Welcome to the Best of Birthful. Creator and host Adriana Lozada curated and edited each selection in this playlist of the show’s most popular episodes. It’s a tailored introduction to the expansive catalog she amassed over the first five years of Birthful’s 300+ shows.
Cristen Pascucci, founder of Birth Monopoly, raises awareness about what she coined as “obstetric violence” and advocates for human rights and informed consent in perinatal care. She talks about how to protect your rights as a pregnant person, and what to do if they are being violated.
- Birth Monopoly resources
- Mastering Respectful Confrontation: A Guide to Personal Freedom and Empowered, Collaborative Engagement, by Joe Weston
- Human Rights In Childbirth
- VBAC Facts
- Evidence Based Birth
- Obstetrician Ethics: Awesome Guidelines from the National OBs’ Group, Birth Monopoly
Related Birthful episodes:
- Place of Birth as Your #1 Cesarean Risk, with Dr. Neel Shah
- Know What You’re Up Against When Giving Birth at a Hospital, with Mimi Niles
- Why You and Your Care Provider Must Decide Everything Together, with Dr. Brad Bootstaylor
- Choosing Your Care Provider, with Robin Elise Weiss
- All About Midwives, with Melissa Cheyney
- Showing up at Your Birth, with Shalome Stone
- Healing Your Birth Story and Birth Trauma, with Pam England
[Best of Birthful] Tips to Advocate for Yourself During Birth
Hey, mighty one. With nearly 300 Birthful episodes in over five years, it may be hard to know where to begin listening to the show. To make it easier, we’ve put together the Best of Birthful series, which showcases some of our favorite or most relevant episodes. This is one of those. If you enjoy what you hear, make sure you subscribe. It’s free, and that way you won’t miss a thing. Enjoy.
Hello, mighty parents and parents to be. Thank you as always for all the love you give the show and your feedback. I have the immense pleasure of talking with Cristen Pascucci, who is the founder of Birth Monopoly, where she advocates for a freer maternity care market, working closely with leading national advocates, organizations, and birth lawyers, as well as educating the public and healthcare providers about women’s human and legal rights in childbirth. Welcome, Cristen.
Lozada: So, we’re talking today about informed consent in childbirth, and you know, things related to that. Let’s start right at the… What does that even mean?
Pascucci: Informed consent is one of our most basic rights in our healthcare. It’s sort of rooted in the idea that each of us owns our own bodies, which you know, sounds really simple, and sort of basic, but it means a lot in, especially in maternity care. So, informed consent is the process by which a healthcare provider informs a patient about the risks, and benefits, and alternatives to anything that they’re suggesting, and then gets the free, non-coerced consent of the patient to perform that procedure or whatever it is.
And that also includes the right of refusal, which is really important. That’s the right to say no to anything that has to do with your body. So, this is really critical in maternity care because just the way sort of that field has evolved, women have often been sort of treated like passive people rather than active sort of directors in their own births. So, in a lot of times, there’s a little bit of a learning curve when it comes to informed consent, because you’ll see a lot of routine practices, and procedures, and policies don’t necessarily come with informed consent, even though women are definitely owed informed consent.
Lozada: Let’s talk a little bit more about what… So, in terms of this informed consent and refusal, the right of autonomy of your body, basically, and decision making.
Lozada: So, I understand that how maternity field has evolved into this, and it is a tricky situation where you’ve got the consideration of the mother and the consideration of the baby, and so sometimes when I speak to whoever about this concept of your rights in childbirth, there’s always the, “But not if it’s gonna harm the baby.”
Pascucci: What about the baby?
Lozada: Right. So, can you talk a little bit about that?
Pascucci: Yeah. Well, you know, I think it’s important for people to have a little bit of context for the system, which is, and I’m not saying anything new here, a lot of our routine procedures and policies and practices are actually harmful to babies. And a lot of the things that you see families sort of pushing back on are those very things. So, families are saying, “Huh. Well, you know, I’ve done a bunch of research and I realized that actually this isn’t good for the baby, and so I’m going to exercise my right to informed consent and refusal in this instance and say I’m gonna opt for something different, or I’m gonna just say no to that thing.”
So, I think it’s really important that people understand that, that I think we can assume for the most part that the mother and or the parents are most concerned about the safety of the baby. And if we start with that, it sort of switches the onus from what the care provider is sort of dictating about it to the care provider empowering the mother to make the choice that’s right for her and her baby. Does that make sense?
Lozada: Yeah. Absolutely. Absolutely. In terms of putting that into practice, like finding their voice and getting their wishes across, how can the laboring women and her support team communicate with care providers to make sure they’re heard?
Pascucci: Yeah. Well, I would say just to cut to the chase on the whole thing, the number one most important thing is who you pick as your care provider. And I know that unfortunately, not everyone has a choice or has a lot of choice in that. For those who do have a choice, I would say exercise that choice. Find someone who it’s not going to be a struggle, or it’s not going to be a fight, or it’s not where you’re gonna have to figure out how to communicate with them. Find someone who already communicates in those terms, and then you can skip this whole issue.
But of course, you can’t always predict either who you get, and you might have different staff members, which… You know, nursing staff, or aids, or techs, and those aren’t necessarily things you can plan for. But I think starting with a sense of confidence about what your rights are and almost like grounded in yourself I think is really, really important. So that you don’t… So that you’re not automatically starting out like on your back foot, where you feel like you have to ask permission, because it really should be the other way around. And I think developing that sense of confidence comes from educating yourself, from practicing how you’re gonna communicate, which I’ve made a handout about just to get people sort of warmed up to that idea.
I also, for people who have the time, look into nonviolent communication skills. Mastering Respectful Confrontation is a great book by Joe Weston, and you know, that just sense of confidence that comes from being… knowing your rights, feeling like a valued, respected person, with maybe having a little bit of practice in what exactly you’re gonna say when you have some questions, or you need a little more time, or you’ve already decided that that’s something that you’re going to refuse.
Lozada: And you know, it is kind of weird and bizarre that we’re talking about arming yourself with or learning techniques for nonviolent forms of communication as part of a birth skills and tools for your birth.
Pascucci: I know!
Lozada: You know?
Pascucci: I know. It seems kind of ridiculous sometimes, but you know, unfortunately it’s just reality. From a personal perspective, it was… I wasn’t used to being treated like… without a lot of respect. This sounds like such a ridiculously privileged statement, but it’s just true. I just wasn’t used to being treated in such a sort of… like I was a child. And so, it caught me off guard even though I went in really confidently. It was like, “Oh my goodness. I don’t even know how to talk to these people.” Because I’m so thrown off by the way I’m being treated right now, it’s just really bizarre to me.
So, I don’t know. I just… My point is just that you can’t prepare too much. You never know how you’re gonna react when you’re under a little bit of pressure and you’re dealing with some sensations in your body, as well.
Lozada: I mean, with Birth Monopoly, you also have all your merchandise that says, “You’re not allowed to not allow me.”
Lozada: Yeah. That’s such an incredibly to the point, essential core of this whole idea of the care providers are allowing you to do this and this and this and this during birth.
Pascucci: Right. And it really is the other way around. Like from a legal rights point of view, from a human rights point of view, from an ethical point of view, it is the mother who gives or does not give permission to anyone else to do anything to her body.
Lozada: No matter what.
Pascucci: Yeah. It’s not the other way around.
Lozada: So, knowing all of these things, having practiced, I always feel silly role playing, practicing in front of the mirror, but yeah, there’s something about your body doing that muscle memory.
Pascucci: Yeah. Well, I think it’s really helpful to practice with… You know, have someone pretend to be a nurse or a doctor, and you know, have them get aggressive with you, or have them get passive aggressive with you. It is really helpful. You know, it’s just one of those things. You don’t ever think you’re gonna be in that situation, and then when you are, it can be really uncomfortable, and like you said, it might feel silly, but man are you gonna be grateful for that little bit of muscle memory if you ever actually need it.
Lozada: So, what if you practice your phrases and you’re like… You managed many ways of saying no thank you, and can we have more time, and you are still not being heard? Like if you need to take it to the next level? What suggestions do you have for that?
Pascucci: Well, I would also say something that we haven’t talked about very much is the role of the partner. You know, we always say that it’s the mother’s right and it’s the mother’s responsibility, but the fact is that’s a really big responsibility to put on someone who’s in labor, you know? When she’s made it clear that… And you know, obviously I’m not talking about speaking on behalf of the mother, but you know, when she’s made clear how she feels about something, if she says for example, “No, I don’t want to get in bed. I’m gonna walk around.” And you know, she’s being repeatedly pressured to do something different, it’s totally appropriate for the partner to step in and give her that space, you know? The power dynamic I think is a little bit different when it comes to the birthing person versus someone else and the partner versus someone else. It can be really helpful to have a little bit of a united front there and say very respectfully, “You know what? She’s said that she needs to walk around, so I think we’re just gonna let her walk around. Thank you very much.”
I would say at some point, you might want to just say very firmly, “I do not consent. I want you to put that in my record.” I think that doing that sometimes can break the spell of what’s going on in there. When you remind someone that you know what? This stuff is being documented. There’s a bigger world than the little bubble that’s happening right in this room right now. I think once you hear the words, “I do not consent,” and then to actually write those words down, I do not consent, I think is kind of powerful for a person who’s trying to get someone to do something that they don’t consent to.
Another thing you can always do, if it’s something that they clearly feel really strongly about, and a lot of times, frankly, you’ve got a nurse who… She has a job to do. She’s been told these are the standard practices for the average woman who comes in. And all she knows is it’s her job to get those things done. It can be really helpful to reassure them by saying, “I would be happy to sign a waiver about this thing.” You know, I think there’s that fear of liability in the back of healthcare providers’ heads a lot of times. Even when they can’t articulate to themselves that that is what’s motivating them, and I’ve heard about parents using that sort of tactic successfully.
So, another thought is to bring someone else in the room, and again, this is when a doula or a partner would probably need to help out. You know, I’ve heard of people asking for the chaplain to come in, which is sort of like a neutral third person, hopefully, who might bring a little bit of calm and break some of the tension. Every hospital has a patient advocate or a patient liaison. Some of them advocate more for patients and some of them advocate more for their employer, which is the hospital, so that’s something to bear in mind.
But again, when you’re sort of out of other options, those are good kind of last resorts. In really extreme situations, I used to run a hotline where women would be basically in the moment and would call me and I would have to help them basically do a legal intervention, and sometimes we’d have to call the hospital with a lawyer and say, “You can’t legally force that woman into that C-section,” or something like that. But hopefully our parents aren’t gonna be getting anywhere close to needing that level of intervention.
Lozada: Yeah. And it’s so amazing that you are doing that and having that extra support for women in labor, and also baffling and crazy that that was needed.
Pascucci: Yeah. Yeah, I know. Well, you know, there’s such a misunderstanding about the rights of pregnant people. I mean, such a misunderstanding. There’s some places that I swear they’ve never even heard the term informed consent and refusal. There’s just such a variation in awareness and practice around informed consent and refusal.
Lozada: And so important why we need to keep sharing these things and making sure people understand that they have that right. Yeah. So, we’re gonna talk a lot more about that and hospital policy. So, let’s talk about that additional layer of that, that affects everyone. The nurses, the staff, you, the care providers. Can we talk about where that comes from, what it means, how it affects or interacts with a person’s right to informed consent and refusal?
Pascucci: Yeah. I think that is one of the big pain points, is that every hospital has policies and protocols that they, again, there’s a variation. That some hospitals view those policies and protocols as guidelines and some hospitals view them more as requirements. It’s a really harmful dynamic. You know, for birthing women to have that idea that anyone can let, or allow, or not let, or not allow them to do anything, but a lot of times when we’re told it’s hospital policy, we think, “Oh. Well, then my rights end at hospital policy.”
The reality is like I had mentioned a couple minutes ago about nurses, nurses are responsible for policies and protocols. However, your legal rights as a patient are not less than their obligations to their employer, if that makes sense. So, your legal rights trump the preferences of the hospital. Whether those preferences are policies, or they’re just routines, or they’re protocols, or whatever that is, we’re talking about our most basic civil rights here, which is why I always talk about nonviolent communication and mastering respectful confrontation. Because it takes some skills to sort of like directly contradict something that someone’s saying to you without escalating the situation.
And even more than that, keeping those people on your team. You might need those people’s help. There’s a good chance that you’re gonna want their cooperation, and we want everybody to be on the same page.
Lozada: Yeah, because it’s not like you say, “Well, no, I’m not gonna not eat or drink,” and then, “Goodbye, I’m out of here.” You still have to do the rest of your labor and push-
Pascucci: You’re still gonna be here for another day. Right.
Lozada: Right. So, that brings a great point of that’s the great fear, right? Of being labeled as difficult, or problematic, or being retaliated in some way, that your care deteriorates even more because you’ve refused to-
Pascucci: Yeah. Absolutely.
Lozada: … do something. Yeah.
Pascucci: Yeah. That’s definitely sadly and unfortunately, and it’s something we hate to have to talk about, but exercising your rights doesn’t come with impunity, unfortunately. When you’re in a system that is really weighted heavily against you using your rights, it’s not as simple as just saying, “Well, this is what I’m gonna do and live with it.” And everybody says, “Okay, great! Awesome. How can we support you next?” You know?
They’re human beings. They have emotions, and they have feelings, and they have motivations, and fears, and biases, just like you do, and just like I do, and we have to work with that.
Lozada: Yeah, and I think what makes it extra hard is that a lot of those policies aren’t evidence based. They aren’t necessarily what is best for mom and labor or baby, like you mentioned earlier.
Pascucci: Yeah, and that’s true, but again, that’s probably something that you can figure out much earlier in pregnancy with your care provider, and say, “How do you feel about this? Is this a standard practice for you? Is this… Have you done this before? Have you done this a lot? Do you get a lot of moms asking for this? How do you feel about it?” So, you should be able to get a feel for that.
Lozada: You’ve gotta bring that confidence also into your… the visits with your care provider, because sometimes it can be intimidating that you have five minutes with your-
Pascucci: Right, but that’s a problem.
Lozada: Yeah. Huge.
Pascucci: I mean, you deserve to have your questions answered. That is all there is to it. You are the person who is at the center of that care, and if they don’t have time for your questions, then I would really consider that seriously. What’s it gonna be like when you’re giving birth with them? Are they going to have time for you? Are they gonna prioritize your comfort and your providing you with information?
That’s the last thing I would want to be in that situation, would be in giving birth and having a care provider refuse to elaborate on something, or refuse to engage with me, and just say, “Well, that’s just how we do it.” That’s not cool.
Pascucci: It’s not good care.
Pascucci: I remember one woman saying that… She said, “Every time I go to a new practitioner, the first thing I say to them is, “Listen, I’m one of those patients, so I just want to warn you. I’m one of those patients. I want to know everything, and I have lots of questions, and I want to talk about everything.”” And you know, and she’s very friendly, and very approachable about it, but I think that’s a really good way to start out, like gauge their reaction to that.
I was really lucky when I started with a new OB practice that I walked in during pregnancy with a piece of paper that had a list of questions, and the doctor immediately said, “You know what? Just stop right there. I think you might be a really good fit with one of our midwives. I can see you have a lot of questions, and that is really what they’re great at.” And so, she offered for me to have my next appointment with a midwife instead of with her or one of the other OBs, and that was really awesome. I didn’t even know that a nurse midwife or a midwife was an option. And so, it was really great that she basically was just like, “Look, the model I follow, I don’t have that much time to answer your questions, but that’s important to you. Go to a provider who that’s important to them, too.”
Lozada: Do you, I know you do a lot of advocacy in general for maternity care. Do you find that the system is improving? Is it changing? What is going on to make it… We’ve been focusing on the birth room, but at large, how are things doing?
Pascucci: Wow. That’s a really good question. You know, we’re definitely way further along than we were before, and we have a really long way to go, but it’s really promising, and I’m really excited about it.
Lozada: And I have seen, like for example recommendations and guidelines coming from ACOG, the language change in the past years-
Pascucci: Yeah! Totally.
Lozada: The one that just came out. Yeah. Talk about that.
Pascucci: Well, I was just gonna say, actually I’m glad you reminded me of that, because earlier I was saying that there’s been more communication with the medical community. So, I was with Improving Birth for three and a half years, and one of the, or a couple of the things that we did there was to communicate directly with ACOG, which I remember at the time that we had the idea, I was just like, “Why don’t we just write ACOG?”
So, there have been a couple of instances where we’ve simply written them letters or even met with them, and that is super cool, because I don’t think that’s ever happened before, you know? Like I don’t think that ACOG has ever, ever engaged with consumers, ever. To my knowledge, and I could be wrong about that. But you know, I think that’s a really big deal.
And one of the really eye opening things actually about talking to ACOG is that they have this idea that they’re really in touch with consumers, and I definitely would not agree with that statement, so I think it was really great to be able to say like, “Actually, guys, I think you don’t even have a clue what’s going on.” You know, they’re an elite group of doctors, and they probably are seeing much more evidence-based practice in the high quality progressive facilities where they are but can be very disconnected from the stuff we see in Birmingham, Alabama, or even Lexington, Kentucky, where I live.
Lozada: Yeah. And I think… Thank you for going and talking to ACOG. And I also think communication and awareness, I think the media awareness, the mistreatment in maternity care that’s been labeled “obstetric violence,” having that be something that’s being discussed in the media, or in headlines-
Pascucci: Well, yeah, and like that was… That didn’t happen by accident. You know, I led media strategy at Improving Birth for the years that I was there, and that was one of our top, top goals, was getting the maternity care crisis in media, and then I made it my personal goal about obstetric violence, and it’s really cool to look back and see that now we’re talking about things that were like not even mentioned five years ago, like were not even in the media, are absolutely in the media and yeah, and so I think that’s… It’s raising a lot of awareness, and hopefully paving the road for a much bigger conversation.
Lozada: Huge, and people do need to hear these stories, and I encourage listeners to do a Google search for obstetric violence, so they can see what that’s about. Like just as people don’t sometimes know that they have those choices to… and from some things as simple as wear your own clothes, that you don’t have to wear the gown, to-
Pascucci: Yeah, yeah, all those little ways that you can sort of assert your humanity.
Lozada: Yeah, and show that you’re not a patient. You’re just a woman in labor. You’re not sick.
Pascucci: Yeah! Yeah. And you’re not like a gadget, or a widget on an assembly line, that you are an individual and you expect individualized care.
Lozada: And listeners, moms need to safeguard your environment. Safeguard your birth. Make sure your voice is heard.
Pascucci: You know what? You know, I say be selfish. This is the one time in your life when you need to give yourself permission to be totally selfish. Be catered to. You deserve to be catered to. And if that’s a hard thing to swallow or a hard way to carry yourself, remember that you are protecting your baby, so it’s a big responsibility, and I think we’ve gotta be real clear about that and really embrace that responsibility. It’s I do have the right to be selfish on behalf of my baby. I do.
Pascucci: Because you know what? You’re gonna have to be for the rest of your life. You might as well start now.
Lozada: Indeed. Absolutely. Know your rights. Yes. Cristen, thank you so, so much for this fantastic talk.
Lozada: You’ve been listening to a Best of Birthful episode. To listen to the original, longer version of this episode, click on the link in the show notes. And there are many more where this came from. Look for episodes with the words Best of Birthful in the title to continue your deep dive to inform your intuition. You can find the in-depth show notes for this episode at Birthful.com. You can also connect with us directly on Instagram. We’re @BirthfulPodcast.
Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Virginia Lora is the managing producer. Cedric Wilson is our lead producer. Alie Kilts contributed to the production of the Best of Birthful series. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen. Come back every week for more ways to inform your intuition.
Lozada, Adriana, host. “Best of Birthful: Tips to Advocate for Yourself During Birth.” Birthful, Lantigua Williams & Co., July 21, 2021. Birthful.com.
About Cristen Pascucci
After the birth of her son in 2011, Cristen left a career in public affairs to study American maternity care and women’s rights within it. In 2012, she joined ImprovingBirth as vice president, spearheading a multi-year grassroots media strategy to get the maternity care crisis in national news, creating a legal advocacy hotline for pregnant women, and raising awareness around obstetric violence through consumer campaigns, including 2014’s #BreaktheSilence. Cristen has helped organize, strategize, and publicize major lawsuits related to obstetric violence in hospitals. She is co-creator of the Exposing the Silence Project and host of Birth Allowed Radio. As founder of Birth Monopoly, Cristen advocates for a freer maternity care market, working closely with leading national advocates, organizations, and birth lawyers, as well as educating the public and healthcare providers about women’s human and legal rights in childbirth. After six years of full-time work on the issue of obstetric violence, Cristen is now working on a documentary film on the subject: Mother May I?
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