CTGs and well behaved women

It was Eleanor Roosevelt who said that “well behaved women rarely make history”. I contend that well behaved women also rarely get the births they want. Well behaved midwives will struggle to practice midwifery and will find themselves captured in complying with obstetric technological interventions.

A recently published paper caught my eye (Westergren et al., 2025) as it provides examples of how being “well behaved” plays out in birth. I was particularly interested in seeing how CTG monitoring played a role in what was happening in this research.

How was it done?

This research was conducted as an ethnography, with one researcher (a midwife) spending time observing midwives at work as they cared for women during labour and birth in two hospitals in Sweden. Interviews with the midwives and the woman provided additional information. The aim of the research was “through a gender perspective, to explore the paradox of childbirth becoming increasingly medicalised despite the vast evidence of the benefits of low-intervention physiological birth” (p.2).

The authors explained their position on gender, describing it as a socially constructed set of norms, roles, and entitlements. They notes that gender systems are typically patriarchal, in that the traits associated with masculinity (such as order, logic, hierarchy, efficiency, productivity, and action) are more highly valued than traits associated with femininity (like emotion, intuition, stillness, social connection, and patience). The researchers looked to see how these played out in the birth setting.

The researcher attended eight births, and seven of these women experienced the use of continuous CTG monitoring. Other interventions were also common (such as IV access, epidurals, urinary catheterisation, and labour augmentation). Both hospitals had central fetal monitoring systems.

What did they find?

Even though it was not the primary focus of this research, the relationship between CTG monitoring and masculine workplace priorities was clear. Both hospitals were understaffed, so CTG monitoring was used to achieve “efficiency”, without critical consideration of the way in which this ultimately increases workload for midwives. A lot of the midwives’ focus was on doing tasks, rather than being with women.

The CTG monitors occupied physical and psychological space in the birth room for both women and midwives:

On one site there were three monitors in the birth room, one behind the bed, one beside the bed, and one in front of the bed, allowing both the midwife and the couple to see the CTG displayed from every angle in the rooms…

The midwife is focused on the electronic fetal monitor, continuously monitoring the fetal heart rate and the uterine contractions. The monitor’s sound is audible and hard, like someone bouncing a slightly heavier than normal table tennis ball at a rate of 150 bounces per minute and doing so for three hours straight. The ping-pong sound reverberates in the room, and when the fetal heart rate drops during contractions, both the midwife and the birthing woman and her partner anxiously fix their eyes on the monitor.
p. 6

Midwives lacked the power in both settings to regulate their own work, with hospital hierarchies placing obstetricians in charge of midwives, who were in turn considered to be in charge of birthing women. This created tension between two feminine-coded practices. Midwives wanted to be” well behaved” and not push back against obstetric practices, but also to work in relationship with birthing women and to respect their goals for their birth. The nature of the workplace meant that compliance with obstetric guidelines and instructions won out, with examples given about midwives not being permitted to use birth stools, or to reduce the rate of an oxytocin infusion when the CTG pattern was abnormal.

Women in this study performed gendered roles too, and these impacted on their care and the stories they used to make sense of their experiences. Women were “very polite and kind during labour and birth, inclined to put the needs of others – the baby’s, the partner’s, the midwife’s, or even other birthing women’s – ahead of their own”. Both the woman and their midwives assumed that women would comply, and there were times when interventions were used without discussion or consent.

One woman rationalised her experience of not being provided timely analgesia during labour as being okay, because other women must have been a higher priority for that midwife. Others blamed their “deficient bodies” for their experiences, such as one woman who had been forced to remain flat on her back during the pushing stage felt that the slow progress she made was her fault for not finding the right pushing technique, rather than this being a reflection on the decisions made by the midwife.

The take home message

This paper is worth reading – and it is open access (linked in the reference list below). I encourage you to download it and take a look as there is more to it than I have captured in this short summary. The main point that came out of the paper for me was the way that the feminine gendered social expectations that women will be well behaved, nice girls, who don’t ruffle feathers 0r rock the boat, plays into patriarchal / obstetric power, allowing it to operate unchecked. This blocked birthing women and midwives from accessing other positive feminine coded attributes that are linked to midwifery philosophy. These other attributes would have allowed midwives to be “with woman”, to build relationships that created space for women’s empowerment and to discover their self-efficacy in birth, and to be patient and allow for birth to unfold at a physiological pace.

I encourage you to spend some time reflecting this week on this question – in what ways does my desire to please the people around me ultimately undermine my personal goals and sense of wellbeing? I think you will discover that it is time to stop being a well behaved woman or midwife! One small and easy way you can begin that transformation is to sign up to my newsletter, where you will begin to be connected to others who are also working on escaping the pressure to be well behaved when it comes to fetal monitoring practices.

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References

Westergren, A., Edin, K., Nilsson, B., & Christianson, M. (2025, Apr 10). Invisible but palpable- gender norms in childbirth : A focused ethnography on woman-midwife interaction and birth practices in two Swedish hospital labour wards. BMC Pregnancy Childbirth, 25(1), 419. https://doi.org/10.1186/s12884-025-07554-8