer will lead to a different pathway to appropriately care for her and her baby. So, if we take her weight and ask if she smokes, the pathway will go one way or another depending on the answers.”
Every midwife will say no two pregnancies are the same. As such, no two women are the same either and for a woman to receive the appropriate care, honesty about her lifestyle is essential. Yet there is a fear of reprisal if a woman admits to an eating disorder or discloses anxiety. What is needed against the backdrop of the new mothers on social media “bouncing back” is the reality of pregnancy, birth and motherhood.
The Rotunda is proactive in keeping the lines of communication open with women. Their podcast Real Talk with Real Mums is an expert-advised 10-episode podcast series presented by Louise McSharry which looks at issues of pregnancy while battling various pregnancy-related stigmas. Hearing not only the voices of health professionals but the real experiences of women who have gone through the pregnancy journey shares the familiarity with women who may feel alienated in their own experience.
“I would go a step further,” says Gannon. “Pre-conceptual care is also important. Educating our young women at schools about their bodies, fertility and family planning can create a balance in our understanding of pregnancy and birth and help tackle stigma.”
Essentially, education is key which Susan Hogan, the lead of parent education at the Rotunda, emphasises. "Knowledge is power," she says. "If women are well prepared, have attended a good-quality antenatal class and understand about labour and birth, they will understand their choices." With an average of 300 weekly attendees at the varying classes provided by the Rotunda (currently through online methods), including emotional wellbeing, fear of childbirth, parental education and nutrition classes, Hogan has a firm grasp on the support women need throughout pregnancy but acknowledges women need support in approaching and discussing their care with medical professionals. Empowering women to speak up is part of her remit in educating pregnant women.
“We teach women the B.R.A.I.N. acronym to encourage them to speak confidently and discuss their care with health professionals,” says Hogan. “B stands for benefits. R stands for risks. A stands for alternatives. I is intuition. And N stands for nothing. Helping women navigate discussions with the medical team means they can ask relevant questions and get the right answers. By using B.R.A.I.N. they can very quickly ask their healthcare provider what are the benefits of doing this? Are there any risks to me or my baby? Is there an alternative? I usually say to them once you have your Bra questions answered your intuition may kick in and guide you. And finally, when they understand the why, they can ask what happens if we do nothing? Being part of the decision making is essential for women and as a by-product can challenge any stigma they feel in those choices.”
Giving women a voice comes with them also understanding the events of pregnancy and birth. To do this, women need transparency and bodily autonomy. With the introduction of a birth reflections service, The Rotunda recognises that women will have questions following the birth of their baby, questions which are often not asked straight after birth or even a month after. Every pregnancy and birth is different, with bodies and babies changing potential plans.
For women to understand the events of a birth, the birth reflections service gives them the opportunity to discuss why certain things happened. This gives women the chance to understand or come to terms with a traumatic birth which can alienate a woman and lead to PTSD, depression or anxiety. While the service is not a counselling facility, it opens up a conversation and understanding surrounding birth which can counter the potential for a woman to feel marginalised or stigmatised.
“Our aim,” says Gannon, “is to respect women’s voices. Give women the right information so they can make informed decisions to continue with their lifestyle choices as safely and as healthily as possible. If there is something a woman is concerned about, no matter what maternity hospital or service they are attending, if they feel judged or stigmatised they need to tell us. If we don’t know about it, it’s difficult for us to help.”
Women's Health Gap
Part 1: Unheard and dismissed
Part 2: Discussing fertility issues
Part 3: The female body
Part 4: Stigmas surrounding pregnancy