How do I keep that knife a threat and not a prediction?

In which she explores if it's really possible to be a human in a system

Last week, in my piece about obstetric providers only knowing what they know (which is to say, what birth looks like when medically managed) and not what they don’t, I mentioned that I once worked with an OB who would casually text me the knife emoji whenever she wanted to let me know she was losing patience with someone’s labor.  I received a bunch of messages about this particular anecdote, and yes, it’s appalling. To be fair to her, she wasn’t the only one whose shorthand for surgical birth was the knife emoji (is that more appalling, or less?); to indict her even more I’m also certain that on at least one occasion the knife was accompanied by the happy devil emoji. In any event, here is what I think is more interesting about that anecdote:

At the time, when I was receiving those texts, I didn’t think much of it.

Yes, it’s true.  Even me, your humble author devoted to exploring and educating on the way in which obstetrics and midwifery is rooted historically in structures of oppression such as capitalism, colonialism, and slavery, did not consciously register, much less say, “that is an incredibly dehumanizing and abusive thing to do.” I remember reacting to it, on a nervous system level, with dread and a pit in my stomach or a spike in irritability, but if I thought anything consciously, it was something more like how do I keep that knife a threat instead of a prediction?  Working in the Medical Industrial Complex (MIC), mine was a mind always oriented toward strategy.

When birthing people use words like “humiliating,” “belittled,” “brutal and barbaric,” and “being treated like a piece of meat,” or an “animal” to describe their experiences in the MIC¹ , this is exactly why. Because the MIC is a world in which it’s considered unremarkable or normal to use a knife emoji to convey your clinical opinion about a person you’re supposedly caring for. On one of the single most impactful days of their lives.

Here’s the thing about working in institutions: it institutionalizes you.

And I don’t just mean in the shocking, unquestionably abusive ways we read news stories about; the stories about doctors coercing people to have c-births and telling the person, baldly, “my license is more important than you.”² Yes, these cases very much exist: it’s well established that a form of obstetric violence is providers threatening legal repercussion or the involvement of child protective to coerce clients into compliance.³ But what I want to talk about today is subtler than that, though it is still part of the overarching culture of violence against birthing people.

Pregnant people often tell me, “I really like my OB” (it’s rare anyone ever says “I really trust my OB,” which in and of itself is interesting) or “my midwife says I can…” (push on hands and knees, receive intermittent monitoring, decline a particular intervention, receive delayed cord clamping, etc.) to explain why they have chosen a particular practice. To explain why, in essence, they think they will be the unique individual who will escape the MIC without the interventions they don’t want.  Yet it’s rare that, months later, the story of their birth matches the expectations or hopes that person had based on their prenatal interactions with their provider.

Here's the thing most of those people don’t understand. It’s not that OBs and midwives are intentionally baiting and switching people (though that happens, too). It’s that even in the best case, even if they very much like you back, even if they very much want to facilitate the kind of birth you want, they are at the end of the day part of a system they need to navigate, and that will always take precedence over you as an individual.  And I don’t mean that just in the way of institutional protocols and policies they are subject to (which is, of course, also true).  What I mean is that everything they can and can’t do for you depends on the relationships they have established in that system and their relative power within it, things that change and shift from day to day as different interactions and cases inflect both those individuals and the culture of “the floor” generally.  One of the things I was most surprised about when I got my first midwifery job was the way in which most of my mental energy went not to the carework itself but the interpersonal work: getting to know and gaining the trust of dozens of others midwives, obstetricians, and nurses;  making sense of the roles of the random people who would show up on the floor to represent the hospital’s more bureaucratic interests; getting a feel for the politics (i.e. who hated who); gaining acceptance and avoiding suspicion ; becoming adept at delicately dancing in the various power differentials among all of us; soothing the fears – and therefore attempting to temper the newly conservative management – of my colleagues each time we experienced something traumatic.  (Grey’s Anatomy wasn’t wrong: the drama was in the relationships. Except there was way too little hot sex for my liking.)

Or put a different, simpler way: establishing and maintaining how well liked I was. Because I couldn’t do good work or provide good care if everyone I relied upon to help me provide that good care hated me.

The truth is this: no matter how much you like your care provider or believe they want for you what YOU want for you, their loyalty is never going to lie with you because it actually can’t.  The institutionality of your care ensures this. You are just one person they will care for, in a sea of hundreds and thousands of people they will care for, within a context of a team they have to work with every single day, long after you have given birth.

It's not that midwives or even the nurses with whom I worked didn’t question much of the management that we, the frontlines of most of the care, were expected to implement though such management was usually the result of someone else’s agenda or clinical decision. Many of us had entered the job with lofty and idealistic dreams about making a difference in the systems we were working in, of fighting the good fight, of centering the birthing people, not the institution. Complaining about the agendas or practices of the institution, in the breakroom or at the nurses’ station, was a reliable part of our days.  Carving out some version of care that somehow balanced the defensive medical recommendations we were expected to enforce while maintaining some humanity for birthing people was the animating question of our jobs.  Some battles, to be sure, were impossible to fight: the culture of induction and augmentation was certainly Too Big To Fail.  But what we pushed back against, or not, was often not a matter of courage; it was typically a matter of strategy, a constant calculation of which battle was worthy of being picked and which wasn’t. Which battle was worth the potential fallout and which wasn’t.  Which was likely to succeed, and which wasn’t.  Sometimes refusing to drug test someone without their consent was more important than fighting for a little more time for another person before they got augmented, because, let’s face it, they were probably going to get augmented anyway, be it now or later,  and fighting for both would risk too many grudges, too much potential for people to label you as difficult or irresponsible or condescending and lead to their undermining you the next time you needed them or refusing you the next time you tried to advocate for a patient when it really mattered.  You have to be a team player, after all. Sometimes putting in a clinically unindicated internal fetal monitor so an overburdened nurse didn’t have to keep adjusting the external one that wasn’t staying on meant she’d have your back when advocating for a client to rest more before pushing or laugh when you physically block her from suctioning a baby who didn’t need suctioning instead of move around you and do it anyway.

In an institution where care is given by a team, you can’t do good for anybody if you’re hated by everybody.

But lest I make the motivations of which battles to pick and which not to sound completely altruistic, there is also, simply, that people enjoy being part of a team.  It’s universally acknowledged most humans long for a sense of belonging, and I doubt anyone would dispute that most people would prefer a work environment that involves rapport and trust and belonging rather than hostility and disdain and sabotage.⁴ Not only do providers have to work with their coworkers long after they have or have not advocated for you in the way you want and have or have not ruffled any feathers on your behalf along the way, those coworkers are often people with whom they have developed deep relationships and real affection for. And further: in a field where the work involves matters of life and death, who wants to risk being the scapegoat? When I first started working in the MIC, as a very green midwife who felt enormously the weight of her responsibility, my very worth as a midwife was defined by the approval and respect of my team.  What other measure was there?  There was so much I didn’t know and couldn’t judge myself. I relied on those more experienced than me to judge my worth and competence for me.

The trick is, the same people you work so hard to gain respect and trust from are the same people who you routinely see engage in a procedure explicitly against a birthing person’s will, or without giving them a choice or time to consider it.⁵ (The same people, ahem, who send you knife emojis.)

All of this works together to subtly and not-so-subtly create a distinction between hospital staff and the people they care for, and much of this is by design that’s become so naturalized we don’t even think to question it. Take the norms of costuming, for example: we’ve accepted hospital gowns and white coats and scrubs as somehow necessary or more sterile, but that’s absurd. Their real function is to both deindividuate (to take away individuality) and individuate (to separate one group from another). Hospital “patients,” including birthing people, wear white gowns.  Hospital staff wear scrubs – sometimes in different colors or with a white coat over them to mark their place in the hierarchy. This denotes everyone’s place in the system, stripping away markers of the birthing person’s humanity, so it is easier to “treat” them without regard for their individual stories, and separating those in power from those who aren’t. 

But how will you know I’m a Real Medical Professional unless I wear my green pajamas?

What about the way in which birthing people are commonly referred to as their room number or their diagnosis: “12 is pushing” or “the diabetic needs her insulin at 3:30?” This was something that struck me on my very first day as a student on Labor and Delivery but that I myself was forced to participate in because if I referred to someone by name the very same people who were digitally penetrating her often did not know who I was talking about. This reinforces a power differentials and dehumanization: we have names; the patients have numbers. All of this is taken for granted as part of the culture of the floor, but none of it is neutral or benign.⁶

I could go on; the examples are endless. But the point is this: of course I didn’t register the knife emoji; I was working in a place that structurally was trying to groom me to identify with the person who was sending me the knife emoji, that was structurally trying to ensure that the parts of my brain linked to empathy wouldn’t activate too much while watching someone in pain⁷ . The institutional socialization of the MIC is so powerful that the longer providers work there, the less they tend to register the humanity of the people they care for.⁸ Conversely, the more clinicians humanize the people they care for, the less satisfied and more disillusioned they are with their work.⁹ In other words, the institutionalization of care appears to be something of a contradiction; the two are fundamentally at odds.

Many would argue this is protective, of course. And maybe you don’t want your oncologist or the orthopedist setting your broken bone over-empathizing with your pain; maybe you want them cognitively focused on problem solving and treatment (let’s ignore here that there’s also data that humanizing “patients” might improve outcomes¹⁰ and let’s also ignore that this is hardly relevant to birth, which is not a pathology and during which the care most people need is actually PRIMARILY empathy). There’s also the old chestnuts of trauma and exploitation that people love to use to justify some of these behaviors:

Another explanation commonly given by professionals in the attempt to “justify” the violent scenario of obstetric care is based on elements such as work overload, scarce human resources, physical and mental exhaustion of professionals, precariousness of the conditions for care provision, and lack of adequate infrastructure in institutions. These problems altogether generate stressful, disqualified environments favorable to the occurrence of the different types of [obstetric violence], culminating in the lack of commitment of health professionals, who also feel violated by inadequate working conditions. Moved by a feeling of impunity and passivity, health professionals perpetuate violent practices during obstetric care, replacing ethical relationships with inhuman, highly technological and invasive care.¹¹

I get it, I really do. Providers are often working in dehumanizing conditions themselves. Compassion fatigue is real.

It’s almost like what I said at the beginning of this newsletter is true: working in an institution institutionalizes you.

Dear readers, I’m only briefly touching on the intersections of some very complex issues here, but before I compose an entire treatise, I’ll end there for now. What questions do you have? What specific elements do you want me to unpack and dive deeper into in upcoming newsletters? Let me know; til then I remain your faithful and recovered knife-emoji overlooker,

Robina

1. Reed R., Sharman R., Inglis C. (2017). Women’s descriptions of childbirth trauma relation to care provider actions and interactions. BMC Pregnancy and Childbirth 17(21) 1-10. https://doi.org/10.1186/s12884-016-1197-0

2. As is alleged in the case Dray v. Staten Island Univ. Hosp., No. 500510/2014 (N.Y. Sup. Ct. Kings County).

3. I myself, a highly educated medical professional (but of course also a woman of color), have been subjected to such tactics in my life: my family was threatened with CPS involvement when I asked to sign my then 9 year old daughter out of the hospital where she was being treated for a minor injury, not 5 miles from the one where I myself worked, in order to obtain a second opinion on the appropriate course of action. This was after she had been admitted without our full consent.

4. See, for a start:

Ching, H. Y., Fang, Y. T., & Yun, W. K. (2022). How New Nurses Experience Workplace Belonging: A Qualitative Study. SAGE Open, 12(3). https://doi.org/10.1177/21582440221119471

Levett-Jones T., Lathlean J. (2008). Belongingness: A prerequisite for nursing students’ clinical learning. Nurse Education in Practice, 8(2), 103–111. https://doi.org/10.1016/j.nepr.2007.04.003

Panda S., Dash M., John J., Rath K., Debata A., Swain D., Mohanty K., Eustace-Cook J. (2021). Challenges faced by student nurses and midwives in clinical learning environment – A systematic review and meta-synthesis. Nurse Education Today, 101, 104875. https://doi.org/10.1016/j.nedt.2021.104875

5. In a survey of birth workers (including doulas, childbirth educators, and labor and delivery nurses), Roth et al found that more than half had witnessed a physician engage in a procedure explicitly against a woman’s will, and nearly two-thirds had witnessed providers “occasionally” or “often” engage in procedures without giving a woman a choice or time to consider the procedure.

See: Roth, L.M., Heidbreder, N., Henley, M.M., Marek, M., Naiman-Sessions, M., Torres, J., & Morton, C.H. (2014). Maternity Support Survey: A Report on the Cross-National Survey of Doulas, Childbirth Educators and Labor and Delivery Nurses in the United States and Canada. www.maternitysupport.wordpress.com

6. It’s worth also noting here that homebirth midwives or midwives engaged in community birth don’t escape this kind of thinking simply by virtue of working outside of the medical industrial complex.  It takes conscious effort and consistent self inquiry; we have all been educated and indoctrinated into a colonized, paternalistic, white supremacist approach toward birthwork, as I’ve written about before.

7. Cheng, Y., Lin, C., Liu, H., Hsu, Y., Lim, K., Hung, D., & Decety, J. (2007). Expertise modulates the perception of pain in others. Current Biology, 17, 1708–1713.

8. Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., . . . Scheffer, C. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine, 86, 996–1009.

9. Vaes, J., & Muratore, M. (2011, July). Defensive dehumanization in the medical practice: The effects of humanizing patients’ suffer- ing on physicians’ burnout. Symposium conducted at the 16th general meeting of the European Association for Social Psychol- ogy, Stockholm, Sweden.

10. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians' empathy and clinical outcomes for diabetic patients. Acad Med. 2011 Mar;86(3):359-64. doi: 10.1097/ACM.0b013e3182086fe1. PMID: 21248604.

11. Jardim, D. M. B., & Modena, C. M. (2018). Obstetric violence in the daily routine of care and its characteristics. Revista Latino-Americana de Enfermagem, 26(0).doi:10.1590/1518-8345.2450.3069